RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01181
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20040628

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Supply Specialist, medically separated for “bilateral plantar fasciitis with cavus foot deformity” with a 0% disability rating.  

CI CONTENTION:  “Problem continued during military services and continued/got worse after military service.”  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 - 20040520	VARD - 2050307	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Plantar Fasciitis w/Cavus Deformity	5399-5310	0%	Plantar Fasciitis Left Foot	5276	10%	20050307	
			Plantar Fasciitis Right Foot	5276	10%	20050307	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20% 	

ANALYSIS SUMMARY:  

Bilateral Plantar Fasciitis with Cavus Deformity.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s plantar fasciitis condition began in late 1995 or early 1996. Treatment consisted of physical therapy ultrasound treatments, molded arch supports, and a profile.  In 1999 he was given a permanent profile for no running, jumping or marching and was treated with night splits and inserts without relief.  On 23 May 2000, the CI was seen in consultation by a podiatrist who noted a cavus foot type with very tight plantar fascia bilaterally, which exhibited considerable discomfort along the medial border.  The majority of the CI’s pain was near the insertion of the fascia into the medial tubercle of the calcaneus.  In August 2000 he underwent bilateral plantar fascial releases; however, 5 months postoperatively he had continued pain.  A trial of ultrasound was instituted and a splint was fabricated.  On 10 December 2001, the CI complained of severe pain after he restarted running 1 month earlier.  Examination revealed palpable scar tissue distal to the calcaneus with decreased range of motion (ROM) of the ankles due to tight posterior musculature.  The surgical scar areas were injected with an anesthetic and steroid combination.  Heel lifts were prescribed along with pool therapy.  An X-ray series was negative for a fracture or heel spur in August 2002.  The CI had no gait instability when examined in September 2003.  In March 2004 he was again diagnosed with plantar fasciitis, equinus (inability to flex the foot toward the lower leg) bilaterally, and collapsing cavus foot (high arch) type and was given custom inserts and was to stretch as directed.  Further surgery was offered, but the CI refused.   

The 19 April 2004 MEB NARSUM examination, 2 months prior to separation, noted complaints of bilateral heel pain.  Physical examination showed a positive equinus bilaterally with a collapsing cavus foot type.  The CI had pain to palpation of the plantar fascia, which appeared to be intact despite the surgical release procedures performed in 2000.  During 28 April 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, the CI reported plantar fasciitis, “feet go numb on occasion while walking,” and foot surgery.  Physical examination showed bilateral arch tenderness.  The commander’s statement dated 30 April 2004 indicated the CI dealt with heavy supplies and equipment at times and his profile prohibited him from perform the basic functions required of his MOS.  An L3 profile was issued on 19 April 2004 and approved on 4 May 2004 for bilateral plantar fasciitis with limitations of unlimited running, moving with a fighting load, and constructing an individual fighting position.  
	
At the 27 October 2004 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported bilateral plantar fasciitis with pain as 5-6/10 (10 being the worst pain) during activities and 9/10 shortly after the activity was completed with burning and shooting pain and increased heat in the feet.  Physical examination showed an upright and steady gait without assistive devices.  The range of motion was restricted related to bilateral plantar fasciitis with right dorsiflexion 0-5 degrees (normal 20) and plantar flexion 0-20 degrees (normal 40).  Left dorsiflexion was 0-13 degrees and plantar flexion was 0-30 degrees.  Inversion and eversion were painful and mildly limited.  The feet were markedly tender to palpation.  There were no areas of erythema (redness).  The nails were intact and there was no swelling or atrophy noted of the feet.  No mechanical aids were used.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral plantar fasciitis with cavus foot deformity condition 0%, coded 5399-5310 (Group X muscle injury).  The VA rated the plantar fasciitis, left foot condition 10%, coded 5276, (flatfoot, acquired), based on the C&P examination 4 months after separation, citing limited motion and pain.  The VA rated the plantar fasciitis, right foot condition 10%, coded 5276, based on the C&P examination 4 months after separation, citing limited motion and pain.  X-rays of the feet dated 27 October 2004 showed no bony erosions, no fractures or soft tissue calcification, and no bony abnormalities.  

The PEB combined the bilateral plantar fasciitis conditions as a single unfitting condition coded 5399-5310 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 plantar fasciitis was presented together above.  In this case, a bilateral condition was profiled and the bilateral plantar fasciitis was implicated by the NARSUM and was alluded to in the commander’s statement.  Members agreed that each foot’s plantar fasciitis condition is separately unfitting and that identical coding and ratings are applicable.  Use of the analogous code 5399-5310 is appropriate since plantar aponeurosis is explicitly mentioned as an important plantar structure, which had been the source of the CI’s disability bilaterally.  Members discussed the applicable rating for each foot with slight disability offering 0%, moderate 10%, and moderately severe 20%.  Since the CI was unable to perform his MOS, had been on profile for a long time, had undergone surgery on each foot, although unsuccessful over the long haul, and was considered for additional foot surgery, a 10% rating for each foot is reasonable and not inconsistent with the VA rating after separation.  However, members determined that the condition of either foot did not rise to a moderately severe level.  Members also considered use of code 5278 (claw foot (pes cavus), acquired), which requires for a bilateral disability the “great toe dorsiflexed, some limitation of dorsiflexion at ankle, definite tenderness under metatarsal heads,” however, only a 10% rating is available, which offers no benefit to the CI.  On the other hand, the 30% rating for a bilateral disability requires “all toes tending to dorsiflexion, limitation of dorsiflexion at ankle to right angle, shortened plantar fascia, and marked tenderness under metatarsal heads.”  However, there was insufficient evidence to support a 30% rating in the absence of all toes tending to dorsiflexion or limitation of dorsiflexion at the ankle to a right angle nor was there significant shortened plantar fascia or definite tenderness under the metatarsal head.  While the CI underwent bilateral surgical procedures, subsequent examinations noted fascia being present and the CI’s tenderness was predominately about the heels.

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 plantar fasciitis, right foot condition, coded 5399-5310 and a disability rating of 10% for the plantar fasciitis, left foot condition, coded 5399-5310.

BOARD FINDINGS:  In the matter of the plantar fasciitis, right foot condition, the panel unanimously recommends a disability rating of 10%, coded 5399-5310 IAW VASRD §4.71a.  In the matter of the plantar fasciitis, left foot condition, the panel unanimously recommends a disability rating of 10%, coded 5399-5310 IAW VASRD §4.71a.  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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Plantar Fasciitis, Right Foot	5399-5310	10%	
Plantar Fasciitis, Left Foot	5399-5310	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160705, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170018491, 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