RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01376
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20050706

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Communications Cable Systems Journeyman, medically separated for “plantar fasciitis” and “chronic low back pain,” rated 10% each, with a  combined disability rating of 20%.  

CI CONTENTION:  “I was found unfit for service due to medical conditions and not medically retired…asking for a review of this decision.”  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 - 20050517	VARD - 20060317	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Plantar Fasciitis	5310-5399	10%	Plantar Fasciitis, Right Foot	5299-5284	10%	20051220	
Chronic Low Back Pain	5343	10%	Post Traumatic Arthritis, Lumbar Spine, Status Post (S/P) Fracture L4	5243	20%	20051220	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Plantar Fasciitis.  The MEB and the PEB combined the right and left plantar fasciitis conditions under a single disability rating, coded 5310-5399 (analogous to Group X muscle injuries) and rated 10%.  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.  

According to the service treatment record (STR) and the MEB narrative summary (NARSUM), the CI’s plantar fasciitis began in September 2002 after he heard a “snap” in the right foot or ankle.  He was treated with medications, ice, stretching exercises, physical therapy and custom orthotics which greatly improved his symptoms to the point he was only evaluated once during 2003 for foot complaints.  He began complaining of right foot pain again in May 2004.    

At the 20 August 2004 family practice (FP) clinic visit, the physician noted that the CI’s plantar fasciitis had improved.  The 9 November 2004 FP evaluation documented intermittent plantar fasciitis and that the CI was walking regularly for exercise and experienced foot pain after prolonged walking.  

The 15 March 2005 MEB NARSUM examination, 4 months prior to separation, noted complaints of bilateral foot pain that was worse after activities, particularly in the mornings.  He was able to walk 30 minutes 3 times per week without difficulty.  Physical examination showed full range of motion (ROM) of both feet with tenderness on the medial plantar surface distal to the heels.  At the 13 April 2005 pain clinic visit for his back condition, 3 months prior to separation, the CI reported that he had excellent results from the first epidural steroid injection (2 months earlier) and he was able to run in the interim.  

At the 20 December 2005 VA Compensation and Pension (C&P) evaluation, 5 months after separation, the CI reported his right foot did not have pain at rest but did cause pain, weakness and stiffness with standing and walking.  He was unable to run at all.  The physical examination showed a normal gait and arches with no signs of deformity or use of custom footwear.  There was tenderness on the right plantar surface but none on the left.  There was no evidence of claw foot or hammertoe, metatarsalgia, hallux valgus or hallux rigidus.  Dorsiflexion of all toes was normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the plantar fasciitis 10%, coded 5310-5399.  The VA rated the right plantar fasciitis condition 10%, coded 5299-5284, (analogous to foot injuries, moderate), based on the C&P evaluation, citing moderate symptoms.  

The panel first considered if the right and left plantar fasciitis conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, both feet were considered to fail retention standards and were implicated by the NARSUM, though neither was implicated in the profile or the commander’s statement.  Review of the STR evidence shows that the majority of the visits for foot pain were for the right foot and not the left although there were entries for both.  Since undue speculation would be required to conclude that impairment from either would not have unacceptably interfered with duty performance, members agreed that each foot was reasonably justified as separately unfitting.  

The panel next addressed ratings for each unfitting foot.  There was no evidence of acquired flat foot (5276), claw foot (5278), or severe hallux valgus (5280) in either foot to justify a rating under the respective codes.  There was no evidence of hammer toe (5282), fractures with malunion or nonunion (5283) or injuries to either foot that would be characterized as moderate (5284) to validate ratings under those codes.  There was no evidence of metatarsalgia to substantiate a 10% rating using code 5279 which specifies unilateral or bilateral.  Panel members agreed that the degree of disability displayed in the bilateral foot condition is best characterized as slight (0%) under code 5310, which would constitute a rating disadvantage to the CI.  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 plantar fasciitis condition.  

Chronic Low Back Pain (LBP).  According to the STR and the MEB NARSUM, the CI’s LBP condition began in mid-2003 but increased in April 2004 after falling down stairs.  Plain film X-rays showed a possible L4 pars interarticularis fracture.  A follow-up magnetic resonance imaging (MRI) study showed a small disc bulge without herniation at L4-L5 or central canal stenosis, and mild right sided neuroforaminal narrowing.  There was no surgical indication.  

The 15 March 2005 MEB NARSUM examination, 4 months prior to separation, noted complaints of intermittent LBP that radiated to the right leg at times.  He denied weakness in his legs.  Physical examination showed full ROM of the back with no tenderness.  

At the 20 December 2005 VA C&P evaluation, 5 months after separation, the CI reported he was working for a cable television company installing high-speed internet cable.  He complained of constant, non-radiating pain aggravated by activity and that he was unable to bend or squat.  Physical examination showed forward flexion of 80 degrees (normal 90) and combined thoracolumbar ROM of 205 degrees (normal 240).  Although the examiner reported that “muscle spasms appear[ed] to be present,” and that there was a “loss of lordosis,” plain film X-rays performed the same day showed an unremarkable evaluation with the normal lordotic curvature being well maintained.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP condition 10%, coded 5343 (presumably this is an error and the PEB intended to use code 5243 (intervertebral disc syndrome (IVDS)).  The VA rated the LBP condition 20%, coded 5243, based on the C&P evaluation, citing spasm and loss of lordosis.  There was no evidence of decreased forward flexion less than 60 degrees, combined ROM less than 120 degrees, muscle spasm or guarding severe enough to result in abnormal gait or abnormal contour to satisfy the requirements of a 20% rating as specified by the General Rating Formula for Diseases and Injuries of the Spine.  There was no documentation of IVDS with incapacitating episodes totaling at least 2 weeks duration which would provide for a higher rating under that formula.  While the CI may have experienced radiating pain from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the LBP condition.  

BOARD FINDINGS:  In the matter of the plantar fasciitis condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the chronic low back pain condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel, recommends no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170301, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

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

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-01376.

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.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have 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.  Accordingly, I accept their recommendation that your application be denied.

						Sincerely,

								XXXXXXXXXXXXXXXXXX
								Director
								Air Force Review Boards Agency

Attachment:
Record of Proceedings