RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01167
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070601

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

CI CONTENTION:  “I still have issues with my feet and causes problems with my knees.”  The CI’s 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 panel 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 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 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 – 20070419	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Planar Fasciitis	5399-5310	0%	No VA Exam in Evidence	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA 	

ANALYSIS SUMMARY: 

Bilateral Plantar Fasciitis.  The PEB combined the right and left foot conditions as a single unfitting condition coded analogously to 5310 code (muscle group X injury) and rated 0%.  The 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 or implied adjudication that each condition was separately unfitting.  The Panel’s initial charge in this case was therefore 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 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 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 the right and left foot conditions are presented together, with attendant recommendations regarding separate unfitness and rating in the rating discussion.

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the bilateral foot pain began at the end of Basic Combat Training in September 2006.  Bilateral foot radiographic (X-rays) studies on 1 December 2006 showed a possible stress change/reaction (precursor lesion to stress fracture) of a mid-portion left foot metatarsal.  A 13 December 2006 diagnostic imaging (bone scan) study showed mild stress changes/reactions of the bilateral knees with no evidence of stress fractures (repetitive stress induced fractures).  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 MEB.  The MEB forwarded “bilateral plantar fasciitis” for PEB adjudication. 

The 28 March 2007 Report of Medical Examination for the MEB (DD Form 2808) documented moderate asymptomatic pes planus (flatfoot).  In the 6 April 2007 NARSUM, 5 months before separation, the CI complained of bilateral foot pain that was present 50 percent of the day.  Pain was exacerbated by prolonged standing, prolonged walking, and activity and controlled with Motrin 800 mg 1 or 2 tabs a day.  Symptoms were incompletely relieved with physical therapy (PT), stretching exercises, orthotics, and medication.  There was no surgical indication and the CI declined intervention such as injections for her plantar fasciitis (sole connective tissue inflammation).  The bilateral foot examination revealed tenderness at the insertion of the plantar fascia.  The feet were symmetrical, with appropriate hind foot varus, and significant loss of the nonflexible arches.  Motor (able to fire extensor halluces longus, flexor halluces longus, extensor digit rum, brevis and flexor digit rum), sensory, and neurovascular functions were grossly intact.  Goniometer measured active range of motion (ROM) was foot inversion of 5, foot eversion of 5, forefoot adduction of 15, and forefoot abduction of 10 degrees.  The examiner recounted the findings of the X-rays and bone scan.  Pain was rated as slight and constant per the American Medical Association pain rating guidelines.  The diagnosis listed bilateral plantar fasciitis.  

The panel directed attention to its rating recommendation based on the above evidence.  The panel must first considered whether the right and left foot conditions remained separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 0% rating under an analogous 5310 code (muscle group X injury), citing bilateral plantar fasciitis and rated for slight pain.  There was no VA Compensation and Pension examination or VA rating decision in evidence.  

There is no specific diagnostic code for plantar fasciitis (analogizes to 5020 [synovitis]).  There was no weakness for consideration under 5277 (weak foot).  There was no evidence of sensory pathology for consideration under 5279 (metatarsalgia).  There was no deformity for consideration under 5278 (claw foot), 5280 (hallux valgus), 5281 (hallux rigidus), 5282 (hammer toe), or 5283 (metatarsal bones malunion/nonunion of).  The 5276 (acquired flatfoot) mild (0%) rating indicates symptoms are relieved with orthotics.  The medical examination for the MEB (DD FORM 2808) documented moderate asymptomatic pes planus and the NARSUM documented orthotics, symmetrical feet, appropriate hind foot varus, and significant loss of the nonflexible arches.  There was no severe disability with evidence of marked deformity, accentuated pain on manipulation and use, swelling on use, or characteristic callosities consistent with the severe unilateral/bilateral (20%/30%) rating.  

The panel agreed the condition did not exceed the moderate unilateral/bilateral (10%/10%) rating.  The 5310 code used by the PEB characterizes and rates impairment as slight (0%), moderate (10%), moderately severe (20%), and severe (30%).  All panel members agreed the limitations described and examination findings did not exceed a moderate level and discussed whether the condition more nearly approximated the slight or moderate.  The panel agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion) and the plantar fascia tenderness more closely approximated the moderate (10%) than the moderately severe (20%) rating under 5310 (muscle group X, foot muscles) or 5284 (foot injuries, other).  The panel concluded that the evidence did not provide sufficient grounds for recommending separate disability ratings in this case, and that the combined rating of 10%, coded 5399-5310, is a good analogy to both the pathology and disability.  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 bilateral plantar fasciitis condition, coded 5399-5310.  

BOARD FINDINGS:  In the matter of the bilateral plantar fasciitis condition, the panel unanimously recommends a disability rating of 10%, coded 5399-5310 IAW VASRD §4.71a.  There were 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	
Bilateral Plantar Fasciitis	5399-5310	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150609, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170011787, XXXXXXXXXXXXXXXXXXX

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