RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01091
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20020710

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Petroleum Supply Specialist, medically separated for “chronic pain, left knee, and both heels” with a disability rating of 10%.  A “bilateral plantar fasciitis” condition was determined to have existed prior to service (EPTS) and was not rated.   

CI CONTENTION:  “The achilles tendon contracture has prevented me from wearing all leather boots, which restricts me from certain jobs.”  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 progression or complications of service-connected conditions after separation.  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 - 20020429	VARD - 20021030	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Left Knee, and Both Heels	5099-5003	10%	Degenerative Joint Disease of Left Knee	5010	10%	20021005	
			Right Achilles Tendon Contracture	5299-5271	10%		
			Left Achilles Tendon Contracture	5299-5271	10%		
Bilateral Plantar Fasciitis	5299-5276
5399-5310	EPTS	Bilateral Plantar Fasciitis	5099-5021	10%		
			Bilateral Pes Planus	5276	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Pain, Left Knee, and Both Heels.  The PEB combined the two Medical Evaluation Board (MEB) conditions of “achilles tendon contracture bilaterally” and “left knee pain, chronic” as a single unfitting condition of “chronic pain, left knee, and both heels” coded under an analogous 5003 code (degenerative arthritis) and rated 10%.  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 the PEB’s approach of combining conditions under single ratings were 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 Disability Evaluation System (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.  The evidence for both Achilles, the left knee, both heels are considered separately, with attendant recommendations regarding separate fitness, and separate rating if indicated.  

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s left knee and bilateral heel/Achilles condition began in July 1998 without specific injury or trauma.  In January 2000 he injured his left knee. The CI underwent treatment with podiatry, and was prescribed nonsteroidal anti-inflammatory medications, bilateral orthotics, arch supports, night splints and physical therapy for his Achilles tendon/heel pain, without relief.  There was no surgical indication.

The 8 April 2002 MEB NARSUM examination, 3 months prior to separation, noted complaints of bilateral Achilles tendon pain and left knee pain.  The CI provided a history of bilateral arch pain and Achilles tendon pain since 1997.  His left knee pain presented after he injured his left hamstring while moving furniture.  He initially complained of intermittent pain with activities, specifically walking, running, and jumping, that progressed to chronic pain with running.  It was noted that he had no follow-up for his knee condition since April 2000 at which time he had a normal knee examination.

Physical examination showed bilateral feet range of motion (ROM) at 0 degrees dorsiflexion (normal 20) and 45 degrees plantar flexion (normal).  There was tenderness along the Achilles tendon bilaterally.  The left knee demonstrated “full ROM without laxity, medial or lateral and no evidence of instability.  Gait was unremarkable.”

At the 5 October 2002 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI reported that he used no assistive devices or canes for ambulation and he had occasional swelling and weakness in his left knee and used a brace.  He had knee pain when standing for long periods of time, but could walk several miles despite his knee pain.  His knee pain was relieved by rest.  Physical examination showed left knee ROM to 140 degrees (normal) with pain in the posterior thigh at 80 degrees from extension.  Both heel cords were tight even with flexed knees and he could only dorsiflex his foot to neutral and plantar flex to 25 degrees.  There was tenderness of the insertion of his plantar fascia and to his heel, and there was no pain on palpation of the Achilles tendon.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic pain, left knee, and both heels condition 10%, coded 5099-5003 (degenerative arthritis), citing the US Army Physical Disability Agency pain policy.  The VA rated the left knee condition 10%, coded 5010 (traumatic arthritis), based on the C&P examination 3 months after separation, citing painful and limited motion of a major joint.  Additionally, the VA rated the right and left Achilles tendon condition 10% each, coded analogous to 5271 (limited motion of ankle), citing moderate limitation of motion.

The panel considered whether the left knee condition, when considered separate from the bilateral heel and Achilles tendonitis conditions, was unfitting for continued military service.  The NARSUM noted there had been no evidence of locking, and that the CI complained of intermittent pain with activities.  The examiner noted that there had been a follow-up evaluation of the left knee in April 2000 with a normal left knee examination, and the CI had had no follow-up examination since then.  At the NARSUM, left knee examination demonstrated full ROM without evidence of instability, inflammation or laxity and gait was normal.  The commander’s statement did not document any symptoms specific to the left knee as significantly impairing duty performance. 

The STR demonstrated minimal treatment of the left knee, with absence of treatment recorded in the 12 months prior to separation.  The panel members concluded that the preponderance of evidence showed the left knee condition would not reasonably have caused the CI to be referred into the DES or be found unfit, nor were any physical findings documented by the MEB or VA examiners which would logically be associated with significant disability.

The panel next considered the evidence for the bilateral heels condition, Achilles tendonitis.  The STR demonstrated that the CI initially complained of left heel pain in December 2000.  In October 2001 he complained of left greater than right heel pain and was assessed with bilateral Achilles tendonitis.  Treatment records beyond October 2001 did not document one heel being worse than the other.  The CI was assessed with Achilles tendon contracture bilaterally, and that condition appeared to have been the source of the tendonitis.  There were multiple treatment entries for this condition and evidence that his condition did not improve despite multiple treatment modalities.  The NARSUM examiner stated, “My examination today demonstrates Achilles tendon bilateral ROM 0 degrees dorsiflexion, 45 degrees plantar flexion.”  Painful motion was not recorded.  The C&P examination recorded 25 degrees of plantar flexion.  The commander’s statement implicated this condition as interfering with satisfactory duty performance.  Panel members agreed that the evidence reasonably justified that the functional limitations of the condition contributed to the CI’s inability to perform his military duties, and accordingly a separate disability rating is recommended for each heel condition of Achilles tendonitis.

The panel proceeded to the ratings recommendation based on the evidence cited above.  That evidence recorded ankle ROM compensable at the 10% level for moderate limitation of motion.  Panel members agreed, a 10% rating and no higher was justified for each heel.  There was no path to rating either heel greater than 10%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the each heel condition, coded 5299-5271.

BOARD FINDINGS:  In the matter of the chronic pain, left knee, and both heels, due to Achilles tendonitis condition, the panel majority recommends that each joint be separately adjudicated as follows: not unfitting left knee condition and unfitting left and right heel condition, analogously coded 5299-5271 and rated 10%, both IAW VASRD §4.71a.  The single voter for dissent recommends no change and elected not to submit a minority opinion.  There are no other conditions within the panel’s scope of review for consideration.  

The panel 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	
Achilles Tendonitis/Left Heel	5299-5271	10%	
Achilles Tendonitis/Right Heel	5299-5271	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150611, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170007441, XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	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