RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00387
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20020320

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Light Wheeled Vehicle Mechanic, medically separated for “chronic bilateral heel pain” with a disability rating of 10%.

CI CONTENTION:  The CI contends that his condition continues to worsen and negatively impacts his daily activities.  He also feels that he should have been awarded a percentage for his flat feet, lower back and knees.  His complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is based upon a review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:

SERVICE PEB - 20020108	VARD - 20030218	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Heel Pain	5099-5003	10%	Left Achilles’ Tendonitis	5099-5024	10%	20020130	
			Right Achilles’ Tendonitis	5099-5024	10%	20020130	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Bilateral Heel Pain (Tendonitis).  The PEB combined the left and right Achilles’ tendonitis diagnoses as a single unfitting condition under a single code and rating.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and that there was no need for separate fitness adjudications.  The Board also noted that “bundling,” the combining of two or more major joints, may be permissible under VASRD criteria of 5003, and that this approach does not necessarily compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates that it alone would not have caused the member to be referred into the DES or be found unfit because of physical disability.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.

The earliest entry in the service treatment records (STR) for this complaint was in January 2001 (7 months after enlistment), at which time conservative treatment with orthotics and physical therapy was initiated.   Magnetic resonance imaging was bilaterally normal.  A rheumatology consultant excluded systemic inflammatory disease, and podiatry confirmed a diagnosis of bilateral Achilles’ tendonitis.  There was STR documentation of normal gait, painful motion, normal strength, and the absence of joint instability or impingement; and, there was no indication of greater acuity on the right or left.  Ankle range of motion (ROM) measurements by physical therapy in September 2001 (7 months before separation) were bilateral dorsiflexion to 10 degrees (normal 20) and plantar flexion to 35 degrees left and 25 degrees right (normal 45).   Surgery was not indicated; conservative treatment did not result in sufficient improvement to allow unrestricted duty; and, the CI was referred for a Medical Evaluation Board (MEB) which in turn forwarded “mechanical bilateral Achilles tendonitis without objective findings” to the PEB.

The MEB narrative summary (NARSUM) examination on 29 November 2001 (5 months before separation) documented “constant pain with weight bearing” rated “frequent [and] moderate.”  The physical examination recorded bilateral tenderness at the Achilles’ insertions and normal sub-talar (hindfoot) motion.  Bilateral ankle ROM was dorsiflexion 10 degrees and plantar flexion 40 degrees, specifying painful motion.  The commander’s performance statement did not provide evidence probative to separate fitness implications of either extremity, and the profile was for “bilateral Achilles tendonitis.”

A VA Compensation and Pension (C&P) examination on 30 January 2002 (2 months before separation) documented “daily and constant [bilateral heel pain] waxing and waning throughout the day dependent upon his level of physical activity.”  The physical examination recorded a normal gait and bilateral tenderness at the Achilles’ insertions.  Bilateral ankle ROM measurements were normal, but painful motion at end ranges was specified.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral heel pain condition 10%, analogously coded 5099-5003 (degenerative arthritis), citing the U. S. Army Physical Disability Agency (USAPDA) pain policy, which was compliant with VASRD §4.71a criteria under 5003 for two or more major joints.  The VA rated the bilateral heel condition 10%, for right and left Achilles tendonitis, respectfully, analogously coded 5099-5024 (tenosynovitis) based on the VA C&P examination 2 months before separation, citing limitation of motion.  Members agreed that alternative rating under code 5271 (ankle, limited motion) would not support a rating higher than 10% for “moderate” limitation for either ankle based on the above ROM evidence. There was no ankylosis, fracture deformity, flail joint or instability, nonunion/malunion, or other ratable criteria in evidence that would support a rating higher than 10% under any alternative foot or ankle code (included consideration of the 5010 [Group X] muscle code).  The Board was thus left with deciding whether the heel pain conditions were reasonably justified as separately unfitting as a basis for recommending a bilateral 10% or separate 10% ratings (as elaborated in the introduction).

In this case, there was no evidence that one extremity caused more functional impairment than the other, and the overall functional impairment interfered with MOS requirements.  Members agreed, given the pathology and clinical acuity described above, that it would be overly speculative to conclude that the impairment confined to a single extremity would have permitted adequate performance within the MOS.  Each extremity was therefore reasonably conceded as separately unfitting, justifying separate ratings; and, there was sufficient evidence of painful motion to support the minimum 10% rating for each joint.  After due deliberation, considering all of the evidence and conceding VASRD §4.3 (reasonable doubt), the Board recommends separate left and right 10% ratings for Achilles’ tendonitis under code 5099-5024.

BOARD FINDINGS:  In the matter of the service-combined bilateral Achilles’ tendonitis, the Board unanimously recommends that each extremity be rated as separately unfitting at 10%, each coded 5099-5024 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  

The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Left Achilles’ Tendonitis	5099-5024	10%	
Right Achilles’ Tendonitis	5099-5024	10%	
COMBINED w/ BLF	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150530, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB										

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

21 DEC 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160018713 (PD201500387)

1.  I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA