RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01033
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080620

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Veterinary Food Inspector, medically separated for “left navicular stress fracture…” and “right plantar fasciitis,” rated 10% and 0%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  “I still have problems with the diagnosis I was given upon discharge.  I have trouble walking, exercising.”  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 - 20080529	VARD - 20090313	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Navicular Stress Fracture…	5284	10%	Left Foot Stress Fracture of Navicular, Resolved	5299-5284	0%	20081024	
Right Plantar Fasciitis…	5399-5310	10%	Plantar Fasciitis, Bilateral	5299-5276	0%	20081024	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Left Navicular Stress Fracture.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left foot pain, which began in December 2007 with no reported injury or trauma, was determined by radiographic imaging to be due to a navicular stress fracture in March 2008.  A prior diagnosis of plantar fasciitis was also present.  There was no surgical indication.

The MEB NARSUM examination on 8 May 2008 (approximately 6 weeks after navicular stress fracture was diagnosed and treatment begun, and 6 weeks prior to separation) noted complaints of “left greater than right foot pain” which prevented participation in physical fitness testing or alternate events.  She could not run, march or jump.  Physical examination showed ambulation utilizing a walking boot on the left foot.  There was no left foot swelling.  Tenderness of the left navicular bone, plantar fascia and Achilles tendon was present.  Ligaments were non-tender and stable.  Left ankle dorsiflexion was 10 degrees (normal 20) and plantar flexion was 45 degrees (normal 45).

At the 24 October 2008 VA Compensation and Pension (C&P) evaluation, performed 4 months after separation, the CI reported no impediments to activities of daily living.  She complained of left foot pain with walking or twisting of her foot.  Pain was absent when not bearing weight.  A flare-up lasting 30-45 minutes occurred every morning.  Physical examination showed a normal gait without use of assistive devices, and the CI could walk on her toes and heels.  Tenderness of the left plantar arch and dorsum of the foot was present.  There was no evidence of abnormal weight bearing or abnormal shoe wear.  Although the absence of pes planus was noted, the examiner also stated that “the arch is present but is low in the left foot.”  There was “no discomfort or difficulty with range-of-motion testing.”  X-ray of the left foot was negative and the examiner rendered diagnoses of left foot stress fracture (resolved), and plantar fasciitis of left foot with “no functional impairment.”

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left navicular stress fracture “as well as concomitant plantar fasciitis” condition 10%, coded 5284 (foot injuries, other), citing “moderate” as the rating rationale.  The VA rated the left navicular stress fracture condition 0% coded 5299-5284, based on the C&P examination 4 months after separation, stating that the condition was resolved with no objective residual findings.  The VA additionally rated bilateral plantar fasciitis at 0% (see below).  Members agreed that the PEB properly subsumed plantar fasciitis of the left foot under the overall rating for the left foot stress fracture condition.  The impairment from plantar fasciitis was the same as that from the navicular stress fracture, and IAW §4.14 (avoidance of pyramiding), more than one rating based on the same impairment is prohibited.  The panel considered a rating higher than the PEB’s 10%.  Under the 5284 code a 20% rating requires evidence of a “moderately severe” condition.  However, this was not an accurate descriptor and therefore a 20% rating was not justified via that code.  Under the 5271 code, it was agreed that the next higher 20% rating was not indicated in the absence of marked limitation of ankle range of motion.  There was no evidence of pes cavus or tarsal bone malunion to warrant rating under the respective 5278 or 5283 codes.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left navicular stress fracture with plantar fasciitis condition.  

Right Plantar Fasciitis.  According to the STR, the CI’s bilateral plantar fasciitis condition first presented in June 2007.  There was no surgical indication.  The MEB NARSUM examination (6 weeks prior to separation) noted complaints of plantar fasciitis pain present “80-85% of the time during the day while awake.”  Physical examination showed use of a walking boot on the left foot (for navicular stress fracture, as previously described).  All tendons in the right foot operated normally and ligaments were stable.  There was tenderness of the right Achilles tendon, and at the arch and insertion of the plantar fascia.  

At the 24 October 2008 C&P evaluation, 4 months after separation, the CI reported pain in the morning in both feet which improved somewhat with stretching.  Walking worsened the pain, and wearing high heels caused pain after 30 minutes.  Physical examination showed a normal gait without use of assistive devices, and the CI could walk on her toes and heels.  Dorsiflexion and plantar flexion of all toes was normal.  Tenderness of the right plantar fascia was present and there was mild pain on plantar manipulation.  There was no abnormal callus formation or abnormal shoe wear pattern.  X-ray of the right foot was normal.  The examiner rendered a diagnosis of plantar fasciitis right foot with “no functional impairment.”

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right plantar fasciitis condition 10%, coded 5399-5310 (muscle injuries, Group X), citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The VA rated bilateral plantar fasciitis 0% coded 5299-5276 (flatfoot acquired).  The panel considered the PEB’s coding route for the right foot which, under 5310, confers a 10% rating for “moderate” and 20% for “moderately severe” muscle disabilities.  All members agreed that the condition was most accurately depicted by the “moderate” descriptor, therefore a 10% rating was warranted.  Under the 5276 code, it was agreed that the condition was no more than “moderate” (with weight-bearing line over or medial to great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet, bilateral or unilateral); therefore a rating higher than 10% was not warranted using this path.  Other foot codes were either inapplicable or offered no rating advantage to the CI.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right plantar fasciitis condition.  

BOARD FINDINGS:  In the matter of the left navicular stress fracture as well as concomitant plantar fasciitis condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the right plantar fasciitis condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There were no other conditions within the panel’s scope of review for consideration.  The panel, 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 20150607, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170011793, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.

Sincerely,