RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02214
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20070904

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Health Services Management Helper, medically separated for “right plantar fasciitis” and “left patellar tendonitis and patellofemoral syndrome”, rated 10% and 10%, with a combined disability rating of 20%.

CI CONTENTION:  The CI made no specific contention.  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 - 20070719	VARD - 20080311	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Plantar Fasciitis	5399-5310	10%	Right Plantar Fasciitis	5020	10%	20080114	
Left Patellar Tendonitis and Patellofemoral Syndrome	5099-5003	10%	Patellofemoral Pain Syndrome, Left knee	5014	10%	20080114	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Right Plantar Fasciitis.   According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right plantar fasciitis began in basic training where a podiatrist confirmed the diagnosis on 25 May 2006 based on tenderness on palpation of the inferior heel/arch of the right foot.  Treatment consisted of orthopedic footwear (KLM/heel cups) and an arch support, stretches, and Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID)).  On 13 July 2006 she reported the inserts caused her to develop blisters.  X-rays of the right foot demonstrated a calcaneal heel spur along the insertion of the plantar tendon without acute findings and naproxen (an NSAID) was prescribed along with a profile.  Physical therapy was instituted and consisted of friction and ice message, taping, and stretching through October 2006.  Because of chronic pain and failure of the prior therapy, she was fitted for custom orthotics on 21 February 2007 and subsequently had her profile extended.  On 11 May 2007 she reported severe pain in her right foot that she would have to “crawl on my hands and knees” to avoid bearing weight on the foot.  X-rays of the right foot on 14 May 2007 demonstrated no osseous, articular or soft tissue abnormality and the alignment was normal.  

The 29 May 2007 MEB NARSUM examination, 3 months prior to separation, noted complaints of right heel and foot pain increased with walking and prolonged standing.  Physical examination showed tenderness to palpation of the plantar aspect of the right foot and heel.  There was no ecchymosis, swelling or deformity of the foot.

At the 14 January 2008 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported the foot pain was “excruciating” and rated it at 9/10 (10 being the worst pain.  The pain was aggravated with standing for a matter of minutes and walking for less than 5 minutes.  Physical examination showed a normal gait before and after the examination without any evidence of abnormal weight bearing.  There was no erythema, edema, or bony abnormalities noted of her feet, but they were quite sensitive to any type of light palpation.  The plantar fascia was somewhat sensitive bilaterally, but did not seem to be the primary location of her pain.  She was able to stand on her toes, although it was uncomfortable; however, she was unable to stand on her heels.  A squeeze test caused significant pain and she had pain overlying the right first and second metatarsals.  Pedal pulses were 2+ and there was no skin breakdown.  Light touch was intact and the Achilles tendon was nontender.  There was no pes planus or other abnormalities.  The examiner was unable to definitively diagnose plantar fasciitis or any other foot condition based on the examination and opined that the calcaneal spur should not cause her diffuse foot pain.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right plantar fasciitis condition 10%, coded 5399-5310 (muscle Injuries, group X).  The VA also rated the right plantar fasciitis condition 10% coded 5020 (synovitis), based on the VA C&P examination 4 months after separation, citing painful or limited motion of a major joint
or group of minor joints.   Although the CI reported significant pain in the right foot, other than the calcaneal spur, clinical findings prior to separation were confined to tenderness to palpation of the plantar aspect of the right foot and heel, while at the post-separation VA examination, the plantar fascia was somewhat sensitive, but did not seem to be the primary location of her pain, although a squeeze test caused significant pain and she had pain overlying the first and second metatarsals.  Members, therefore, felt the CI’s condition did not rise to a moderately severe level at the time of separation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right plantar fasciitis condition

Left Patellar Tendonitis and Patellofemoral Syndrome.  According to the STR and the MEB NARSUM, the CI’s left patellar tendonitis and patellofemoral syndrome (left knee) condition began in May 2006 of an unknown etiology.   X-rays of both knees dated 20 July 2006 were normal and showed no significant osseous (bone), articular, or soft tissue abnormalities.  On 20 July 2007 the CI was diagnosed with patellar tendonitis and patellofemoral syndrome of the right knee, which is not in the scope of review, and was given a PF (patellofemoral) brace for the right knee.   On 6 February 2007 she reported chronic left knee pain for several months and was referred for physical therapy, while on 21 February 2007 she reported a history of bilateral knee pain left worse than right.  Pain was located anteromedially and was sharp.  The left knee caught during movement with a clicking sensation; and, a popping was heard.  On 9 May 2007 she reported she ran a day earlier and had a hard time walking afterward.  Examination revealed tenderness on palpation of the left knee and pain with motion.  On 11 May 2007 she reported severe left knee pain and described it as “flicking behind the kneecap” and reported the knee pain “tripled” since first evaluated.  X-rays of the left knee on 11 May 2007 were normal.  Magnetic resonance imaging (MRI) on 17 May 2007 demonstrated no significant abnormalities.  On 23 May 2007 the CI had a Hyalgan (hyaluronate, a viscosupplement) injection into the knee.   

The 29 May MEB NARSUM examination (per orthopedic consult 29 May 2007), 3 months prior to separation, noted complaints of “horse shoe pain” at the left knee, which increased with walking and prolonged standing.  There was no redness, warmth or swelling of the knee and no joint stiffness or locking up.  Physical examination showed tenderness to patellar compression, tilt and excursion.  A full range of motion (ROM) was present.  Pivot shift and dial tests (to determine instability) were negative and there was no laxity (negative Lachman’s, negative posterior drawer, stable to varus and valgus stressing at 0 and 30 degrees).  There was no medial or lateral joint line tenderness and a McMurray’s test (to determine a meniscal tear) was negative.  On 30 May 2007 the CI received another Hyalgan injection into the knee.  That evening after possibly overextending her knee, she went to the Emergency Room with pain in the left knee and an inability to move the knee.  Treatment consisted of Toradol (ketorolac, an NSAID) intramuscularly and prescriptions for naproxen, an NSAID and Lortab (hydrocodone, a narcotic, and acetaminophen, a pain reliever).  An X-ray of the left knee was negative.  On 20 June 2007 the ROM of both knees was 0-100 degrees and they were ligamentously stable.  She received another Hyalgan injection into the knee on 20 June 2007 and another one in July 2007.  

At the 14 January 2008 VA Compensation and Pension (C&P) evaluation, performed 4 months after separation, the CI reported knee pain which she rated at 8/10 with occasional edema with walking and occasional locking.  Physical examination showed her gait to be normal.  There was no erythema, effusion, patella alta or baja (high or low kneecap), genu valgum (knock-knee) or varum (outward bowing) and no varus or valgus laxity.  The patellar apprehension test was positive as was the patellar compression test.  McMurray’s test was negative on the left side.  The CI reported significant tenderness along the medial and lateral joint lines as well as pain directly over the patella.  A drawer’s test was negative.  Extension was 0 degrees and flexion 100 degrees with pain noted. Ten repetitions were performed with pain throughout the repetitions and evidence of fatigability.  There was no evidence of weakness, incoordination, or flare-ups.  Post-exercise extension was 0 degrees and flexion was 100 degrees with pain noted.  X-rays of the left knee were normal.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10%, coded 5099-5003 (arthritis, degenerative).  The VA also rated the left knee condition 10% coded 5020 (synovitis), based on the VA C&P examination 4 months after separation, citing painful or limited motion of a major joint or group of minor joints.   
There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261). However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  There was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under those codes.  There was no fracture, nonunion or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  Therefore, there was no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left patellar tendonitis and patellofemoral syndrome condition.  

BOARD FINDINGS:  In the matter of the right plantar fasciitis condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the left patellar tendonitis and patellofemoral syndrome condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There were no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150814, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-02214.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  The Board recommended no re-characterization or modification of your separation.

I carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  I accept their recommendation that your application be denied.

Sincerely,

XXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings