RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02586
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090505

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, MLRS Operational Fire Direction Specialist, medically separated for “bilateral plantar fasciitis pain,” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  No specific contention was 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 - 20090129	VARD -20091229 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Plantar Fasciitis Pain	5299-5284	10%	Bilateral Plantar Fasciitis	5099-5020	10%	20090310	
		10%	Right Achilles Tendonitis	5271	10%	20090310	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Bilateral Plantar Fasciitis Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s left and right foot conditions began in October 2006 with marching and impact activities.  An examination in June 2007 revealed mild tenderness on the right medial heel along the plantar fascia.  At a podiatry clinic examination in December 2007 the CI had bilateral tenderness at the origin of the plantar fascia.  There was no pain with squeezing the calcaneus and his arches were normal on and off weight bearing.  X-rays of the right foot demonstrated no evidence of fracture, dislocation, or other acute osseous abnormality, and no significant soft tissue, joint or osseous abnormality was identified.  A January 2008 podiatry examination the CI noted slight improvement with inserts, but discomfort continued.  In March 2008 he was fitted with night splints.  In May 2008 the podiatry examination showed bilateral tenderness at the origin of the plantar fascia and the CI underwent extracorporeal shock wave therapy (orthotripsy).  Foot X-rays in August 2008 were normal, but on examination he had tenderness of the Achilles tendon approximately 3-8 cm proximal to the insertion at the right lower extremity and tenderness of the plantar fascia at the heels bilaterally.  The examiner reviewed the X-rays and noted an infracalcaneal exostosis (bone spur) on the right.  

A podiatry examination on 10 November 2008, showed bilateral feet and ankles without open lesions, ecchymosis, erythema or calor (heat).   Pedal pulses were palpable bilaterally and capillary fill time was less than 3 seconds of all toes bilaterally. There was no edema and light touch sensation was intact bilaterally.  Muscle compartments of the feet were soft bilaterally and strength was normal bilaterally.  There was no crepitus (grinding sensation) with range of motion (ROM) of the joints of the feet and ankles, and there was symmetric ROM of the joints.  There was no tenderness with ROM of the feet and ankles laterally, but there was tenderness of the Achilles tendon, approximately 3-8 cm proximal to insertion in the right lower extremity.  There was also tenderness of the plantar fascia at the heels bilaterally.  

During the 2 December 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported pain in both heels, the right Achilles tendon and plantar fasciitis in both feet.  Physical examination revealed a full ROM of the ankles and feet bilaterally.  There was tenderness over the metatarsal heads, retrocalcaneal areas bilaterally and the right Achilles tendon, but without swelling or crepitus.

The 15 December 2008 MEB NARSUM examination, 5 months prior to separation, noted complaints of constant bilateral foot pain along the retrocalcaneal and posterior plantar aspects of both feet.  In the right foot, there was pain along the Achilles tendon insertion site.  Symptoms increased with prolonged standing, walking and bearing weight.   ROM testing of the bilateral ankles after repetitive motion, showed plantar flexion of 45 degrees (normal) and dorsiflexion of 20 degrees (normal).  There was tenderness over the metatarsal heads and retrocalcaneal areas in the feet bilaterally.  There was no edema, erythema or open lesions about the ankles and feet.  Strength was normal bilaterally.  An L3 profile was issued on 23 December 2008 for bilateral foot pain and right Achilles tendonitis.  

At the 10 March 2009 VA Compensation and Pension (C&P) general medical examination, 2 months before after separation, the CI reported right ankle Achilles tendonitis and bilateral plantar fasciitis.  Physical examination showed tenderness at the right Achilles tendon insertion.  There were no signs of edema, effusion, weakness, redness, heat, guarding of movement, or subluxation.  ROM testing of the right ankle joint for dorsiflexion was 20 degrees and plantar flexion was 45 degrees.  Examination of the feet revealed tenderness of the plantar surfaces bilaterally and right ankle tenderness.  There was no painful motion, edema, disturbed circulation, weakness, muscle atrophy, heat, redness or instability of either foot.  There was active motion in the metatarsophalangeal joint of both the left and right great toes.  Alignment of the right Achilles tendon was normal on weight bearing and non-weight bearing.  Pes planus and pes cavus (high arch) were not present bilaterally.  He did not have any limitation with standing and walking and did not require any type of support with his shoes.  X-rays of the right ankle, right foot, and left foot dated 10 March 2009 were negative. 

At the 8 October 2009 C&P joints examination, 5 months after separation, the CI reported right ankle pain above the joint in the mid tendon.  Physical examination showed poor propulsion.  Dorsiflexion was 5 degrees and plantar flexion 45 degrees, both without pain or loss of motion with repetition.  At the 3 November 2009 C&P feet examination, 6 months after separation, the CI reported pain in the right Achilles tendon.  There was no swelling of the right foot, but there was painful motion with ankle plantar flexion and dorsiflexion and tenderness near the Achilles tendon watershed area and the posterior talofibular ligament.  The CI also had difficulty standing on his toes and was guarded due to pain.   X-rays showed bilateral calcaneal spur formation.  The examiner’s diagnosis was right Achilles tendonitis.  At an orthopedic surgery consultation on 11 January 2010, 8 months after separation, the CI complained of right ankle pain.  Since separation he worked as an 18 wheeler truck driver.  Examination revealed no limp while walking.  He had slightly hypermobile joints and a tight Achilles tendon on the right.   An MRI demonstrated a nonspecific ill-defined pattern of fluid accumulation or edema within and/or along the margins of the posterior talofibular ligament.  Primary diagnostic considerations included a grade 2 sprain versus posterolateral impingement syndrome.  There were no remarkable findings referable to the Achilles tendon.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral plantar fasciitis 20% (10% right and 10% left), analogously coded 5299-5284 (foot injuries, other), citing satisfactory evidence of painful motion.  Achilles tendonitis of the right foot was also diagnosed, but not rated due to overlap of symptoms.  The VA rated the bilateral plantar fasciitis 10%, analogously coded 5099-5020 (synovitis), based on the C&P examination, citing slight tenderness over the plantar surface of both feet and limited motion of a major joint or group of minor joints.  The VA also rated the Achilles tendonitis 10%, coded 5271 (ankle, limited motion of), based on the C&P joints examination, citing moderate limited motion of the ankle to include guarding of motion and instability.

Panel members noted there was no distinct injury to either foot so the proper code at the time of separation for plantar fasciitis would have been 5399-5310 (Group X muscle injury, which includes plantar aponeurosis).  Whether the code 5299-5284 or 5399-5310 is used for rating purposes, neither the plantar fasciitis of the right foot nor the plantar fasciitis of the left foot rose to the level of moderately severe to warrant a rating higher than 10% for either foot.  

However, the PEB combined the right foot plantar fasciitis with the diagnosed right Achilles tendonitis.  Therefore, the panel must determine whether the Achilles tendonitis is in scope.  It was listed in the MEB referral to the PEB, was explicitly noted in the profile, and was clearly addressed by the PEB as Achilles tendonitis of the right foot, but not rated due to overlap of symptoms, but was considered in the overall rating.  The PEB noted “Condition is unfitting because pain prevents wearing IBA/carrying a combat load;” however, it does not say exactly whether the condition is the plantar fasciitis and/or the Achilles tendonitis.  While the CI did not specifically contend the Achilles tendonitis, the panel determined it was in scope.  While the right Achilles tendon inserts on the calcaneus (heel bone), it originates as a union of the gastrocnemius and soleus muscle tendons in approximately the posterior portion of the mid leg.  Therefore, the PEB had a degree of justification for considering the symptomatology from the right Achilles tendonitis overlapped with the plantar fasciitis of the right foot since the plantar fascia originates from the medial tubercle of the calcaneus and inserts into the deep short transverse ligaments of the metatarsal heads.  However, the function of the Achilles tendon and the plantar fascia are different.  Furthermore, the CI had tenderness of the Achilles tendon 3-5 cm proximal to the insertion, thereby favoring its area of inflammation of the tendon more likely in the ankle than the foot.  Therefore, the panel determined the Achilles tendonitis was separately unfitting and warranted a separate rating.  The panel noted that the right ankle ROMs were normal, most proximate to separation, during service and 2 months after separation.  It was not until 5 months after separation that dorsiflexion decreased to 5 degrees, but there was no specific evidence to explain the decrease other than the CI was employed as a truck driver of an 18 wheeler.  Therefore, the panel determined that a 0% rating using code 5271 was the maximum rating available in the absence of painful motion, and use of any other ankle codes cannot offer a higher rating.

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 left and right plantar fasciitis.  In regards to the right Achilles tendonitis, the panel recommends a disability rating of 0%, coded 5271.  However, this will not change the overall rating IAW DoDI 6040.44, and provides no benefit to the CI.

BOARD FINDINGS:  In the matter of the bilateral plantar fasciitis 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 20170304, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20190006096, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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 been provided to the counsel you listed on your application, Disabled American Veterans (DAV), ATTN: XXXXX XXXXXX, XXXX XXXX XXXXXX XXXXX XXXX, XXXX XXX, XXXXXXX, XX XXXXX.