RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01737
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041001

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Human Resources Administrative Specialist, medically separated for “chronic bilateral foot pain status post (S/P) bunionectomies with plantar fasciitis” with a combined disability rating of 20%.  

CI CONTENTION:  No specific contention made.  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB – 20040621	VARD - 20050414	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Foot Pain S/P Bunionectomies with Plantar Fasciitis	5299-5280	20%	R&L Plantar Fasciitis…	5299-5276	10%	STR	
			R First MTP Joint Arthrosis	5280	10%		
			L First MTP Joint Arthrosis	5280	10%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Bilateral Foot Pain.  The PEB combined the bilateral first metatarsal phalangeal joint (MTPJ) and bilateral heel pain/plantar fasciitis conditions under a single disability rating, coded analogously to 5280 (hallux valgus [bunion]) and rated 20%.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The panel’s initial charge in this case was therefore directed at determining if 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 toe and heel conditions are presented primarily together for brevity, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI was noted to have mild bilateral pes planus (flat foot) at accession.  She was asymptomatic and apparently did well for a while.  On 3 January 2002 she underwent surgery on the left great toe (first metatarsal osteotomy) for what was described as a “long history” of symptomatic hallux valgus (bunion).  The operative report showed a “z-plasty” with shorting of the long portion of the first metatarsal (M, but does not show excision of the head of the MT.  She then underwent a similar procedure on the right great toe on 02 May 2002.  The second page of this report is not in evidence.  The record shows that later that year the CI discussed removal of the surgical hardware with orthopedics, but this does not appear to have been accomplished.  The record then falls silent until 12 April 2004, when the CI received an injection (presumably both feet although it is not clear) for bilateral MTPJ pain.  X-rays showed normal post-operative changes as well as bilateral heel spurs consistent with plantar fasciitis.  Her pain persisted, and in primary care, 1 week later, she was noted to be tender over both MTPJs as well as both heels at the insertion of the plantar fascia.  The CI was then evaluated in podiatry on 29 April 2004 and referred for MEB.  

The 29 April 2004 MEB NARSUM examination, prepared by a podiatrist 5 months prior to separation, noted complaints of pain of both first MTPJs as well as bilateral plantar fasciitis which had not responded to treatment.  The physical examination showed bilateral tenderness at the insertion of the plantar fascia into the heel (calcaneus) bone.  The first MTPJ was “tender upon range of motion” bilaterally.  Motor function was normal.  No comment was made regarding the gait.  The X-rays findings cited above were again noted.  She was thought to have bilateral arthrosis (joint) of the first MTPJ and bilateral heel pain/plantar fasciitis.  It was noted that she could perform low impact activities and bicycle, but could not run or jump.  She could perform the majority of her regular duties if she avoided prolonged standing in military foot gear.  During the 17 May 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported ongoing pain and the occasional use of crutches.  The physical examination showed tender first MTPJs bilaterally and tender heels.  She was using a cane.  There was no VA examination in evidence proximate to separation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral foot condition 20%, coded 5299-5280 (analogous to hallux valgus, unilateral).  The VA rated bilateral plantar fasciitis 10%, coded 5299-5275 (analogous to acquired flatfoot), based on the STR, citing treatment for foot pain with plantar fasciitis and heel spurs.  The VA additionally rated each foot separately at 10% for hallux valgus, coded 5280 (hallux valgus), also based on the STR, citing tenderness with range of motion and an abrupt end to range of motion.  

The record showed that the bilateral first MTPJ arthroses and bilateral heel pain were both profiled and found to be medically unacceptable.  The commander only noted that her physical impairment limited duty requirements without further specification.  The PEB listed both conditions as causal of the unfitting bilateral foot pain.  The evidence supported a finding that the bilateral plantar fasciitis and bilateral MTPJs were separately unfitting at separation.  The panel then considered the rating.  

The code 5020 (synovitis) supported a 10% rating for bilateral plantar fasciitis without incapacitation.  The code 5276 (flat foot) also supported a 10% rating for bilateral impairment at a moderate level.  As the CI was noted to have asymptomatic pes planus at accession and there was no evidence of progression, the 5020 code was thought to better represent the predominant pathology.  The panel next considered the bilateral MTPJ pain.  The code 5280 is specific for hallux valgus.  A 10% rating is supported for resection of the metatarsal head for severe impairment if equivalent to amputation of the great toe.  The operative reports did not indicate that either metatarsal head had been resected.  While the CI did use a cane at the MEB examination, its use was not attributed to any one condition.  A 10% rating for each foot is supported under the code 5283 (tarsal or metatarsal bones, malunion or non-union) at a moderate level of impairment.  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 plantar fasciitis condition coded 5020, and ratings of 10% each for the first MTPJ arthrosis conditions coded 5283.  

BOARD FINDINGS:  In the matter of the bilateral plantar fasciitis condition, the panel recommends a disability rating of 10% coded 5020 IAW VASRD §4.71a.  In the matter of the bilateral first MTPJ arthrosis conditions, the panel recommends disability ratings of 10% each, coded 5283 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends 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 the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Bilateral Plantar Fasciitis	5020	10%	
Right First MTPJ Arthrosis	5283	10%	
Left First MTPJ Arthrosis	5283	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161106, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180005498, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXX.
	
Sincerely,					      
Enclosure