RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01450
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060927

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Medical Logistics Specialist, medically separated for “bilateral foot pain” with a disability rating of 0%.  

CI CONTENTION:  The CI contends that her conditions have not improved.  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 – 20060622	VARD – 2000207	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Foot Pain Secondary to Plantar Fasciitis With Finding of Mild Flexible Pes Planus (EPTS)	5399-5310	0%	Bilateral Plantar Fasciitis/Tendonitis	5276	10%	20060915	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral Foot Pain Secondary to Plantar Fasciitis with findings of Mild Flexible Pes Planus.  The PEB rated the bilateral feet as a single unfitting condition coded 5399-5310 (analogous to Group X muscle which includes the plantar fascia) 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.  The panel’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining both feet 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 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.

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral foot pain began in early 2005 and was aggravated by the wear of boots.  She was referred to podiatry (record not in evidence) and issued arch supports which were not used.  She did accomplish the prescribed stretching and used the night splints.  A bone scan on 13 June 2005 did not show uptake of the feet or ankles.  She was then issued custom orthotics (shoe inserts) and underwent steroid injections, but had persistent pain.  The right foot, the more symptomatic, was casted for 4 weeks with no improvement in her symptoms, but with aggravation of the left foot.  X-rays on 13 March 2006 showed bilateral flat feet (pes planus) with some inner (medial) deviation of the 4th and 5th toes.  The podiatrist noted mild spurring of the heel bone (calcaneus) bilaterally, consistent with the plantar fasciitis condition.  As the CI had failed all conservative measures, an MEB was initiated.  

At the 15 March 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported chronic bilateral foot pain without relief from treatment.  The physical examination showed bilateral tenderness of the plantar fascia which was aggravated by toe and heel walking.  The range of motion (ROM) was normal.  

The MEB NARSUM examination dated 26 April 2006, 5 months prior to separation, recorded that the CI had increased pain with activity and standing.  The ROM for the ankles and feet was full, but dorsiflexion (toes up) of the ankles was painful.  The plantar fascia were tender bilaterally.  She was diagnosed with bilateral plantar fasciitis and, right greater than left, flexor digitorum longus tendinitis (the tendon which pulls the toes down).  

At the VA Compensation and Pension (C&P) evaluation performed on 15 September 2006, 2 weeks before separation, the CI reported bilateral plantar fasciitis and bilateral tendinitis of the feet.  She denied limitations in the activities of daily living.  On examination, her gait and posture were normal and no assistive device was in use.  The feet and Achilles tendons were tender bilaterally, but the ankle ROM was full and pain free.  There was no additional limitation with repetition.  X-rays were normal bilaterally both weight bearing and non-weight bearing.  She was diagnosed with bilateral plantar fasciitis and bilateral Achilles tendinitis.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral foot pain condition 0%, analogously coded 5399-5310 (Group X muscle injury), citing slight muscle injury.  The VA combined the bilateral plantar fasciitis and bilateral Achilles tendonitis for rating which was 10%, coded 5276 (flatfoot, acquired), based on the VA C&P examination 2 weeks before separation, citing pain on manipulation and use of the feet.  The rater noted that the symptoms were similar (and implied that they were not severable).  

The panel first considered if the bilateral plantar fasciitis condition should be severed into 2 unfitting conditions.  While the right foot was more symptomatic and casted, both were profiled, treated with orthotics and splinting, and both (apparently) were injected.  The panel agreed that the evidence reasonably justified that the functional limitations of the each foot independently contributed to the CI’s inability to perform her military duties and accordingly a separate disability rating for each foot is recommended.  

The panel then considered the evidence for rating.  It noted that the primary limitation was from the plantar fasciitis for which the CI had been treated for over a year.  The ROM of the ankles and feet was normal as was the gait.  The podiatrist noted that there was also flexor digitorum longus tendinitis on the MEB NARSUM and the VA examiner diagnosed bilateral Achilles tendonitis, which was not recorded by either the MEB or PEB.  While the CI carried multiple diagnoses for the feet, the limitations overlapped and were not severed by the examiners.  The panel noted that the assignment of the same findings to multiple conditions is a violation of VASRD §4.14 (avoidance of pyramiding).  The panel determined that the plantar fasciitis diagnosis best fit the clinical picture.  No specific code for plantar fasciitis is found in the VASRD.  The VA rated the CI for bilateral pes planus.  The panel observed that this was not always evident and mild when present on either examination or X-ray.  The PEB used the code 5310 which includes the plantar aponeurosis (plantar fascia).  A single rating of 0% (slight) was assigned.  The panel observed that the CI had a normal gait, but significant tenderness which limited activity.  This was determined to be more consistent with a moderate impairment for each foot.  After due deliberation, and considering all of the evidence, the panel recommends a disability rating of 10% for the right foot condition and 10% for the left foot condition, analogously coded 5399-5310.  

BOARD FINDINGS:  In the matter of the bilateral foot conditions, the panel unanimously recommends that each foot be separately rated at 10%, coded 5399-5310, IAW VASRD §4.71a. and 4.73.  

There were no other conditions within the Board’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	
Left Foot	5399-5310	10%	
Right Foot	5399-5310	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150617, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170008504, 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