RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01537
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051003

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a mobilized Army Reserve E4, Motor Transport Operator, medically separated for “chronic bilateral foot pain,” with a disability rating of 0%.

CI CONTENTION:  The CI’s foot still causes pain.  His 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 - 20050803	No VA Claim	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Foot Pain	5399-5310	0%	NA	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Chronic Bilateral Foot Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI experienced an atraumatic onset of left foot pain in January 2004.  He was treated with temporary casting and a trial of crutches, but the pain persisted even with orthotics and other non-invasive modalities.  Diagnostic imaging (serial X-rays, bone scan, MRI) yielded some non-specific findings but did not identify any specific pathology.  Nearly all STR entries were confined to treatment of the left foot and addressed a diagnosis of left plantar fasciitis.  There were two podiatry entries late in the course that noted a diagnosis of bilateral plantar fasciitis, near or soon after the time that an MEB was initiated for the left foot; but, there was no elaboration of symptoms and no directed examinations of the right foot in evidence.  The only ankle range of motion (ROM) evidence in the Service file was a physical therapy entry in June 2004 (16 months before separation) that documented 0 degrees of dorsiflexion (normal 20) and normal plantar flexion.  There was no corroboration in STR clinical entries of an antalgic gait or use of an assistive device (as noted below in the NARSUM).  Surgery and injections were discussed and refused (provider controversy regarding whether that was reasonable).  A protracted trial of conservative treatment did not result in sufficient improvement to allow unrestricted duty, and the CI was referred for an MEB which in turn forwarded “bilateral plantar fasciitis” to the PEB.

The NARSUM examination on 29 June 2005 (3 months before separation) documented bilateral foot pain (no distinction right versus left) that varied “from 2/10 at rest to 7/10 after walking.”  The examiner noted a 10-minute walking tolerance, intolerance of boots or prolonged standing, and that the CI “uses a cane to reduce the left heel strike.”  The physical examination recorded an antalgic gait and “bilateral pes planus with bunion deformity and tenderness of heels left worse than right.” 

The commander’s performance statement did not provide evidence probative to separate fitness implications of either foot (or whether unilateral or bilateral), and the profile was for “plantar fasciitis” (unilateral or bilateral not specified).  There was no VA claim, evaluation, or treatment; and, there was no other post-separation evidence in this case.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated analogously to code 5310, the muscle disability code for Group X (movements of forefoot and toes).  Bilateral rating under this code, however, is not compliant with VASRD §4.55 (principles of combined ratings for muscle injuries) which stipulates that each muscle group must be rated separately.  The Board’s initial charge was to determine whether a recommendation for separate ratings of each foot was appropriate.  In that regard, the Board provides the following clarification concerning its approach to PEB consolidated ratings.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting and that there was no need for separate fitness adjudications.  Furthermore, bilateral rating is offered under some foot codes, and that approach does not necessarily violate the VASRD §4.7 directive to choose the higher of two valid ratings.  When considering a separate rating for each foot, the Board considers each one to be reasonably justified as separately unfitting unless a preponderance of evidence indicates it would not cause the member to be referred into the disability evaluation statement or be found unfit because of physical disability.  

The evidence makes clear that the left foot was associated with significantly more disability than the right one in this case.  The disparity was such that the question was raised of whether the right foot was reasonably justified as separately unfitting.  The STR indicated that the right foot became incidentally symptomatic concurrent with MEB proceedings for the left foot.  The NARSUM did not accurately reflect the dominantly unilateral clinical course detailed in the STR; and, it could be reasonably concluded from the source STR clinical evidence (unrefuted by the profile or commander’s statement) that the degree of acuity manifested by the right foot alone would not have precipitated MEB proceedings and resulted in separation.  After due deliberation, members agreed that there was insufficient performance-based evidence to support a conclusion that the functional impairment from the right foot alone would have rendered the CI unable to perform his duties; thus, it was not eligible for separate service rating.  

Having so concluded, the members turned to deliberation of the appropriate code and rating for the unfitting left foot.  The PEB’s analogous 5310 muscle code (albeit incompatible with bilateral rating) is commonly applied and appropriate for plantar fasciitis.  Code 5310 offers additional ratings of 10% for “moderate,” 20% for “moderately severe,” and 30% for “severe” disability.  Analogous rating under code 5276 (flatfoot, acquired [pes planus]) was considered, but the criteria for ratings higher than 10% are quite specific and not satisfied by the evidence; thus, it was not favorable.  Analogous rating under code 5284 (foot injuries, other) was likewise not favorable, offering an equivalent rating scale to that for 5310.  There are no additional coding options under the VASRD which are applicable to this case, even for analogous rating, and members deliberated the appropriate rating under code 5310.  Members agreed that the disability in evidence supported a rating higher than 0% for slight disability, but that it did not reasonably reflect severe disability for a 30% rating.  Although there may have been a persistent gait disturbance and fairly significant functional limitations reported at separation, the overall clinical acuity associated with the diagnosis of plantar fasciitis (as well-established in this case) is typically neither permanent nor severe.  Members thus concluded that the evidence was better aligned with the 10% criterion of moderate disability.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a 10% rating for plantar fasciitis of the left foot under code 5399-5010, and agreed that the right foot was not reasonably justified as separately unfitting for service disability rating.  

BOARD FINDINGS:  In the matter of the PEB-combined bilateral plantar fasciitis condition, the Board unanimously recommends a rating of 10% for an unfitting left foot condition coded 5399-5310 IAW VASRD §4.73; and, unanimously agrees that the right foot condition was not reasonably justified as separately unfitting and thereby not subject to Service disability rating.  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 his prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Plantar Fasciitis, Left Foot	5399-5310	10%	
Plantar Fasciitis, Right Foot	Not Unfitting	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150618, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB										

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

20 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170001288 (PD201501537)

1.  I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a, accept the Board’s recommendation to modify the individual’s disability rating to 10% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA