RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00499
BRANCH OF SERVICE:  Army
DATE PLACED ON TDRL:  20080516
DATE REMOVE FROM TDRL:  20091006

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E3, Pharmacy Specialist Trainee, medically separated from the Temporary Disability Retired List (TDRL) for “chronic right hip pain” and “plantar fasciitis left foot,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The applicant makes no contention.

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 - 20080415/20090910	VARD - 20131112	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL
Removal			TDRL
Placement	TDRL
Removal	
Chronic Right Hip Pain	5019	10%	10%	Right Hip Bursitis	5253	--	10%	
Plantar Fasciitis Left Foot	5399-5310	10%	--	Left Foot Plantar Fasciitis	5276	--	0%	
	5299-5284	--	10%	Left Foot Tarsal Tunnel Syndrome	8520	--	10%	
Left Posterior Tibial Tendonitis	5024	10%	--	Left Shin Splint with History of Left Tibial Stress Fracture
Not in scope	5299-5262	--	0%	
Left Achilles Tendonitis	--	--	Not Unfitting					
COMBINED RATING:  30% → 20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:

Chronic Right Hip Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right hip condition began in October 2007 after using a controlled ankle movement (CAM) walker for treatment of her left foot condition (below).  No trauma was reported.  Despite treatment, the right hip condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “right hip greater trochanteric bursitis” for PEB adjudication.

The MEB NARSUM examination on 17 March 2008 (2 months prior to TDRL placement) noted complaints of right hip pain.  Physical examination showed right hip tenderness and decreased range of motion (ROM) of flexion 110 degrees (normal 125), extension 10 (normal 20), external rotation 50 (normal 45), abduction 45 (normal 45), adduction 30 (normal 45), and painful motion.  The CI was able to cross her legs without difficulty and demonstrated out toeing at approximately 70 degrees.  There was no motor, sensory or neurovascular deficits noted.

The TDRL reevaluation on 15 July 2009 (3 months prior to TDRL removal) noted a mildly antalgic gait and repetitive ROM of flexion 130/129/131 degrees, extension 15/10/12, external rotation 50/--/--, abduction 20/22/26, adduction --, and painful motion.

There was no VA Compensation and Pension (C&P) examination proximate to separation.  The first VA C&P exam was performed in October 2013, 65 months after TDRL placement and 51 months after TDRL removal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right hip condition 10%, coded 5219 code (bursitis), citing limitation of motion both at TDRL placement and TDRL removal.  The VA also rated the right hip condition 10%, coded 5253 code (thigh, impairment) based on the VA C&P examination 51 months after TDRL removal, citing painful motion.

All examination in evidence documented sufficient evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB at both TDRL placement and removal.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion, extension, or thigh impairment for greater than a 10% rating (codes 5251, 5252, or 5253).  Alternative rating analogous to code 5255 (femur, impairment of) was not applicable as there was no fracture or malunion of the femur.

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic right hip pain condition at TDRL placement or removal.

Plantar Fasciitis Left Foot and Left Posterior Tibial Tendonitis.  According to STRs and the MEB NARSUM, the CI’s left foot plantar fasciitis condition began in September 2007 along with posterior tibial tendonitis.  No trauma reported.  Despite treatment, the left foot plantar fasciitis condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “left plantar fasciitis” (and “[left] tibialis tendonitis”) for PEB adjudication.

The MEB NARSUM examination on 17 March 2008 (2 months prior to TDRL placement) noted complaints of left ankle and foot pain, and denied instability.  Physical examination showed good pulses with tenderness over the posterior tibiofibular ligament, posterior tibialis tendon, the insertion of the plantar fascia, and over portions of the plantar arch.  There was no ankle instability and ROM was limited without painful motion to dorsiflexion of 12 degrees (normal 20) and plantar flexion of 6 degrees (normal 45).

The TDRL reevaluation on 15 July 2009 (3 months prior to TDRL removal) noted the CI “presents for TDRL evaluation of right hip bursitis, plantar fasciitis, and left Achilles tendonitis.”  The CI had complaints of bilateral foot pain with prolonged standing.  The CI had foot orthotics, but finds they were uncomfortable and so she did not use them.  Physical examination noted a mildly antalgic gait favoring the right leg.  There was no tenderness to palpation over the plantar aspect of either foot, or over either posterior tibial tendon.  There was tenderness in the left foot near the toes (medial metatarsal phalange joint/MTP).  There was no edema in the lower extremities, and strength, reflexes and pulses were normal.  There was painful left ankle motion with dorsiflexion to 10 degrees and plantar flexion to 27 degrees.  The examiner stated “Tendonitis:  Achilles tendonitis appears to have resolved.”

The Board directed attention to its rating recommendation based on the above evidence.  On TDRL placement, the PEB rated the left plantar fasciitis condition 10%, analogously coded 5399-5310 (muscle Group X), citing rated as moderate due to pain and lack of endurance and also referencing the US Army Physical Disability Agency (USAPDA) pain policy.  The PEB also assigned a 10% rating for left posterior tibial tendonitis under 5024 (tenosynovitis) citing limitation of ankle ROM.

At TDRL removal/permanent separation, the PEB rated the left plantar fasciitis 10%, analogously coded 5284 (foot injuries, other), citing a mildly antalgic gait and rated for moderate injury.  The PEB adjudicated the “left Achilles tendonitis is no longer separately unfitting.”  The VA rated the left plantar fasciitis 0%, coded 5276 (flatfoot, acquired) based on the VA C&P examination 51 months after TDRL removal, citing unilateral involvement and mild symptoms.  The VA additionally rated left foot tarsal tunnel syndrome 10%, coded 8520 (sciatic nerve) also based on the VA C&P examination 51 months after TDRL removal, citing mild incomplete paralysis (examination showed sensory deficit and positive electrodiagnostic testing).

Board members agreed, at TDRL placement, there was insufficient evidence to support left plantar fasciitis at a “moderate” or more severe muscle injury IAW VASRD §4.73, or greater than a 10% rating under code 5020 (synovitis).  There were no other applicable VASRD coding when separately apportioning the CI’s ankle disability/symptoms from the left posterior tibial tendonitis IAW VASRD §4.14 (avoidance of pyramiding).  The Board agreed, at TDRL removal, the left posterior tibialis tendonitis did not demonstrated marked limitation of ankle motion to support a rating higher than 10% assigned by the PEB.  Additionally, considering the left lower extremity conditions to include plantar fasciitis and tibial tendonitis, there was no rating scheme to support a 20% combined disability.

The Board agreed, at TDRL removal/permanent separation, there was insufficient evidence to support left plantar fasciitis at a “moderately severe” foot injury higher than the 10% rating awarded by the PEB.  Regarding alternative ratings, there was no evidence of ratable muscle injury or left foot limitations that would rate higher than 10%.  At TDRL removal/permanent separation, the PEB stated that “left Achilles tendonitis is no longer found to be separately unfitting by the PEB.”  Although the TDRL-placement condition was “left posterior tibial tendonitis,” there was no abnormal Achilles or posterior tibial tendon examination findings at TDRL removal.  The Board considered that the PEB found no tendinopathy unfitting.  This tendinopathy was not contended; and therefore, outside the PDBR’s scope of review.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the plantar fasciitis left foot condition on TDRL placement or removal.

BOARD FINDINGS:  In the matter of the chronic right hip pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the plantar fasciitis left foot condition and IAW VASRD §4.71a and §4.73, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left foot posterior tibial tendonitis condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150602, 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

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160018729  (PD201500499)

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, I accept the Board’s recommendation and hereby deny the individual’s application. This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA