RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01481
BRANCH OF SERVICE:  NAVY 	SEPARATION DATE:  20020703

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Information Systems Technician Seaman, medically separated for “conversion disorder” with a disability rating of 0%.  

CI CONTENTION:  The CI requested that all conditions be reviewed and noted that her blackouts have increased and caused secondary injury that make her unable to work, and that she requires a caregiver and is unable to drive.  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 - 20020306	VARD - 20020817	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Conversion Disorder	9425	0%	Near Syncope	8999-8910	0%	20010820	
Near Syncopal Episodes	Cat II					
Nonresolving Subjective Pain of Bilateral Plantar Fascia	Not Unfitting	Left Foot Strain	5284	10%	20010820	
Bilateral Flexible Cavus Deformity	Not Unfitting	Right Foot Strain	5284	10%	20010820	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Conversion Disorder.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s conversion disorder condition began in December 2000.  On 4 December 2000 the CI was seen in the Emergency Room (ER) after slipping in the shower where she struck her head and had a loss of consciousness.  On examination there was swelling and bruising to the left frontal area with a 1/2 cm superficial laceration to the lateral aspect of the eyebrow.  Computerized tomography (CT) of the head was negative.  In January 2001 the CI noted dizziness from Vioxx (rofecoxib, a nonsteroidal anti-inflammatory drug (NSAID)).  An undated ER note indicated the CI complained of black out episodes with loss of vision and consciousness for 1 minute without falling.  She reported seven similar episodes since December mostly in the early morning or evening.  An EKG (electrocardiogram) earlier in the day showed a normal sinus rhythm and a sinus arrhythmia.  On 17 January 2001, neurologic evaluation noted no post-ictal period, loss of urine, tongue biting, or loss of consciousness.  The CI stated she was aware of the events and her surroundings, but was not capable of averting an episode from proceeding.  Examination was normal except the CI walked with a limp due to plantar fasciitis.  On 25 January 2001, internal medicine evaluation noted the syncopal episodes were unlikely cardiogenic or neurologic in nature, but were likely secondary to hypoglycemia.  On 28 February 2001, the CI reported being involved in a motor vehicle accident 5 days earlier at which time she was a rear seat restrained passenger.  There was no loss of consciousness.  She initially felt fine, but noted back pain.  Chest X-rays and thoracic and lumbar spine series showed no evidence of fracture.  Treatment consisted of Vicodin (hydrocodone, a narcotic and APAP (acetaminophen, a pain reliever) for lumbar and thoracic paraspinal muscle strain.  On 27 March 2001, neurology consultant noted that a full workup including magnetic resonance imaging (MRI) of the brain and entire spine was within normal limits as were an electroencephalogram (EEG) and full laboratory studies.  The neurologist very seriously doubted a primary central nervous system cause of her symptoms.  He highly suspected near-syncope from non-neurogenic cause such as a vasovagal etiology since the events occurred upon awakening and were so brief.  A trial of Neurontin (gabapentin) as a neural stabilizer was prescribed.  In May 2001, the CI had an episode of chest pain, which was felt to be costochondritis (inflammation of the cartilage between the ribs and sternum).  Neurontin, which aggravated the condition and increased the number of events to twice a day, was discontinued.  A tilt test and echocardiogram were normal.   

The 31 May 2001 MEB NARSUM examination, 14 months prior to separation, noted complaints recurring near-syncopal episodes.  Physical examination showed a well-developed, well-nourished, well-hydrated female in no acute distress, who was alert and oriented times three.  She was lucid and fluent.  Neurologic evaluation was unremarkable, but her gait was noteworthy for a limp due to chronic plantar fasciitis (see below).  The glucose level on 7 June 2001 was 85 mg/dl (normal 75-110).  During the 11 June 2001 MEB examination (recorded on SF Forms 93 and 88 and DD Form 2697), 13 months prior to separation, the CI reported tunnel vision and loss of feeing and sight.  The examiner reported no findings on physical examination, but noted the CI had blackouts on DD Form 2697.  The non-medical assessment (NMA) dated 3 July 2001 indicated the CI had not been on full duty status since 22 December 2000; however, she acquired the necessary skills to perform as a capable watch stander and was able to accomplish routine tasks, but required supervision.  Furthermore, her job assignment in the administrative department was deemed not appropriate for her rate/rank. 

At the 20 August 2001 VA Compensation and Pension (C&P) evaluation, 11 months before separation, the CI reported “tunnel vision,” and  sensations of “can’t feel body, pins and needles and vertigo (spinning or dizziness).  Physical examination was normal, although no neurologic evaluation was in evidence.  Hearing was within normal limits.  On 18 September 2001, the CI reported symptom frequency decreased to once a week since implementing a high carbohydrate diet.  The examiner raised a psychogenic versus a hypoglycemic induced etiology and the CI was to use a glucometer to check her sugar level.    

The 5 October 2001 Internal Medicine MEB Addendum, 9 months prior to separation, noted the CI was seen no less than five times for evaluation of presyncopal and syncopal episodes.  Multiple orthostatic vitals and EKGs, tilt table testing, Holter testing, and echocardiography were normal as were laboratory studies.  An MRI, EEG, and an ophthalmologic evaluation failed to reveal an etiologic cause for the episodes.  No organic etiology could be found for the CI’s presyncopal spells. Given the frequency of the spells, the examiner was concerned that that CI would be unable to perform her duties.  Glucose levels ranged from 45-152 mg/dl and most were greater than 100 mg/dl and were not associated with symptoms, although the CI did not have any syncopal episodes within almost a month earlier.  

The 14 February 2002 MEB Psychology Addendum, 5 months before separation, noted symptoms over several months including headaches, forgetfulness, dizziness, loss of consciousness, loss of vision, ringing in the ears, change in appetite, and constipation.  At the time of the examination the CI reported she was pregnant and noted decreased sleep, increased weight, changes in appetite and decreased energy.  She reported no suicidal or homicidal ideation and had not been prescribed medication for psychological, emotional or drug problems.  Neurontin increased her syncopal episodes for one to two a day to eight a day.  The examiner noted that the episodes never happened while driving and she never hurt herself falling down; and she did not get “too concerned about it [the episodes].”  The psychologist noted those symptoms were consistent with a conversion disorder and a precipitating stress was “her husband going out to sea.”  The psychologist noted the CI was under-reporting her concerns or was truly under-concerned with her symptoms; and, at the same time, was overdefensive, which was consistent with a conversion disorder.  He concluded that the syncopal-like episodes, based on medical findings, the interview and psychological testing, were most likely a conversion disorder.  At a psychology visit on 13 May 2002 the CI reported she was still having syncopal episodes once a week either early in the morning or late at night.  She denied any psychological distress--no depressed mood, no anxiety, and no anhedonia.  On examination she was alert and oriented, well groomed, and in moderate distress (32 weeks pregnant).  Speech was normal in rhythm, rate and tone.  Affect was dysthymic and in the normal range.  Thought processes were linear, logical, and goal directed. Thought content indicated there was no homicidal ideation, psychosis, mania, or focus on stressors.  The CI denied suicidal ideation, plan or intent and contracted for safety.  Cognitive functioning, judgment, and impulse control were intact and insight was fair.  The examiner noted the CI’s level of function represented a significant improvement in her level of functioning since the prior assessment and her Global Assessment of Functioning (GAF) score was 61-70 (some mild symptoms).   

At a 7 February 2003 VA examination for epilepsy and narcolepsy, 7 months after separation,  the CI reported recurrent syncopal spells or fainting spells for about 1½  years without a pattern or trigger mechanism.  Workup studies included an EEG, EKG, MRI, Holter monitor, tilt table evaluation of her blood pressure as well as a glucose tolerance test were all normal.  Neurologic examination was unremarkable.  The examiner’s impress was chronic conversion reaction spells with minimal disability and no progression.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the conversion disorder condition 0%, coded 9425 (hypochondriasis).  The PEB listed the near syncopal episodes condition as a related diagnosis (Category II) contributing to the disability in this case.  The panel concluded the Category II diagnosis was not a separate condition which could be reasonably justified as separately unfitting nor would a separate rating be achievable without violation of VASRD §4.14 (avoidance of pyramiding).  The VA did not rate the conversion disorder condition, but rated the near syncope 0%, coded 8999-8910, for near syncope, based on the C&P examination 11 months before separation.  

Members noted the PEB used code 9425; however, VASRD code 9424 (conversion disorder) is more applicable, albeit both codes 9425 and 9424 are in the group of somatoform disorders.  Nevertheless, the PEB rating of 0% requires:  “A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication.”  However, according to the NMA, the CI’s assignment was not appropriate for her rate/rank and she needed supervision for routine tasks.  Therefore, a 10% rating, which requires “Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication” is more applicable because the CI’s symptoms were transitory with an uncertain etiology, and when she did have the presyncopal or syncopal episodes, there was a decrease in work efficiency.  Panel members agreed that the condition did not rise to a 30% rating that requires:  “Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events).”  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 conversion disorder condition, coded 9424.  

Contended Category III PEB Conditions:  Nonresolving Subjective Pain of Bilateral Plantar Fascia and Bilateral Flexible Cavus Deformity.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended Category III conditions (conditions that are not separately unfitting and do not contribute to the unfitting conditions) were not unfitting.  The CI was on limited duty for plantar fasciitis; however, the NMA did not address either condition.  On 23 January 2001, the CI was seen for plantar fasciitis with most pain at the mid arch area.  There was moderate tenderness to palpation bilaterally of the plantar fascia with cavus (high arch) of the central slip (plantar aponeurosis-thickened band of deep fascia) of the left foot most prominent.  A note dated 1 February 2001 indicated the CI had bilateral plantar fasciitis, right greater than the left, since July 2000.  The CI described the pain as needles shooting into the foot and cramping.  She had difficulty running and walking and had no success with arch supports.  On examination she had tenderness bilaterally over the medial arches.  A note dated 13 February 2001 indicated the CI was previously treated with iontophoresis (electrical stimulation to deliver medication), but she had pain with weight bearing greater than 20 minutes.  On 20 February 2001, the CI was again treated with iontophoresis, heat, ice, and stretches.  In April 2001, the CI noted worsening of pain with activity and had an antalgic gait.  Dorsiflexion of the left was 14 degrees (normal 20) and on the right 4 degrees.  The examiner noted the CI may have had sympathetic involvement.  At the 31 May 2001 NARSUM examination her gait was noteworthy for a limp due to chronic plantar fasciitis.  An Addendum to the Neurology MEB dated 12 July 2001 noted the CI complained of plantar fasciitis and her condition had not improved despite her limited duty status and conservative treatments.  Examination revealed the CI stated that she had moderate tenderness to palpation of the bilateral plantar fascia, especially at the medial central slip bilaterally.  There was no edema, erythema (redness), ecchymosis (black and blue marks), or effusion.  No cellulitis was present and gross neurovascular status was intact bilaterally.  Dermatological status was within normal limits.  Muscle strength and ankle range of motion (ROM) was within normal limits and intact bilaterally.  The CI did exhibit a mild flexible cavus foot type deformity bilaterally.  She did exhibit a prominent medial central plantar fascial slip bilaterally.  The impression was the CI experienced chronic plantar fasciitis secondary to her semi- flexible pes cavus deformity.  The CI was on limited duty status until 13 February 2001 when she complained of the same symptoms.  Physical examination revealed that all parameters were within normal limits and she still complained of nonresolving subjective pain to her bilateral plantar fascial bands secondary to her prolonged standing and walking as required by her job.  On 3 April 2001 the CI stated that no matter what form of rehabilitation therapy and reconditioning exercises were prescribed, none had been effective.  The examiner’s final diagnosis was nonresolving subjective pain of bilateral plantar fascia with bilateral flexible cavus deformity that existed prior enlistment and was service aggravated.  The senior member of the Addendum to the Neurology MEB, a podiatrist, indicated the CI was not fit for continued duty. 

The CI addressed several issues related to the plantar fasciitis in a rebuttal to the podiatry addendum dated 27 July 2001.  She noted she did have “low dye taping” and a cast on her right foot for about a month after she started having problems in early July 2000.  She further noted the “condition was not prior to enlistment.”  The CI had a second podiatry opinion on 23 August 2001 for the bilateral diffuse foot pain, which started during boot camp without an injury or trauma.  Inserts, physical therapy and NSAIDs provided no relief.  On examination the CI had pain with the slightest touch to the bilateral plantar surfaces diffusely and she was unable to dorsiflex secondary to pain.  She also had an antalgic gait secondary to pain.  Daily calf strengthening and no barefoot activity was recommended.  Surgery and cortisone injections were not indicated secondary to pain being diffuse.  Furthermore the examiner recommended administrative separation from the Navy.  

Panel members first discussed whether the conditions were unfitting.  The podiatrist, who authored the Addendum to the Neurology MEB indicated the CI was not fit for further full duty, while the podiatrist, who rendered the second opinion, recommended administrative separation from the Navy.  Panel members noted that the CI had pain in her feet with walking and running and had been on limited duty for plantar fasciitis secondary to bilateral flexible cavus deformity.  Therefore, panel members determined the CI unfit for the bilateral plantar fasciitis that was unresponsive to conservative treatment.  Members discussed rating options and noted that the bilateral plantar fasciitis and the bilateral flexible cavus deformity were combined as single unfitting conditions.  The approach by the PEB commonly 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 directed at determining if the PEB’s approach of combining conditions was justified.  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.  The evidence for the bilateral plantar fasciitis and bilateral flexible cavus deformity conditions was presented together above.  First, panel members determined that code 5399-5310 (analogous to Group X Function:  Movements of the forefoot and toes…) was the most appropriate code for plantar fasciitis as compared to 5284 (foot injuries), 5299-5276 (flatfoot, acquired), and 5099-5003 (analogous to arthritis, degenerative), and that the level of disability level was at least moderate, since the CI had difficulty and pain with walking and running, but not moderately severe since there was no trauma, injury or surgery and the etiology was noted to be as a result of the bilateral flexible cavus deformity.  Therefore, a 10% rating for the right foot and a 10% rating for the left foot was considered by panel members.  Since the bilateral flexible cavus deformity contributed to the bilateral plantar fasciitis, members determined that the flexible cavus deformity of each foot represented a Category II condition (conditions that contribute to the unfitting conditions).  Panel members concluded the Category II diagnosis was not a separate condition which could be reasonably justified as separately unfitting nor could a separate rating be achievable without violation of VASRD §4.14 (avoidance of pyramiding).  

After due deliberation, the panel agreed that the preponderance of the evidence with regard to the functional impairment of bilateral plantar fasciitis favors its recommendation as additionally unfitting conditions for disability ratings.  Right foot plantar fasciitis is appropriately coded 5399-5310 and meets the VASRD §4.73 criteria for a 10% rating and left foot plantar fasciitis is appropriately coded 5399-5310 and meets the VASRD §4.73 criteria for a 10% rating.  

BOARD FINDINGS:  In the matter of the conversion disorder condition, the panel unanimously recommends a disability rating of 10%, coded 9424 IAW VASRD §4.130.  In the matter of the contended right foot plantar fasciitis condition, the panel unanimously agrees that it was unfitting and recommends a disability rating of 10%, coded 5399-5310 IAW VASRD §4.73.  In the matter of the contended left foot plantar fasciitis condition, the panel unanimously agrees that it was unfitting and recommends a disability rating of 10%, coded 5399-5310 IAW VASRD §4.73.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Conversion Disorder	9424	10%	
Bilateral Plantar Fasciitis, Right Foot	5399-5310	10%	
Bilateral Plantar Fasciitis, Left Foot	5399-5310	10%	
COMBINED W/ BIL FACTOR	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150616, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve Affairs)
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 13 Oct 17 ICO XXXXXXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 20 Sep 17 ICO XXXXXXXXXXXXXXXXXXX  
	(d) PDBR ltr dtd 28 Sep 17 ICO XXXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 28 Sep 17 ICO XXXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 11 Apr 17 ICO XXXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 16 Jun 17 ICO XXXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 25 Sep 17 ICO XXXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 20 Sep 17 ICO XXXXXXXXXXXXXXXXXXX 

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (i) are approved.  The official records of the following individuals are to be corrected as follows:

     a. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     b. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.

     d. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.

     e. XXXXXXXXXXXXXXXXXXX, former USN: Placement on Temporary Disability Retired List with a 60 percent disability rating for six months at time of separation followed by a permanent disability rating of 20 percent.

     f. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 0 percent) effective date of discharge.

     g. XXXXXXXXXXXXXXXXXXX, former USMC: Placement on Temporary Disability Retired List with a 50 percent disability rating for six months at time of separation followed by a permanent disability rating of 10 percent.

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

     h. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 
     
3.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.

                                  XXXXXXXXXXXXXXXXXXX
                                  Principal Deputy, Assistant Secretary
                                  Of the Navy (Manpower and Reserve Affairs)	
                                  Performing the Duties of Assistant 
                                  Secretary of the Navy 
                                  (Manpower and Reserve Affairs)