RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02094
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060713

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

CI CONTENTION:  His condition continues to worsen and impact his daily activities.  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 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 - 20060324	VARD - 20060715	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Foot Pain	5099-5003	0%	Plantar Fasciitis, Right Foot	5099-5020	0%	20050428	
			Planta Fasciitis, Left Foot	5099-5020	0%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Bilateral Foot Pain.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral foot pain condition began in September 2003 after falling seven to eight feet during obstacle course training.  Treatment for plantar fasciitis consisted of nonsteroidal anti-inflammatory drugs (NSAIDs).  Custom orthotics were prescribed in November 2004.  X-rays of the feet on 8 December 2004 were normal.  The CI had multiple visits for plantar fasciitis between December 2004 and June 2005 during which time he received three steroid injections, orthotics and profiles without relief.  At a podiatry visit on 8 August 2005 the CI was felt to be a poor surgical candidate for his bilateral symptomatic plantar fasciitis.  A podiatry note dated 16 August 2005 indicated the CI failed all nonoperative treatment and continued to have pain on the medial aspect of his plantar arch.  On examination his skin was normal and his neurovascular status was grossly intact.  Bilateral ankle, subtalar joints, and midfoot ranges of motion (ROMs) were normal.  Pes cavus was present bilaterally.  Tenderness to palpation was along the medial plantar tubercle (inner heel) and along the medial and central bands of the plantar fascia.  X-rays indicated an elevation in the calcaneal inclination angle of about 27 degrees (normal 18-22).  

Despite treatment, the bilateral foot pain condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “chronic bilateral foot pains due to symptomatic pes cavus and plantar fasciitis” for PEB adjudication.

During the 10 January 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported plantar fasciitis and pes cavus (high instep/arch) and a history of childhood leg brace use to correct pigeon toes.  The examiner noted prominent pes cavus.  There was tenderness noted along the medial plantar tubercle and along the medial and central bands of the plantar fascia.  X-rays of the feet in January 2006 were normal.  The 1 February 2006 MEB NARSUM examination, 5 months prior to separation, noted complaints of aggravating and constant foot pains.  Physical examination revealed stable ankles bilaterally.  Prominent pes cavus was noted bilaterally.  There was no skin discoloration and no edema.  Neurovascular status was normal.  Tenderness was noted along the medial aspects of the plantar arches bilaterally, the medial tubercles bilaterally and on the medial aspects and central bands of the plantar fascia.  Pain was noted in plantar flexion and dorsiflexion of both feet.  Pain was noted in plantar inversion of the right foot and absent in the left.  Pain was also present in the plantar eversion of the left and absent in the right.  No limitations of movement noted.  The examiner’s diagnosis was chronic bilateral foot pains due to symptomatic pes cavus and plantar fasciitis.  The commander’s statement dated 6 February 2006 indicated the CI was issued a permanent profile in August 2005 for bilateral foot pain with limitations of no running, no marching over 1/4 mile, and no physical training.    

At the 28 April 2006 VA Compensation and Pension (C&P) evaluation, 3 months before separation, the CI reported pain located on the bottom of the feet constantly, which radiated to his ankles.  Physical examination revealed a normal gait.  The CI did not require an assistive device for ambulation.  The right and left feet were tender.  Pes planus and pes cavus were not present.  No hammer toes were present nor was Morton’s metatarsalgia.  There was no hallux valgus or hallux rigidus.  The CI did not have any limitation with standing and walking.  He required foot supports, but symptoms and pain were not relieved by corrective shoe wear.  Muscles and joints of the feet were normal.  Non-weight bearing X-rays of the feet were normal.  The examiner’s diagnosis was plantar fasciitis, bilateral feet based on the subjective factors of pain, weakness, and stiffness and the objective factors were tenderness, bilateral feet and foot support.  A C&P examination on 23 August 2007, 13 months after separation revealed right and left foot tenderness without painful motion and gait was normal.  Neurologic evaluation for pain in both feet and the finding of a positive Tinel’s sign (to determine nerve irritation) at the posterior tibial nerve bilaterally in October 2007, 15 months after separation, revealed no weakness or atrophy, brisk reflexes and intact sensation.  Electrodiagnostic studies of the nerves of the feet revealed no evidence of a focal or generalized neuropathy and a normal right abductor hallucis muscle (involved in abduction and flexion of the great toe).  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral foot pain condition 0%, coded 5099-5003 (arthritis, degenerative), citing no limitation of movement and rated as slight bilaterally per the VASRD.  The VA rated the plantar fasciitis, right foot condition 0% and the plantar fasciitis, left foot condition 0%, both coded 5099-5020 (synovitis), based on the C&P examination 3 months before separation, citing “a noncompensable evaluation is assigned unless there is objective evidence of painful or limited motion of a major joint or group of minor joints.”  The VA rating was increased to 10% under an alternate rating criteria for the bilateral condition based on pain on manipulation at the VA examination 13 months after separation.  

The PEB combined the bilateral foot pain conditions as a single unfitting condition coded 5099-5003 for slight disability and rated 0%.  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 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.  The evidence for the bilateral foot pain conditions was presented together above.  In this case, a bilateral condition was profiled, and the bilateral foot pain condition was implicated by the NARSUM and in the commander’s statement.  Members agreed that each foot condition is separately unfitting and that identical coding and ratings are applicable.

The PEB’s bilateral rating of 0% analogously to code 5003 does not comport with the VASRD §4.71a stipulation for a 10% rating under 5003 for “2 or more major joints”, the latter without regard to ROM limitation or other factors; however, there was no X-ray evidence of degenerative arthritis.  Furthermore, the bilateral foot pain, whether from plantar fasciitis, foot injuries, or pes cavus or a combination of the conditions is better coded using alternative coding options including an analogous code 5399-5310 (Group X: plantar aponeurosis) and code 5284 (foot injuries).  The panel members discussed whether either foot condition rose to a moderate level of disability warranting a 10% rating versus a slight level of disability at a 0% rating.  The CI did not have any surgical procedures nor were there any objective findings of muscle or bone abnormalities, albeit the CI had tenderness of the plantar arches and central bands of plantar fascia.  Therefore, panel members determined neither foot condition rose to a moderate level.  Code 5279 (metatarsalgia, anterior (Morton's disease), unilateral, or bilateral) with a 10% rating was raised; however, the CI had plantar fasciitis, which involves the midfoot and hindfoot and not the forefoot which is the locus of metatarsalgia.  Code 5278 (claw foot (pes cavus), acquired) was then considered since pes cavus was noted on examination; however, a 10% rating for either unilateral or bilateral pes cavus requires “great toe dorsiflexed, some limitation of dorsiflexion at the ankle, definite tenderness under metatarsal heads,” but there was no great toe dorsiflexion or limitation of dorsiflexion at the ankle, although there was tenderness of the plantar arches and the plantar fascia, which extended to the metatarsal heads.  Therefore, based on an examiner’s diagnosis of pes clavus and tenderness, panel members considered a 10% rating, and no higher, for bilateral involvement to be not unreasonable.  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 foot pain condition, coded 5278.  

BOARD FINDINGS:  In the matter of the bilateral foot pain condition, the panel unanimously recommends a disability rating of 10%, coded 5278 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 Foot Pain	5278	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150723, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170009997, 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