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Dear XXXXXXXXXX:

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.

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX  	CASE:  PD-2017-03924
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080215

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Cannon Crewmember, medically separated for “degenerative arthritis of the left talonavicular joint” and “plantar fasciitis, bilateral feet,” rated 10% and 0% respectively, with a combined disability rating of 10%.  

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 - 20080923	VARD - 20080722	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Degenerative Arthritis of the Left Talonavicular Joint	5003	10%	Plantar Fasciitis and Degenerative Joint Disease, Left Foot	5299-5021	10%	20071105	
Plantar Fasciitis, Bilateral Feet	5399-5310	0%					
			Plantar Fasciitis, Right Foot	5299-5021	10%	20071105	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Degenerative Arthritis of the Left Talonavicular Joint.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s left foot condition began in February 2006 after twisting his ankle while running.  Weight-bearing X-rays showed bilateral talar beaking.  A CT of the feet showed a linear lucency which extended to the navicular bone at the talonavicular joint and was interpreted as “degenerative changes of the navicular bone at the talonavicular joint.”  During the 24 July 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, the CI reported no specific complaints.  Physical examination of the left foot was within normal limits with pain on weight bearing.  

At the 5 November 2007 Compensation and Pension (C&P) examination, 3 months before separation, the CI reported constant 8/10 left foot pain worse with activity.  Physical examination showed left foot tenderness without painful motion, edema, disturbed circulation, weakness or atrophy and gait was within normal limits.  There was no limitation with standing or walking.  Range of motion (ROM) testing of the left ankle joint showed dorsiflexion of 20 degrees (normal) and plantar flexion of 45 degrees (normal).  Joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use.  There was no indication of a malunion to the os calcis or astralgus on the left.  

The 20 November 2007 MEB NARSUM examination, 3 months prior to separation, noted the CI could only stand for 30 minutes due to pain.  Physical examination showed diffuse tenderness at the left foot talonavicular joint and at the tarsal metatarsal joint medially.  The ROM evaluation showed dorsiflexion of 3 degrees and plantar flexion of 43 degrees without painful motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left talonavicular condition 10%, coded 5003 (arthritis, degenerative), citing limitation of motion.  The VA rated the left talonavicular joint (combined with the left plantar fasciitis) 10%, analogously coded 5021 (myositis), based on the C&P examination, citing painful or limited motion of a major joint or group of minor joints.  

There was no foot weakness which supported a rating under the diagnostic code for weak foot (5277).  There was no evidence of claw foot (5278), acquired flatfoot (5276) or metatarsalgia (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 moderately severe ongoing foot pain that could be analogously coded under 5399-5310 (Group X. Function: Movements of forefoot and toes) for a 20% rating.  There was no other VASRD §4.71a rating under any applicable code for the left foot.  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 talonavicular condition.  

Bilateral Plantar Fasciitis.  The PEB combined the left and right plantar fasciitis as a single unfitting condition coded 5399-5310 and rated 10%.  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’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.  

According to the STR and MEB NARSUM, the CI’s left plantar fasciitis began in February 2006 (as noted above) while running.  Pain to the plantar aspect of the left foot, medial heel area and sole of the left foot were reported.  The CI was diagnosed with plantar fasciitis for which he received extensive treatment.  In January 2005, the CI reported a right foot problem with no history of trauma.  

During the MEB examination, 7 months prior to separation, the CI reported no specific complaints.  Physical examination of the left foot was within normal limits with pain on weight bearing.  There were no notations regarding the right foot.

At the C&P examination the CI reported constant 8/10 left foot pain worse with activity.  Physical examination showed no painful motion, edema, disturbed circulation, weakness or atrophy and gait was within normal limits.  The CI did not have any limitation with standing or walking and there was no indication of a malunion to the os calcis or astralgus on the left or right, but there was left and right foot tenderness.  The ROM evaluation of the left and right ankle joints showed dorsiflexion of 20 degrees bilaterally and plantar flexion of 45 degrees bilaterally.  The left and right joint functions were not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use.    

The MEB NARSUM examination, 3 months prior to separation, showed tenderness at the plantar medial aspect of the calcaneous and plantar fascia at the mid-foot.  Examination of the right foot showed tenderness at the plantar medial calcaneous.  The ROM study showed left ankle dorsiflexion of 3 degrees and plantar flexion of 43 degrees and right ankle dorsiflexion of 0 degrees and plantar flexion of 50 degrees.  There was no painful motion in either foot.  

The panel first considered if the left and right feet, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The panel majority agreed that the evidence reasonably justified that the functional limitations of the condition contributed to the CI’s inability to perform his military duties and accordingly separate disability ratings are recommended.  

Plantar Fasciitis Left Foot.  The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral plantar fasciitis 0%, analogously coded as 5310, citing slight muscle injury.  The VA rated the left plantar fasciitis (combined with the left talonavicular condition) 10% analogously coded 5021, based on the C&P examination, citing painful or limited motion of a major joint or group of minor joints.  

The panel noted the left foot had already been rated for degenerative arthritis of the left talonavicular joint.  Though a separate condition it is similar in its effect upon the CI’s ability to walk and stand for prolonged periods.  Thus in compliance with VASRD §4.14 (avoidance of pyramiding) the panel could not recommend an additional rating for the left foot plantar fasciitis.  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 left plantar fasciitis.  

Plantar Fasciitis Right Foot.  The panel directed attention to its rating recommendation based on the above evidence.  The VA rated the right plantar fasciitis 10%, analogously coded 5021, based on the C&P examination citing painful or limited motion of a major joint or group of minor joints.  

There was no ankle ankylosis to support a rating under the diagnostic code (5270).  The panel majority agreed there was evidence of ongoing foot pain affecting function which could be described as moderate and analogously coded under 5399-5310 to justify a 10% rating.  There was no foot weakness which supported a rating under the diagnostic code for weak foot (5277).  There was no malunion or nonunion of the tarsal or metatarsal bones to support a rating under diagnostic code 5283.  There was no evidence to justify a 20% moderately severe rating under diagnostic code (5284).  There was no evidence of claw foot (5278) or acquired flatfoot (5276).  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 10% for the right plantar fasciitis, analogously coded 5399-5310.  

BOARD FINDINGS:  In the matter of the left talonavicular condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the left plantar fasciitis and IAW VASRD §4.73, the panel recommends no change in the PEB adjudication.  In the matter of the right plantar fasciitis the panel majority recommends a disability rating of 10%, coded 5399-5310 IAW VASRD §4.73.  The single voter for dissent recommends no change and does not elect to submit a minority opinion.  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	
Degenerative Arthritis of the Left Talonavicular Joint	5003	10%	
Plantar Fasciitis Left Foot	5399-5310	0%	
Plantar Fasciitis Right Foot	5399-5310	10%	
COMBINED	20%