RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03439
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20050110

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Automated Logistics Specialist, medically separated for “chronic bilateral heel pain from persistent plantar fasciitis” 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 - 20041029	VARD - 20050510	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Heel Pain 	5399-5310	0%	Bilateral Plantar Fasciitis	5299-5277	10%	20050121	
Bilateral Knee Pain	Not Unfitting	Right Knee Retropatellar Syndrome	5299-5260	10%	20050121	
		Left Knee Retropatellar Syndrome	5299-5260	10%	20050121	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  40% 	

ANALYSIS SUMMARY:  

Chronic Bilateral Heel Pain from Persistent Plantar Fasciitis.  The PEB combined the left and right heel pain as a single unfitting condition coded 5399-5310 for mild disability and rated 0%. The approach by the PEB commonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The panel’s initial charge in this case was 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.  

According to the service treatment record and MEB narrative summary (NARSUM), the CI’s bilateral heel condition began in mid-2002 when he began complaining of a painful arch in his right foot in the absence of trauma.  A physical assistant’s note dated 3 January 2003 indicated the CI had been treated numerous times without resolution of the pain.  Examination of the right foot revealed no edema, ecchymosis (black and blue on the skin) or gross deformities.  There was slight tenderness to palpation on the plantar aspect without any nodules or masses and full range of motion (ROM) of the toes.  X-rays were normal without any bony changes.  

A podiatry note dated 29 September 2003 indicated a worsening condition of the knees and ankles.  Examination revealed the CI walked with his feet externally positioned (abducted).  The working diagnosis was degenerative joint disease.  X-rays of the feet dated 14 June 2004 demonstrated possible remote trauma to the left dorsal talus (bone) in an otherwise unremarkable bilateral foot series.  X-rays of the ankles showed the osseous structures and joint spaces were intact with a left os naviculare (an accessory ossicle adjacent to the medial side of the navicular bone) present.  There was also mild bilateral Achilles spurs. The ankle mortise was well-maintained bilaterally and bone mineralization was preserved.  

At a podiatry clinic visit on 1 July 2004 the CI complained of plantar fasciitis of the right foot, which worsened and was described as dull, chronic pain of the mid arch that worsened in the afternoon.  Examination revealed a “too many toes sign” of the right foot (posterior tibial tendon dysfunction with a flatfoot deformity), an abducted and pronated right foot and a supinated left foot.  The assessment was limb length discrepancy and plantar fasciitis. 

During the 20 July 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported pain in the bottom of the feet depending on how much standing and walking he did or being on certain surfaces.  Physical examination showed normal arches of the feet and “exam today elicits no discomfort.”

The 4 August 2004 MEB NARSUM examination, 5 months prior to separation, noted complaints of right foot arch pain.  The CI noted increased pain with prolonged standing and walking and with walking on uneven terrain.  He also experienced severe pain with attempted running.  A focused podiatric physical examination showed dorsal pedis and posterior tibialis pulses 1/4 bilaterally.  Epicritic sensation (fine discrimination of touch or temperature) was grossly intact in the feet and ankles.  There was tenderness to palpation in the proximal one third and medial band of the plantar fascia bilaterally.  Ankle ROM testing showed 10 degrees of dorsiflexion (normal 20) and 25 degrees (normal 45) plantar flexion bilaterally without pain or crepitus (grinding).  There was no noted edema, erythema (redness) or ecchymoses of the feet or ankles.  

At the 21 January 2005 VA Compensation and Pension (C&P) evaluation, 11 days after separation, the CI reported he was limited to walking 100 yards or standing for 5 minutes and then he had to sit and rest because of pain.  Orthotics and special shoes did not help.  He did not lose any time from work and the condition did not interfere with his activities of daily living.  Physical examination showed no painful motion, edema, weakness or instability.  He did have tenderness mainly over the right long arch just distal to the calcaneus (heel bone), less so on the left.  Manipulation of the forefoot was normal without pain or tenderness.  There was no abnormal weight bearing in his Achilles tendons or midline, and there was no loss of his long arches. 

At a VA podiatry consultation examination on 28 September 2005, 8 months after separation, the CI complained of bilateral heel pain, which he rated 7/10.  The medial tubercle of the calcaneus was tender to palpation.  Pain with palpation of the mid third plantar area with stretch was also present.  The impression was plantar fasciitis of the right foot.  

At the 6 December 2005 C&P evaluation, 11 months after separation, the CI reported pain and stiffness at rest and while standing or walking.  The condition did not result in any time lost from work.  Physical examination of the feet revealed no tenderness, weakness, edema, atrophy or disturbed circulation.  Pes planus was not present.  He had limitations due to pain with standing and walking for 45 minutes.  He did not require any type of support with his shoes.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic bilateral heel pain 0%, coded 5399-5310 (Group X muscle injury), citing bilateral tenderness of heel pads.  The VA rated the bilateral heel condition 10%, coded 5299-5277 (bilateral weak foot), based on the C&P examination 4 months after separation.  In this case, a bilateral condition was initially profiled, but the permanent profile listed only chronic right heel pain; however, bilateral plantar fasciitis was implicated by the NARSUM and in the commander’s statement.  Members agreed that each foot condition was separately unfitting; however, the preponderance of evidence referred to the right foot plantar fasciitis, which warrants a 10% rating for a moderate disability based on pronation of the foot as well as tenderness on several examinations.  However, the left plantar fasciitis findings were more compatible with a slight disability warranting a 0% rating.  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 right heel condition, coded 5399-5310 and a disability rating of 0% for the left heel condition, coded 5399-5310.  

Contended PEB Condition:  Bilateral Knee Pain.  The panel’s main charge is to assess the fairness of the PEB’s determination that the bilateral knee condition was not unfitting.  Although the contended condition was mentioned in the commander’s statement, it was not permanently profiled or judged to fail retention standards.  Although lifting, standing and stooping for prolonged periods were limitations noted by the commander, the CI’s capabilities were such that he could still perform a portion of his MOS tasks and his greatest problems stemmed from the inability to perform tasks that would make him the most combat effective.  At an orthopedic clinic visit dated 18 August 2004, the CI complained of bilateral knee pain, which was refractory to physical therapy.  Pain was described in the anterior knees behind the patellae (kneecaps), which was worse with steps and hills.  There was no instability or mechanical symptoms.  The CI was not particularly limited in the performance of his MOS and exercised on his own avoiding those exercises that elicited pain.  Examination revealed good muscle tone without effusion.  Motor strength was 5/5 with intact neurologic and vascular examinations.  He had full pain free ROM with a mild positive patellar grind.  There was no anterior or posterior or varus or valgus instability.  McMurray’s testing (to determine a meniscal tear) was negative.  There was no tenderness to palpation and leg lengths from ASIS (anterior superior iliac spine) were identical at 98 cm.  X-rays of the knees were unremarkable and there was no evidence of degenerative arthritis in the knees.   The examiner’s impression was bilateral RPPS (retropatellar pain syndrome), which responded to limitation of activity with no evidence of arthritis or evidence of leg length discrepancy.  The examiner additionally noted “[w]ithin the confines of his current permanent profile he is able to perform his MOS specific functions with little problem.  Patient meets retention criteria.”  

At the VA examination dated 21 January 2005 the CI had a normal gait and station.  He indicated his knees hurt all the time, but never wore braces or splints.  Physical examination showed he was able to extend both knees to 0 degrees and flex to 135 degrees (normal 140) where he had 2/10 pain (10 being the worst pain).  Patellar motion had crepitus (grinding sensation) and was painful bilaterally without fluid and his left anterior cruciate ligament was “laxed” more than 1 cm.  The right anterior cruciate ligament was intact and McMurray’s sign was negative bilaterally.  Repetition did not produce weakness, fatigue or lack of endurance of either knee; however, it did cause escalating pain, but did not cause a decrease in his ROM.  The 6 December 2005 examination of the knees showed the general appearance was within normal limits bilaterally.  The ROM was 0-135 degrees bilaterally with pain beginning at 130 degrees bilaterally. There was no specific performance-based evidence from the record that showed the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the bilateral knee condition; and so, no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the bilateral heel condition, the panel recommends a disability rating of 10%, coded 5399-5310 (IAW VASRD §4.71a for the right foot and a disability rating of 0%, coded 5399-5310 IAW VASRD §4.71a for the left foot.  In the matter of the contended bilateral knee condition, the panel agrees that it cannot recommend it for additional disability rating.  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 as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Right Heel Pain 	5399-5310	10%	
Chronic Left Heel Pain	5399-5310	0%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170327, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180008987, 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