RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00575
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20070516

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Trainee, medically separated for “chronic bilateral foot pain” with a disability rating of 0%.  

CI CONTENTION:  “Review all conditions.”  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on 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(s) at the time of separation.  The panel 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 panel 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 - 20070502	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Foot Pain 	5399-5310	0%	No VA Examination in Evidence	
Abnormal Urine	Not Unfitting		
Menorrhagia	Not Unfitting		
Arrhythmia	Not Unfitting		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Chronic Bilateral Foot Pain.  The PEB combined the left and right foot conditions under a single disability rating, coded 5399-5310 (group X muscle function) and rated 0%.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The panel’s initial charge in this case was therefore directed at determining if combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  

According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral foot pain began in basic training and she was diagnosed with right foot stress fracture and left foot sesamoiditis in December 2006.  A January 2007 bone scan showed prominent right foot and ankle stress changes with abnormal uptake in the bilateral tibial sesamoids.  

During the 20 March 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), the CI complained of bilateral foot pain with sesamoiditis and plantar fasciitis and used boot inserts for the fasciitis.  Physical examination noted diminished strength in plantar flexion and tenderness to palpation “all over.”  

The 10 April 2007 MEB NARSUM examination, 1 month prior to separation, noted complaints of bilateral foot pain worsened with activity or prolonged walking/standing and marching.  Evaluation and conservative treatment from podiatry and orthopedics, including custom orthotics, did not effectively relieve her pain and she was not a surgical candidate.  Physical examination showed a normal gait and stance, and pain with toe walking.  Bilateral foot pain was elicited by motion but there was no swelling or erythema.   While the examiner noted bilateral tenderness along the medial arches, there was no tenderness along the medial aspects of the Achilles insertions.  Balance and motor tests were normal and the examiner diagnosed bilateral plantar fasciitis and congenital pes planus foot deformity.  

The 11 April 2007 physical therapy range of motion (ROM) study for the MEB documented right ankle dorsiflexion to 10 degrees (normal 20) and left ankle dorsiflexion to 7 degrees with pain in the soles of both feet limiting greater passive dorsiflexion to 17 and 14 degrees, respectively.  Plantar flexion was to 55 degrees (normal 45) in each ankle and there was pain-limited motion of the great toes bilaterally.  There was no VA examination in evidence proximate to separation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the combined bilateral foot conditions 0%, analogously coded 5399-5310 as noted above.  The PEB cited repetitive strain injury to the plantar fascia and congenital pes planus not noted during enlistment and that the “presumption of permanent service aggravation was not overcome.”  The PEB also stated that the MEB’s “congenital foot deformity, pes planus” diagnoses was not ratable as it was congenital.  The PEB’s note regarding permanent service-aggravation indicated it was considered in the unfitting condition and potentially separately unfitting and ratable.  

In this case, the bilateral plantar fasciitis and pes planus foot conditions were considered to fail retention standards, were implicated by the NARSUM, and profiled.  The commander’s statement and other STR evidence did not provide any information which would permit the panel to discriminate the performance limitations attributable to either foot over the other.  Since undue speculation would be required to conclude that the left or right foot conditions would not have unacceptably interfered with the performance of military duties, members agreed that each condition was reasonably justified as separately unfitting.  

The panel next deliberated rating each condition separately or combined.  While neither foot rated higher than 0% under code 5310 (or any other muscle coding) given VASRD §4.56 (evaluation of muscle disabilities) criteria, plantar fasciitis can be rated analogously to code 5020 (synovitis).  The CI had pain on bilateral foot manipulation and movement, and pain-limited ankle dorsiflexion with functional loss (§4.40, §4.45, and §4.59) which met 10% rating criteria for each foot.  Although the bilateral pes planus was potentially ratable at 10% with pain on manipulation and movement, and symptoms not relieved by orthotics, the panel determined that additional rating was not warranted given the provisions of VASRD §4.14 (avoidance of pyramiding).  Members agreed the most appropriate rating for each foot’s plantar fasciitis and pes planus was 10% using code 5276-5020 (flatfoot-synovitis).  After due deliberation, and considering all of the evidence, the panel recommends a disability rating of 10% for the right foot condition, and 10% for the left foot condition, coded 5276-5020.  

Contended PEB Conditions:  Abnormal Urine, Menorrhagia, and Arrhythmia.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled, implicated in the commander’s statement nor judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the bilateral foot conditions, the panel unanimously recommends each foot condition be separately adjudicated as follows:  an unfitting right foot condition coded 5276-5020 and rated 10%, and an unfitting left foot condition, coded 5276-5020 and rated 10%, both IAW VASRD §4.71a.  In the matter of the contended abnormal urine, menorrhagia, and arrhythmia conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  

There are no other conditions within the panel’s scope of review for consideration.  The panel recommends the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Left Foot Pain	5276-5020	10%	
Chronic Right Foot Pain	5276-5020	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150604, w/atchs
Exhibit B.  Service Treatment Record

AR20180000467, XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,					      
						      					
Enclosure