RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02003
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070123

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Trainee, medically separated for “bilateral lower extremity stress changes” and “plantar fasciitis,” rated 0% each, with a combined disability rating of 0%.

CI CONTENTION:  The conditions worsened after separation.  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 - 20070110	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral LE Stress Changes	5022	0%	No VA Examination Proximate to Separation in Evidence	
Plantar Fasciitis	5399-5310	0%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Bilateral Lower Extremity (LE) Stress Changes. The PEB combined the bilateral LE stress changes conditions under a single disability rating, coded 5022, IAW code 5003, and rated 0%.  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 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 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 lower extremity stress changes conditions are presented together, with attendant recommendations regarding separate unfitness, and separate ratings, if indicated.

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s bilateral LE stress changes began in June 2006.  On 17 July 2006 the CI complained of right hip pain for 4 weeks.  Right hip maneuvers demonstrated pain in the hip flexor muscle when doing flutter kicks.  Range of motion (ROM) maneuvers were normal without pain and the hip showed no weakness.  A right knee was examined without discomfort.  On 28 July 2006 there was pain with active motion of the left hip and all ROMs were normal.  Physical therapy (PT) examination on 1 August 2006 showed a normal gait, a positive scours test (to determine hip pathology) and a negative Faber’s test (to determine hip pathology), and the CI was able to single leg hop with a slight increase in pain.  The examiner’s impression was right hip flexor strain versus bony involvement.  X-rays of the right hip on 1 August 2006 showed an area of periosteal reaction in the lateral aspect of the sub-trochanteric region of the femur.  

A bone scan dated 4 August 2006 demonstrated normal hips with stress changes noted to the femurs bilaterally and her bilateral knees and ankles, as well as the right second metatarsal head.  On 5 October 2006 the CI had no complaint of hip pain prior to or post treatment, only tightness.  On 27 October 2006 the CI reported right knee pain since 6 October 2006 following squatting.  There was no right knee joint swelling, locking, or sudden buckling. The patella demonstrated crepitus (grinding sensation) and there was tenderness at the patellofemoral ligament.  The examiner’s assessment was patellofemoral syndrome. Despite treatment with PT, nonsteroidal anti-inflammatory drugs (NSAIDs), and profiling, she had no relief from her pain and discomfort.  

During the 17 November 2006 MEB examinations (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, the CI reported bursitis of the right hip and left knee pain.   Physical examination revealed tenderness of both hips over the great trochanters and posteriorly and in the inguinal region.  Patrick’s test (to determine hip pathology) was negative.  Flexion was symmetrical at 115 degrees (normal 125), external rotation 45 degrees (normal 60), and internal rotation 25 degrees.  Muscular strength and sensation were grossly intact.  ROM of both knees was 0-135 degrees (normal 0-140).  There was no instability, crepitus, or patellar tilt.  There was tenderness on the medial joint line and at the pes (anserine) bursa.  Motor and sensation were grossly intact.  

The 20 November 2006 MEB NARSUM examination, 2 months prior to separation, noted complaints of bilateral LE stress fractures.  Physical examination showed the CI ambulated well.  Her hips were symmetrical and she was tender over her greater trochanteric bursa bilaterally.  She had no pain with loading or compression.  She was non-tender to the posterior aspect of her hips or within the inguinal regions.  She had a negative Patrick’s test.  ROMs of the hips were flexion at 115 degrees, external rotation 45 degrees, and internal rotation 20 degrees.  Motor and sensory testing was grossly intact in all distributions.  Her knees were symmetrical without edema, effusion, or atrophy.  There was no patella tilt or laxity.  Knee? ROM measurements were extension 0 degrees and flexion 135 degrees.  Straight leg raise was 0-60 degrees.  There was no instability or laxity of the knees or evidence of a meniscal tear.  She had mild discomfort with palpation to the medial joint line as well as over the medial proximal tibia in the area of the pes anserine bursa.  

There was no VA examination proximate to separation in evidence.  At a rural health clinic visit on 9 July 2007, 6 months after separation, the CI reported she felt a pop in her right knee with pain after squatting down and was assessed as having right knee pain with possible internal derangement.  The CI’s history or examination related to the hips was not addressed.  Treatment was with a NSAIDs and PT.  In February 2008 the CI experienced right hip pain and was treated with PT with progressive improvement over several months.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral LE stress condition 0%, coded 5022 (periostitis), citing no ratable limitation of motion.  Panel members noted there was imaging evidence of bilateral LE involvement with stress changes noted to the femurs, knees and ankles bilaterally.  Furthermore, the panel majority noted there was a hip flexion limitation of motion, although not sufficient to warrant a compensable rating.  Therefore, the panel majority determine a 10% rating using code 5022-5003 is reasonable.   Use of code 5255 (femur impairment of: malunion of: with slight knee or hip disability) was raised for each LE; however, the panel majority did not feel there was sufficient disability to warrant a rating greater than 0%.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the bilateral LE stress condition, coded 5022-5003.

Plantar Fasciitis (Bilateral).  The PEB combined the bilateral plantar fasciitis condition under a single disability rating analogously coded 5399-5310 and rated 0%.  As previously noted, 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 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 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 plantar fasciitis conditions are presented together, with attendant recommendations regarding separate unfitness, and separate ratings, if indicated.

According to the STR and MEB NARSUM, the CI’s plantar fasciitis condition began in June 2006.  At the military entrance physical examination on 13 March 2006 her feet had normal arches and were asymptomatic.  On 17 May 2006 the CI reported pain in the left foot for approximately 12 days and pain started in the right foot after a foot march.  Examination revealed pain/swelling across the left first metatarsal.  No pes planus was present; the CI had a high to normal arch.  There was no tenderness of the plantar or posterior aspect of the heel.  There was no tenderness of the medial longitudinal arch of the right foot.  X-rays of the left foot showed slight swelling over the medial side of the mid and proximal forefoot adjacent to the first metatarsal.  No stress fracture was seen. The remainder of the bony structures were normal.  The examiner’s impression was overuse and the CI was referred to PT where she also reported right foot pain.  On examination she had a slight antalgic gait and a high to normal foot arch.  ROM was full and equal bilaterally and strength was normal.  There was tenderness along the shaft of the right first metatarsal.  A physical therapist’s assessment was overuse in the right foot and treatment consisted of ice twice daily, rest, soft sole inserts, and to walk/run at her own pace.  A limited bone scan on 4 August 2006 showed a focal, moderate stress change noted at the right second metatarsal head.  On 12 October 2006 she reported pain was located in both feet at her metatarsal pads and heels.  She had pain at rest, after activity, and at night and ambulated with a slightly sluggish but not antalgic gait.  There was tenderness along the plantar fascia, calcaneal tuberosity, and metatarsal heads.  Dorsiflexion was decreased by 10 degrees bilaterally.  Strength and sensation were intact.  The examiner’s impression was plantar fasciitis. At a PT visit on 18 October 2006 the CI indicated she had pain in her feet with a severity of 5/10.  Her gait was normal.  She had pes cavus and she was tender along the plantar fascia, calcaneal tuberosity, and metatarsal head.  Dorsiflexion was decreased by 8 degrees.  Strength and sensation were normal.  

During the 17 November 2006 MEB examinations (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, and the MEB NARSUM examination 3 days later, the CI reported foot pain (plantar fasciitis).  Physical examination revealed tenderness of the feet bilaterally at the insertion of the plantar fascia.  She had positive motion and strength of the extensor hallucis longus, flexor hallucis longus, extensor digitorum brevis, and flexor digitorum brevis muscles and her Achilles tendons were not tender.  There were no palpable step offs, and she had positive plantar flexion with compression of the gastrocnemius.  There was no VA examination proximate to separation in evidence.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the plantar fasciitis (bilateral) condition 0%, analogously coded 5399-5310 (Group X function), citing minimal intermittent foot pain.  The panel first considered if the right and left foot plantar fasciitis conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Panel members agreed the evidence reasonably justified that the functional limitations of the condition contributed to the CI’s inability to perform her military duties, and accordingly separate disability ratings are recommended.  However, both the right and left foot plantar fasciitis appeared to be slight, and there was insufficient evidence to support a moderate disability.  Therefore, use of code 5399-5310 offers only a 0% rating for a slight disability of the right and left foot plantar fasciitis conditions.  After due deliberation, considering all 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 plantar fasciitis (bilateral) condition.  

BOARD FINDINGS:  In the matter of the bilateral lower extremity stress conditions, the panel majority recommends a disability rating of 10%, coded 5022-5003 IAW VASRD §4.71a.  The single voter for dissent submitted the appended minority opinion.  In the matter of the plantar fasciitis (bilateral) 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	
Bilateral Lower Extremity Stress Changes	5022-5003	10%	
Plantar Fasciitis (Bilateral)	5399-5310	0%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170227, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20190007583, 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 North Dakota Department of Veterans Affairs, Mr. Tom Webb (Room 208A), 2101 North Elm Street, Fargo, ND 58102.

Sincerely,					       

Enclosure

	

Minority Opinion.  The minority voter determined that each LE condition was separately unfitting and each warrants a 10% rating for slight impairment using analogous code 5299-5255.  The minority voter notes that the majority used code 5022-5003 to rate the CI; however, the VA has a distinct protocol for rating shin splints or in this case stress changes.  Simply stated, if the condition is unfitting or service connected from a VA perspective, then code 5255 is used for rating purposes IAW VA rating instruction M21-Part III, Subpart iv, Chapter 4, Section A-Musculoskeletal Conditions.  First, it was considered whether the right LE condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Evidence reasonably justified that the functional limitations of the condition contributed to the CI’s inability to perform her military duties, and accordingly a separate disability rating is recommended.  Use of code 5299-5255 (femur impairment of: malunion of: with slight knee or hip disability) offers a 10% rating option for a slight disability since there were stress changes identified on bone scan at the femurs and knees and the CI had tenderness at the trochanters on multiple examinations.  Additionally, the CI had a positive scours test, which points to hip pathology.  As a result the CI was unable to perform her military duties at the time of separation.  Furthermore, there was no indication or evidence that her right LE pain resolved nor was there imaging evidence of resolution of the bone changes of the femurs or knees noted on the bone scan.  

The panel then considered if the left LE condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Evidence reasonably justified that the functional limitations of the condition contributed to the CI’s inability to perform her military duties, and accordingly a separate disability rating is recommended.  Use of code 5299-5255 offers a 10% rating option since there were stress changes identified on bone scan at the femurs and knees and the CI had tenderness at the trochanters on multiple examinations.  Additionally, the CI had a positive scours test, which points to hip pathology.  As a result the CI was unable to perform her military duties and at the time of separation.  Furthermore, there was no indication or evidence that her left LE pain resolved nor was there imaging evidence of resolution of the bone changes of the femurs or knees noted on the bone scan.  

Therefore, the minority voter recommends the ROP be modified as follows:

After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the right lower extremity stress condition, coded 5255 and a disability rating of 10% for the left lower extremity stress condition, coded 5255.  Furthermore, the minority voter recommends the Board Findings be modified as follows:

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:  

In the matter of the right lower extremity stress condition, the panel recommends a disability rating of 10%, coded 5255 IAW VASRD §4.71a.  In the matter of the left lower extremity stress condition, the panel recommends a disability rating of 10%, coded 5255 IAW VASRD §4.71a

CONDITION	VASRD CODE	PERMANENT RATING	
Right Lower Extremity Stress Changes	5255	10%	
Left Lower Extremity Stress Changes	5255	10%	
Plantar Fasciitis (Bilateral)	5399-5310	0%	
COMBINED	20%