RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01976
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050330

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Electronic Intelligence Interceptor/Analyst, medically separated for “chronic pain in the feet, knees and back” with a disability rating of 0%.  

CI CONTENTION:  “Review all conditions.”  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 - 20050121	VARD - 20050420	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain in the Feet, Knees and Back	5099-5003	0%	History of Plantar Fasciitis and Achilles Tendonitis of the Bilateral Feet…	5276	NSC	20050209	
			Chondromalacia, Left Knee	5299-5019	10%	20050209	
			Chondromalacia, Right Knee	5299-5019	10%	20050209	
			History of Mechanical Low Back Pain…	5237	NSC	20050209	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Chronic Pain in the Feet.  The PEB combined the feet, knees, and back pain conditions as a single unfitting condition analogously coded 5099 5003 and rated 0% with application of the US Army Physical Disability Agency (USAPDA) pain policy and AR 635-40 B24.f.  The 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 also noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The panel’s initial charge in this case was therefore 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 feet, knees, and back pain conditions are presented separately, 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’s bilateral heel and plantar foot condition began in June 2003 after walking, standing, calisthenics, stair climbing, and attempting to run.  X-rays of both feet completed on 9 February 2005 were normal.  At the 22 July 2004 Family Practice evaluation, 8 months before separation, the CI reported ongoing right and left plantar fasciitis.  There was no physical examination.  Her physical profile was renewed. 

The 29 September 2004 MEB NARSUM examination, 6 months prior to separation, noted complaints of constant chronic bilateral foot pain, sharp in the morning with painful heels and Achilles tendon tenderness.  Physical examination showed bilateral feet with plantar fascia pain with palpation and toe raises.  No redness or edema.  At the 18 October 2004 Family Practice evaluation, 5 months before separation, the CI reported right and left ankle pain with weight bearing and limited flexion and extension.  Physical examination showed the left ankle with 1+ swelling at the lateral malleolus, tenderness and a positive talar tilt test.  Right ankle had 2+ swelling at the lateral malleolus, tenderness and a negative talar tilt test.  Pain in both ankles.  Dorsiflexion and plantar flexion diminished.  Both heels were tender.  

At the 9 February 2005 VA Compensation and Pension (C&P) evaluation, 2 months before separation, the CI reported pain, stiffness and swelling of both feet while standing or walking.  Physical examination showed her gait was within normal limits.  Examination of the feet did not reveal any signs of abnormal weight bearing.  She did not require an assistive device for ambulation.  The condition did not cause generalized muscle weakness or muscle wasting.  Examination revealed no joint involvement.  The ankle joint's general appearance was within normal limits on the right side and left side. Examination of the ankles did not reveal any deformity.  The range of motion (ROM) of the right and left ankle joint was dorsiflexion 20 degrees; plantar flexion 45 degrees and the range of motion was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use.  Examination of the right and left feet revealed no tenderness, weakness, edema, atrophy or disturbed circulation.  Flat feet were not present.  She did not have any limitation with standing and walking and did not require any type of support with her shoes.  

The panel first considered if the each foot, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Both feet were profiled and were specified in the commander’s performance statement where he noted that “she is up and down on her feet constantly throughout the day with increasing pain.”  Panel members agreed that the evidence reasonably justified that the functional limitations of each foot contributed to the CI’s inability to perform her military duties and accordingly separate disability ratings are recommended.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic pain in the feet, knees and back conditions 0%, analogously coded 5099-5003 (arthritis, degenerative), citing plantar tenderness and the US Army Physical Disability Agency pain policy.  The VA rated the bilateral feet condition not service connected based on the C&P examination, citing that there were no findings or pathology to render a diagnosis.  The panel noted from the STR that the CI had an ongoing intermittent bilateral foot condition.  The panel found that the C&P examination was both more thorough and more proximate to separation and therefore of greater probative value.  There was no foot weakness which supported a rating under the diagnostic codes for weak foot (5277).  There was no evidence of claw foot (5278) of acquired flatfoot (5276), or metatarsalgia, anterior (Morton’s disease) (5279.  There was no tarsal or metatarsal bone malunion or nonunion (5283), or other foot injuries (5284) to support a moderate rating under their respective diagnostic codes.  There was no evidence of moderate ongoing foot pain that could be analogously coded under 5399-5310 (Group X. Function: Movements of forefoot and toes) for a 10% rating.  There was no other VASRD §4.71a route to a higher rating under any applicable code for either foot.  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 bilateral foot pain condition.  

Chronic Pain in the Knees.  The CI’s knee condition began in March 2002 during a physical training run after she rolled her left ankle and fell onto her knees.  The 29 September 2004 MEB NARSUM examination, 6 months prior to separation, noted complaints of bilateral knee pain especially with weight bearing, squatting, kneeling, and ached with exposure to cold weather.  Physical examination showed bilateral knees were stable in all planes with no swelling.  There was painful flexion and extension on the right.  There was no pain with flexion or extension on the left.  During the 19 October 2004 PT examination, 5 months prior to separation, the CI reported no current complaints.  Physical examination revealed the left knee ROM flexion was 110 degrees (140 normal), extension 0 degrees (0 normal) with pain.  Right knee ROM flexion was 100 degrees, extension 0 degrees with pain.  

At the C&P evaluation the CI reported constant extreme pain and tightness of both knees.  Physical examination showed tests for stability of both knees were normal.  The left knee ROM flexion was 130 degrees and extension was 0 degrees.  The right knee ROM flexion was 130 degrees and extension was 0 degrees.  On both the left and right, the range of motion was additionally limited by pain after repetitive use with pain being the major functional impact.  Her gait was within normal limits.  

The panel first considered if the each knee, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Both knees were profiled and were specified in the commander’s performance statement.  Panel members agreed that the evidence reasonably justified that the functional limitations of each knee contributed to the CI’s inability to perform her military duties and accordingly separate disability ratings are recommended.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic pain in the feet, knees and back conditions 0%, analogously coded 5099-5003 (arthritis, degenerative), citing plantar tenderness and the US Army Physical Disability Agency pain policy.  The VA rated the both the left and right knee conditions 10% each, analogously coded 5299-5019 (bursitis), based on the C&P examination, citing painful or limited motion of a major joint.  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) for each knee.  There was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), to support a rating under that code.  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).  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 chronic left knee pain condition, and 10% for the chronic right knee pain condition, both analogously coded 5099-5003.  

Chronic Pain in the Back.  The CI’s low back condition began in January 2004 with no specific onset of the injury.  The 29 September 2004 MEB NARSUM examination, 6 months prior to separation, noted complaints of low back pain with right sided sciatica.  Physical examination showed straight leg raise negative bilaterally.  Pain with right rotation at waist.  There was no muscle wasting and she was neurologically intact.  During the 19 October 2004 PT examination, 5 months prior to separation, the CI reported no current complaints.  Physical examination revealed spine ROM after three repetitions was a flexion of 80 degrees (normal 90), extension 20 degrees (normal 30), with combined ROM of 215 degrees (normal 240).  There was no mention of pain with the examinations.  The examiner specifically stated that there was only pain with the knee portion of the examination.  

At the C&P examination the CI reported a burning, sharp, and cramping in nature 5/10 low back pain.  Physical examination revealed no complaints of radiating pain on movement.  Muscle spasm was absent.  No tenderness was noted.  There was negative straight leg raising on the right and the left.  There was no ankylosis of the spine.  The ROM of the lumbar spine was flexion of 90 degrees; extension 30 degrees; with combined ROM of 240 degrees.  The ROM was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use.  There were no signs of intervertebral disc syndrome with chronic and permanent nerve root involvement.  Her gait was within normal limits.  

The panel first considered if the back, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The back was profiled and was specified in the commander’s performance statement.  Panel members agreed that the evidence reasonably justified that the functional limitations of the low back pain contributed to the CI’s inability to perform her military duties and accordingly a separate disability rating is recommended.  The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic pain in the feet, knees and back conditions 0%, analogously coded 5099-5003 (arthritis, degenerative), citing plantar tenderness and the US Army Physical Disability Agency pain policy.  The VA rated the bilateral feet condition not service connected based on the C&P examination, citing that there were no findings or pathology to render a diagnosis.  

The panel noted from the STR that the CI had an ongoing intermittent low back pain condition.  The panel found that the C&P examination was both more thorough and more proximate to separation and therefore of greater probative value.  There was no limitation of thoracolumbar spine motion to support a 10% rating under the General Rating Formula for Diseases and Injuries of the Spine and  C&P examination did not note the presence of painful motion, muscle spasm, guarding or localized tenderness.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula.  There was no associated radiculopathy for separate peripheral nerve rating.  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).”  There was no objective evidence of a radiculopathy with functional impairment (such as weakness) that directly impacted fitness for duty.  There was no evidence of painful motion on the two most recent examinations with functional loss to support a 10% rating (based on §4.59, §4.40 and §4.45).  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 back condition.  
BOARD FINDINGS:  In the matter of the left foot pain condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the right foot pain condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the left knee pain condition, the panel recommends a disability rating of 10%, analogously coded 5099 5003 IAW VASRD §4.71a.  In the matter of the right knee pain condition, the panel recommends a disability rating of 10%, analogously coded 5099 5003 IAW VASRD §4.71a.  In the matter of the 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.  

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Foot Pain	5099-5003	0%	
Right Foot Pain	5099-5003	0%	
Left Knee Pain	5099-5003	10%	
Right Knee Pain	5099-5003	10%	
Low Back Pain	5099-5003	0%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170303, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180011483, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

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