RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2017-04003
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060917

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, M1 Armor Crewman, medically separated for “bilateral painful feet” and “bilateral lower leg pains,” each rated 0%, with a combined disability rating of 0%.  

CI CONTENTION:  Review requested of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20060602	VARD - 20061114	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Painful Feet	5399-5310	0%	Bilateral Plantar Fasciitis	5020-5276	0%	20060913	
Bilateral Lower Leg Pains	5022	0%	Right Tibial Stress Reaction	5099-5022	0%		
			Left Tibial Stress Reaction	5099-5022	0%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:

Bilateral Painful Feet.  The PEB combined the right and left foot conditions under a single disability rating, analogously coded 5399-5310 (Group X Function: (plantar fasciitis) muscle injury).  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’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 right and left foot conditions are presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI began experiencing increased pain and cramps on the bottom of both feet in 2004, and in 2006, a podiatrist diagnosed plantar fasciitis which was treated with physical therapy (PT) and nonsteroidal anti-inflammatory medications.  

During the 22 March 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported left ankle pain and foot swelling after prolonged standing or boot use.  Physical examination revealed slight tenderness of the plantar aspect of the left foot.  Lower extremity range of motion (ROM) was full and strength was normal.  On 22 March 2006, bilateral foot X-rays revealed mild bilateral pes planus, a small bilateral Achilles spur, and a left calcaneal plantar spur, with no evidence of fracture.  A bone scan 2 days later showed overuse of the left ankle with mild plantar fasciitis.  

The 12 April 2006 MEB orthopedic consultation, 5 months before separation, noted CI complaints of bilateral lower leg pain.  Physical examination showed a normal gait with full bilateral knee, ankle and forefoot ROM including all digits/toes.  Podiatry consultation the same day recorded complaints of bilateral arch pain, worsened by weight bearing activity, and not relieved by custom boot inserts.  Both feet appeared normal with no vascular, sensory, or skin findings.  There was no tenderness to the plantar fascial band, but foot ROM measurements were within limits without crepitus or pain.  Foot X-rays showed a left foot bipartite fibular sesamoid and minimal plantar calcaneal spurring; and small right foot retrocalcaneal enthesophyte. A bone scan revealed changes consistent with mild plantar fasciitis.  During the 24 April 2006 MEB NARSUM examination, the CI complained of “chronic leg pain” with pain and cramps in the bottom of both feet beginning in 2004.  The examiner summarized the orthopedic and podiatry consults including noting the ability to heel and toe walk without difficulty or abnormality.  

At the 13 September 2006 VA Compensation and Pension (C&P) examination, 4 days before separation, the CI reported foot pain rated at 8-9/10.  Swelling was elicited by activity and he used orthotics.  Physical examination showed a normal gait with no abnormal weight bearing, or evidence of pes planus, pes cavus, hammer toes, Morton's metatarsalgia, hallux valgus, hallux rigidus, or gross joint/muscle abnormalities; however, both feet were tender.  Foot X-rays revealed pes planus of the left foot only on weight bearing, but no bilateral abnormalities with non-weight bearing posture. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral foot condition 0%, analogously coded 5399-5310, citing a slight muscle disability.  The VA rated bilateral plantar fasciitis with left pes planus 0%, dual coded 5020-5276 (synovitis-flatfoot, acquired (pes planus)), based on the C&P examination, citing a non-compensable examination.  Panel members first noted that the commander’s statement and other STR evidence did not provide any information which would permit the panel to discriminate the performance limitations attributable to either foot over the other.  Since undue speculation would be required to conclude that impairment from either foot would not have unacceptably interfered with the performance of military duties, the panel agreed that each foot was reasonably justified as separately unfitting.  

The panel directed attention to its rating recommendation based on the above evidence, and noted there was no penetrating wound or muscle weakness for either foot or other factors under VASRD §4.56 for any rating above slight (0%) muscle injury for either foot.  There was also no evidence of painful motion, foot deformity, limitation on standing/walking, weight-bearing line over or medial to the great toe, and inward bowing of the Achilles tendon for any rating above 0% under code 5020 or 5276 for either foot, or both together.  Although each foot could be separately rated 0%, this provided no benefit to the CI.  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.  

Bilateral Lower Leg Pains.  The PEB combined the right and left leg conditions under a single disability rating, analogously coded 5022 (periostitis).  As discussed above, the panel’s initial charge was directed at determining if combining conditions under a single rating was justified in lieu of separate ratings.  The evidence for the right and left leg conditions are presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated. 

According to the STR and MEB NARSUM, the CI’s bilateral leg condition began in 1997 during his first assignment where he was required to run and ruck over hills and mountains.  A bone scan in 2000 showed chronic stress reactions without fractures, and symptoms persisted or reoccurred with increased physical activity.  During the MEB examination, the CI reported bilateral knee and ankle pain, with a history of stress fractures in both legs.  Physical examination revealed full active ROM of both knees and ankles and normal, bilateral lower extremity strength.  

The MEB orthopedic consultation noted CI complaints of bilateral lower leg pain, and multiple X-rays and imaging revealed chronic tibial stress reactions without progression and no frank fractures.  Physical examination showed a normal gait, and full bilateral knee and ankle ROM with no laxity.  Percussion and palpation along the anterior tibial prominence from knee through ankle elicited a painful response, but there was no focal tenderness.  The provider noted that he was “essentially tender throughout both right and left lower extremities along the tibial prominence.”  The diagnosis was “bilateral lower extremity stress reactions without frank stress fractures.”  The MEB NARSUM examination noted reports of chronic shin splints, and the examiner referenced the orthopedic evaluation, indicating the CI could to heel and toe walk without difficulty. 

At the C&P examination, the CI reported foot pain and swelling elicited by activity.  Physical examination showed a normal gait and posture, but tenderness along the right and left tibia.  Bilateral knee and ankle ROMs were normal and joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use.  Right tibia and fibula X-rays were unremarkable.  

As with the bilateral foot condition, the commander’s statement and other STR evidence did not provide any information which would permit the panel to discriminate the performance limitations attributable to either leg over the other.  Since undue speculation would be required to conclude that impairment from either leg would not have unacceptably interfered with the performance of military duties, panel members agreed that each leg was reasonably justified as separately unfitting.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral lower leg condition 0%, analogously coded 5022, citing full motion of contiguous joints.  The VA rated the right and left tibial stress reaction conditions 0% each, analogously coded 5099-5022, based on the C&P examination, citing a non-compensable examination.  There was no evidence of a frank stress fracture of either leg, or painful motion, or limitation of motion for either knee or either ankle.  The panel considered alternative rating under code 5262 (tibia and fibula, impairment of), but adjudged that there was insufficient evidence of slight knee or ankle disability for either leg to warrant any rating above 0%.  Although each leg could be separately rated 0%, this provided no benefit to the CI.  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 leg condition.  

BOARD FINDINGS:  In the matter of the bilateral foot condition and IAW VASRD §4.73, the panel recommends no change in the PEB adjudication.  In the matter of the bilateral leg 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.  

	PD-2017-04003

AR20190011669, XXXXXXXXXXXXXXXXXXXXXXX 

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.

	PD-2017-04003