RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01217
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030522

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 “bilateral foot pain” and “bilateral Achilles tendinitis,” rated 0% and 0%, respectively, with a combined disability rating of 0%.  

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 – 20030319 	VARD – 20030602 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral foot pain…	5399-5310	0%	Pes Planus Plantar Fasciitis, Left Foot	5310-5276	10%	20030430 	
			Pes Planus Plantar Fasciitis, Right Foot	5310-5276	10%	20030430	
Chronic Bilateral Achilles tendinitis…	5024	0%	Achilles Tendonitis, Right Ankle	5271-5024	10%	20030430	
			Achilles Tendonitis, Left Ankle	5310-5271	10%	20030430	
MDD, Single Episode	Not Unfitting	Major Depression Without Psychosis	9434	30%	20030430	
Mechanical LBP	Not Unfitting	Lumbosacral Strain	5295	10%	20030430	
		Thoracic Strain	5291	0%	20030430	
Mild Bilaterally Patellar Enthesopathy…	Not Unfitting	Bilateral Patellar Enthesopathy	5260-5015	10%	20030430	
Bee Sting Allergy	Not Unfitting	Allergic Rhinitis	6522	0%	20030430	
Hypercholesterolemia	Not Unfitting	No VA rating	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:    

Bilateral Foot Pain/Achilles Tendonitis. The PEB rated the bilateral foot pain, attributed to flat feet (pes planus), and bilateral Achilles tendinitis separately.  However, the CI was evaluated at most clinical appointments for both plantar fasciitis and Achilles tendinitis.  The histories and treatment for these conditions are therefore intertwined.  Accordingly, these are presented together, but then separated for rating purposes.

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI was noted to have asymptomatic, mild pes planus on the accession examination dated 23 January 2001.  The first record in evidence for an evaluation of the feet was dated 2 October 2001.  He reported a history of bilateral heel and plantar foot pain for over 3 months.  He was thought to have bilateral plantar fasciitis and referred to physical therapy (PT), given duty restrictions, and put on medications.  There, on 4 December 2001, he was also noted to have a bilateral Achilles tendinopathy and orthotics (shoe inserts) were issued.  He also began treatment in PT.  On follow-up 1 month later, both conditions were resolving.  He was continued on PT and duty restrictions.  However, a month after that, he reported an increase in his symptoms due to overuse.  Bilateral weight-bearing X-rays of the feet on 12 March 2002 showed a small spur of the left Achilles and bilateral os peroneum (an accessory bone in the peroneus longus tendon of the foot; this can be painful).  The X-rays were otherwise normal.  The CI then had bilateral injections with improvement until he had field training with exacerbation of his symptoms.  An MRI of the Achilles tendons on 9 July 2002 was normal.  On follow-up in podiatry on 29 August 2002, the CI reported ongoing pain despite treatment.  He was placed in a cast without resolution of the pain.  At the 12 November 2002 follow-up in podiatry, the CI was then referred for an MEB due to continued Achilles tendonitis with a heel spur.  The CI was also diagnosed with bilateral plantar fasciitis in podiatry on 5 December 2002.  A weight bearing X-ray of both feet was essentially unchanged.  The MEB NARSUM examination was dated 31 January 2003, 4 months prior to separation.  The CI reported problems with both feet since September 2001 which began after running.  The examiner recorded that the symptoms had progressed despite PT, medications, injections, walking boots, and casting.  It was noted that the CI had fractured both ankles in the mid 1980’s prior to service, but had no sequelae from these injuries.  The 73 inch CI weighed 230 pounds.  The examination of the feet showed pain at the insertions of the Achilles tendons (into the heels) bilaterally as well as bilateral pain over the plantar fascia and heel bones (calcanei).  Dorsiflexion (toes up) was reduced to 10 degrees bilaterally and painful.  Swelling was absent.  The range of motion (ROM) on the 12 March 2003 PT evaluation was full and without restriction.  The CI noted that his pain had decreased with a reduction in activity level.  The MEB forwarded “chronic bilateral Achilles tendonitis”, “bilateral plantar fasciitis” and “bilateral pes planus” for PEB adjudication.  

At the VA Compensation and Pension (C&P) evaluation performed on 30 April 2003, 1 month before separation, the CI reported ongoing bilateral foot pain aggravated by activity.  He used medications with improvement, but did not use an assistive device.  He displayed a painful gait.  Palpation of both the area of the insertion of the plantar fascia into the heels and the Achilles tendons was uncomfortable.  The ROM was reduced in dorsiflexion and plantar flexion (toes down) to 15 and 30 degrees (VA normal 20 and 45 degrees), respectively.  The ROM examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Ankle ROM
(Degrees)	MEB ~2 Mo. Pre-Sep	VA C&P ~1 Mo. Pre-Sep	
	Left	Right	Left	Right	
Dorsiflexion (20 Normal)	Full and Unrestricted	15	15	
Plantar Flexion (45)		30	30	
Comment	Pain decreased with decreased activity	 pain, antalgic gait, tenderness 	
§4.71a Rating	0%	0%	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral foot condition 0%, combining the two MEB conditions, bilateral pes planus and bilateral plantar fasciitis.  The bilateral foot pain condition was analogously coded 5310 (Group X. Function: Movements of forefoot and toes).  The PEB cited mild pes planus, which was an EPTS (existed prior to service) condition, permanently service aggravated.  The chronic bilateral Achilles tendinitis was rated 0% and coded 5024 (Tenosynovitis).  The PEB cited an insidious onset, unresponsive to medical therapy.  It was rated as tenosynovitis without loss of joint motion of the ankles.  The VA rated the left and right foot pes planus, plantar fasciitis at 10% each, analogously coded 5310-5276 (flatfoot, acquired).  It rated the right Achilles tendonitis 10%, coded 5271-5024 (Ankle, limited motion of and tenosynovitis), and left Achilles tendonitis 10%, coded 5310-5271, based on the VA C&P examination 1 month before separation.  It is not clear why the VA examiner used different coding options for each foot for the Achilles tendonitis condition.  

The Board considered the evidence with application of VASRD §4.14 (avoidance of pyramiding).  The Board observed that while there were multiple diagnoses for the feet and ankles, there was a common disability painful and limited gait.  The objective findings include a painful gait, pain at the insertions of the plantar fascia into the heel, pain at the Achilles tendon insertion into the heels, essentially normal X-rays of the feet and a normal MRI of the Achilles tendons.  A bony spur was noted on the left heel on X-rays of the feet, but not seen on X-rays of the ankles, which were normal, or noted on the MRI.  The ROM of the ankles was reduced on the MEB examination, full and unrestricted a few months later in PT, and then slightly limited by pain at the VA C&P a few weeks after that.  A 10% rating for each foot (for the combined conditions) is supported by the codes 5024 and 5271 for painful and limited motion.  A 10% rating is support for both feet under the code 5276 for pain with manipulation of both feet.  The code 5310 also supports a 10% rating for each foot for painful and limited motion.  The Board recognized that the VA assigned compensable ratings for each condition for each foot, but determined that the contributions to the painful gait was not severable between the different clinical diagnoses.  While the CI was tender over the plantar aspect of the foot and over the insertion of the Achilles tendon, the MRIs of the Achilles tendons were, in fact, normal.  The Board therefore assigned the combined disability to the bilateral foot conditions and recommended a rating of 10% for each foot, coded 5310, for a combined rating of 20% with application of the bilateral factor.  The Board recommended no change in the PEB adjudication for the bilateral Achilles tendonitis conditions.  

Contended PEB Conditions:  Mechanical Low Back Pain, Mild Bilaterally (sic) Patellar Enthesopathy with Chronic Knee Pain, Bee Sting Allergy, Hypercholesterolemia, and Major Depressive Disorder (MDD), Single Episode.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  The bee sting allergy and hypercholesterolemia conditions were not profiled, implicated in the commander’s statement, or judged to fail retention standards.  There was no performance-based evidence from the record that either of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for either of these contended conditions and so no additional disability ratings are recommended.  

The MDD was profiled, and was judged to fail retention standards; however, it was not implicated in the commander’s statement.  The commander noted that the CI performed administrative functions and had done so adequately.  The CI had been symptomatic for 6 months at the time of the MEB evaluation.  Multiple recent stressors were noted including the MEB process and imminent separation, health issues in both parents, recent geographical separation from his children, and his wife’s pregnancy.  The examining psychiatrist noted that while the CI did not currently meet retention standards, he had not yet been treated and was expected to improve with treatment.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for MDD and so no additional disability rating is recommended.  

The knee and back conditions were not profiled, but were mentioned in the commander’s statement and were judged to fail retention standards.  However, there was no performance-based evidence from the record that the back and bilateral knee conditions significantly interfered with satisfactory duty performance at separation.  The Board did not find any clinical entries for the knee pain in the year leading up to separation.  An X-ray was done, but as part of the MEB process.  It showed small bony projections into the patellar (kneecap) tendons from the thigh.  The knees themselves were normal.  One entry was found for the low back pain (LBP) condition in 2001 and another in June 2002.  Both were for an acute sprain.  There were no further entries until an X-ray done for the MEB; it was normal.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the back and bilateral knees and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the bilateral foot pain condition, the Board unanimously recommends a disability rating of 10% each, coded 5310, IAW VASRD §4.71a.  In the matter of the bilateral Achilles Tendonitis conditions and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended MDD, bee sting allergy, hypercholesterolemia, mechanical low back pain, and mild bilaterally patellar enthesopathy with chronic knee pain conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 foot pain…	5310	10%	
Right foot pain…	5310	10%	
Chronic Bilateral Achilles tendinitis…	5024	0%	
COMBINED	20%	

The following documentary evidence was considered:

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

AR20170005813, 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