RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02598
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080927

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Food Service Specialist, medically separated for “bilateral pes planus” with a disability rating of 10%.  

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 - 20080717	VARD - 20081203	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Pes Planus	5299-5276	10%	Bilateral Pes Planus	5276	10%	20080725	
			Bilateral Plantar Fasciitis 	5020	10%	20080725	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral Pes Planus. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI was noted to have mild asymptomatic pes planus on his service entry (MEPS) examination.  He began developing bilateral foot pain (confined to soles and arches) in basic training.  Bilateral X-rays demonstrated pes planus on weight-bearing views, but no degenerative changes or other abnormalities.  Provider entries in the STR consistently documented bilateral flattened arches and plantar tenderness (with exceptions).  One podiatry note recorded “excessive pronation of the feet,” but there was no other note of malalignment or objective evidence of marked deformity.  Although there was mention of an associated diagnosis of plantar fasciitis in a primary care and a physical therapy note, podiatry consults and follow-up entries recorded pes planus as the sole diagnosis.  The symptoms did not respond adequately to treatment with orthotics.  There was ample documentation (with no contrary evidence) of a normal gait, grossly normal range of motion (ROM) of the ankles and feet and no swelling.  There were conflicting entries noting both the presence and absence of painful motion.  There was no documentation of callosities, additional VASRD-ratable findings, or alternate diagnoses covered by specific VASRD foot codes.  

The 27 March 2008 MEB NARSUM examination (podiatry), 6 months prior to separation, documented pain “at the bottom of both feet throughout the arches” regardless of whether he was standing or sitting, which prohibited running and heavy lifting.  The physical examination recorded bilateral tenderness over the arches with marked flattening on weight-bearing.  There was no documentation of callosities, deformity, malalignment, swelling, ankle or foot ROM limitation, painful motion, painful manipulation or other positive finding.  The NARSUM podiatrist diagnosed only pes planus without mention of plantar fasciitis.  

The 25 July 2008 VA Compensation and Pension (C&P) examination, 2 months before separation, documented “constant” bilateral “heel to the ball” foot pain that was aggravated by prolonged standing and caused “problems with lifting and carrying” at work.  The physical examination recorded a normal gait, bilateral diffuse plantar tenderness, non-specific arch flattening, pronation, “weight bearing line over or medial to great toe,” a single callus on the left foot (below third metatarsal), no swelling and “no pain at rest.” There was no note of pain on motion or manipulation or documentation of any other deformity or malalignment, ankle or foot ROM limitation or other positive finding.  The C&P examiner diagnosed bilateral plantar fasciitis “associated with” bilateral pes planus.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral foot condition 10%, coded 5299-5276 (analogous to acquired pes planus), citing the applicable bilateral “moderate” criterion of code 5276.  The moderate 10% rating is further defined as “weight-bearing line over or medial to great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet, bilateral or unilateral.”  The criteria for the next higher “severe” rating (30% for bilateral) are “objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities.”  The VA, based on the C&P examination, conferred separate bilateral ratings: 10% under code 5276 citing the above quoted criterion for abnormal weight-bearing line, and 10% under code 5020 (synovitis) stating only that “the evidence shows painful motion.”

The panel first considered the option of separate ratings for each foot in lieu of the combined bilateral rating as adjudicated by the PEB.  In order to recommend separate ratings for conditions consolidated under a single rating by the PEB, the panel must assess whether each condition is reasonably justified as separately unfitting, although it is considered to be so unless there is a preponderance of evidence to the contrary.  That notwithstanding, bilateral rating is offered under various foot codes; and, unless it violates VASRD §4.7 (higher of two evaluations), a bilateral rating under an applicable code is appropriate regardless of separate fitness considerations.

The panel next agreed that separate ratings for pes planus and plantar fasciitis, as conferred by the VA, were not justified for service rating.  Plantar fasciitis might be considered for alternate analogous coding and rating, even though not specifically submitted for PEB adjudication, but it was the associated pain that was unfitting.  Members agreed that the latter could not serve as ratable criterion under separate codes for service rating without pyramiding (VASRD §4.14).  The panel also deliberated whether separate right and left foot ratings could be justified under code 5399-5310 (analogous to the applicable muscle disability code for plantar fasciitis) or any other code.  Members agreed that this could not be justified.  Even if separate unfitness were conceded, as introduced above, code 5276 is quite specific to the condition under adjudication.  There was insufficient evidence of criteria that would support a more favorable rating under alternate codes that would satisfy the provisions of VASRD §4.7 (as above) and/or §4.20 (analogous ratings).  

Having concluded that bilateral rating under the above criteria of code 5276 was appropriate, the panel considered whether a rating higher than 10% was supported by the evidence.  Members agreed that the criteria for a higher rating were not sufficiently supported by the evidence.  Although pronation was noted, there was no indication that it represented a “marked deformity.”  Pain on manipulation was equivocally demonstrated and certainly not “accentuated.”  There was no indication of swelling and callosities were minimal.  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 bilateral foot condition.

BOARD FINDINGS:  In the matter of the bilateral foot 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 20170329, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20190007065, 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.