RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00708
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070218

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Military Police, medically separated for “chronic left shoulder pain” and “bilateral, chronic plantar fasciitis,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  “Review all conditions.”  The CI’s 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 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 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 - 20061106	VARD - 20080812	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Shoulder Pain	5003	10%	Left Shoulder Arthritis	5010-5203	0%	20080307	
Bilateral, Chronic Plantar Fasciitis	5399-5310	0%	Bilateral Plantar Fasciitis	5020-5276	0%	20080307	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY: 

Left Shoulder Pain.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left shoulder condition began on 24 November 2002 after a 4-wheel bike accident (mentioned also as a motorcycle accident or an ATV accident) where he suffered a severely separated left acromioclavicular joint (AC joint) grade III and instability.  On 31 July 2003, the CI underwent a repair of the left AC joint with resection of the left distal clavicle and a Weaver-Dunn procedure to stabilize the joint.  In March 2004, the CI reported pain with any range of motion (ROM) greater than 90 degrees.  Treatment of the left shoulder impingement consisted of a steroid injection and tolmetin, a nonsteroidal anti-inflammatory drug (NSAID).  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic left shoulder pain/AC joint arthritis” for PEB adjudication.

At the MEB examination (recorded on DD Forms 2807-1 and 2808) dated 31 July 2006 and 8 August 2006, approximately 6 months prior to separation, the CI reported he separated his left shoulder in 1993, 1997, and had left shoulder surgery in 2003.  Physical examination revealed a 7 cm anterior scar of the left shoulder.  The AC joint was tender to palpation.  There was a full ROM with tenderness with external rotation and there was good strength (5/5).  Moderate posterior shoulder girdle atrophy was noted.  

The MEB NARSUM examination on 8 August 2006, 7 months prior to separation, noted the CI complained of chronic left shoulder AC joint pain.  Physical examination showed ROM with tenderness on external rotation (painful motion).  He had good strength, with moderate posterior shoulder atrophy.  X-rays dated 5 September 2006 demonstrated no apparent acute fracture, dislocation or subluxation; however, there were changes at the distal clavicle which could have been due to the prior surgical resection. 

At the Orthopedic consult examination on 27 September 2006, 5 months prior to separation, the CI complained of a painful left shoulder with most of the pain over the mid to distal portion of the clavicle and noted after surgery he had physical therapy.  Physical examination revealed prominence over the left distal clavicle compared to right and a loss of posterior shoulder girdle musculature.  There was a slight area of depression anterior and little distal to remnants of the clavicle. The ROM was “full abduction and forward flexion to 90 degrees [normal 180] against resistance reveals some weakness over the left side in comparison to the right.”  

At the 7 March 2008 VA Compensation and Pension (C&P) evaluation, performed 13 months after separation, the CI reported left shoulder joint pain. Physical examination was normal with a full ROM without pain and no joint ankylosis, no objective joint abnormalities, and no inflammatory arthritis.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5003 code (degenerative arthritis) for the left shoulder condition.  The VA assigned a Not Service Connected rating using an analogous 5010-5203 code (degenerative arthritis due to trauma - clavicle or scapula, impairment) for the left shoulder condition based on the VA C&P examination 13 months after separation, citing a normal examination without pain on motion.  Board members noted that the PEB indicated the CI was right hand dominant; however, several entries in the STR noted the CI was left handed.  Nevertheless, the Board agreed there was no ROM limitation which would achieve a rating higher than 10% despite the limitation of flexion to 90 degrees, 5 months prior to separation, since it was against resistance rather than an unimpeded active motion as were the preceding and subsequent examinations.  Furthermore, there was no ankylosis, fracture (nonunion/malunion) or subluxation/instability that would support a higher rating under any other joint code, although there was a resection of the distal clavicle and X-rays prior to separation noted changes at the distal clavicle which could have been due to prior surgical resection, but there was no acute bony abnormality.  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 left shoulder condition.  

Bilateral Plantar Fasciitis.  According to STRs and the MEB NARSUM, the CI’s bilateral plantar heel and mid-foot pain began in September 2005 while running.  On his MEPS [Military Entrance Processing Station] examination in 1996 the CI was noted to have asymptomatic moderate pes planus.  In January 2006 examination revealed pes planus of both feet with plantar tenderness on palpation of both feet.  X-rays of the feet on 5 May 2006 demonstrated findings suggestive of bilateral pes planus.  The CI was treated conservatively by podiatry with inserts, which improved the pain in the arches, but not the heels.  Furthermore, stretching, ice massaging, wearing the inserts, and taking NSAID medication did not resolve the pain.  Examination in June 2006 revealed tenderness to palpation along the medial longitudinal arch with additional tenderness in the region of the medial calcaneal tubercle (heel) bilaterally.  The CI was not a surgical candidate.  Despite treatment, the bilateral 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 “bilateral pes planus and symptomatic plantar fasciitis” for PEB adjudication.  

At the MEB examination (recorded on DD Forms 2807-1 and 2808) dated 31 July 2006 and 8 August 2006, approximately 6 months prior to separation, the CI reported pes planus/plantar fasciitis.  Physical examination revealed bilateral pes planus with tenderness of the mid foot and heel plantar [area] bilaterally and pain with heel raising.  The MEB NARSUM examination on 8 August 2006, 7 months prior to separation, noted complaints of 7/10 pain (10 being the worst pain) of the mid-foot and heel bilaterally with an increase of pain with any high impact activity.  Physical examination revealed bilateral severe pes planus and pain with palpation of the midfoot and heel bilaterally and there was pain with heel raising.

At the VA C&P examination dated 7 March 2008, performed 13 months after separation, the CI reported pain in the arches of the feet.  Examination of the right foot revealed bilateral flatfoot.  There was no pronation of the feet; the arch was present on non-weight bearing, yet it was absent during weight bearing.  The weight bearing line was over or medial to the great toe bilaterally.  There was normal Achilles, forefoot, and midfoot alignment bilaterally and there was no pain at rest or during manipulation. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under an analogous code 5399-5310 (Group X. Function: Movements of forefoot and toes; propulsion thrust) for the bilateral plantar fasciitis condition, citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The VA assigned a 0% rating under an analogous code 5399-5310 for the bilateral plantar fasciitis condition, based on the VA C&P examination 13 months after separation, citing mild plantar fasciitis symptoms.  The PEB combined the bilateral plantar fasciitis conditions as a single unfitting condition coded 5399-5310 for moderate disability, rated 0%. The approach by the PEB commonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The Board’s initial charge in this case was 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 the condition would not cause 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 evidence for the bilateral plantar fasciitis conditions was presented together above.  

In this case, the symptomatic pes planus/bilateral plantar fasciitis conditions were profiled and the bilateral plantar fasciitis conditions were implicated by the NARSUM and in the commander’s statement.  Members agreed that each foot condition is separately unfitting and that identical coding and ratings are applicable.   Use of code 5310 addresses not only plantar aponeurosis, which is the site of inflammation in plantar fasciitis, but also the several intrinsic muscles involved in propulsion as well as select ligament and tendons, none of which were noted to be problematic or impaired.  Board members then had a detailed discussion about whether the plantar fasciitis was slight or moderate for each foot.  Since clinical examinations only noted tenderness to the arches and heels, but did note severe pes planus, members could not determine in the absence of more credible medical evidence whether the plantar fasciitis did rise above a slight level with a 0% rating for either or both feet.  However, because the CI had severe pes planus, members agreed that use of the analogous 5276 code (Flatfoot, acquired) was reasonable and is IAW VASRD §4.7 (Higher of two evaluations); however, although the examiner called the pes planus severe, it does not meet the VASRD criteria for a severe disability in the absence of “objective evidence of marked deformity (pronation, abduction, etc.) pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities:).”  Nevertheless, the limited examination findings were more consistent with a moderate disability warranting a 10% rating for either a unilateral or bilateral condition with pain on manipulation and use of the feet prior to separation.  By the time of the VA C&P examination, albeit the examination was 13 months post-separation, there was no pain on rest or manipulation, which is suggestive that the plantar fasciitis had improved over time.  Board members did note that the CI had pes planus prior to enlistment and he had more than 8 years of military service.  However, while the pes planus was not acquired while in service, nonetheless, it was aggravated with high impact activity, which not only exacerbated the pes planus, but also contributed to the development of the bilateral plantar fasciitis.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the bilateral plantar fasciitis condition, coded 5299-5276.

BOARD FINDINGS:  In the matter of the chronic left shoulder pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral plantar fasciitis condition, the Board unanimously recommends a disability rating of 10%, coded 5299-5276 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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Shoulder Pain	5003	10%	
Bilateral Plantar Fasciitis	5299-5276	10%	
COMBINED 	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150604, 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, AR20170002443 (PD201500708)

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