RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04148
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090827

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Unit Supply Specialist, medically separated for “bilateral plantar fasciitis” and “left ankle degenerative joint disease (DJD) and Achilles tendonitis,” rated 10% each.

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 - 20090521	VARD - 20090519	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Plantar Fasciitis (PF)	5299-5278	10%	Bilateral PF with Pes Cavus	5299-5278	10%	20090313	
Left Ankle DJD and Achilles Tendonitis	5024-5271	10%	Left Ankle Tendonitis	5024-5271	10%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral PF.  The PEB combined the left and right PF conditions under a single disability rating, coded analogously to 5278 (clawfoot [pes cavus], acquired) and rated 10%.  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.  

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s bilateral PF condition began in December 2007 during basic training.  The CI reported left foot pain at a primary care clinic visit on 17 January 2008 and was diagnosed with PF.  A flight medicine clinic examination for complaint of left foot pain on 11 March 2008 diagnosed congenital pes cavus (bilateral).  A bone scan on 27 March 2008 showed focal stress changes of the left mid-foot.  At a flight medicine clinic visit on 3 April 2008, the CI reported the left foot pain was improved with arch supports.  However, when the CI tried to run on a treadmill, the left foot pain returned.  

At a flight medicine clinic visit on 4 September 2008, the CI reported persistent left heel pain, but reduced from earlier and custom orthotics were ordered.  The CI reported the orthotics were not much help and she continued to report pain and swelling of her feet with weight-bearing activities.  An MRI of the left ankle/foot on 21 November 2008 showed arthritis of the tarsal and first metatarsal joints and mild tendonitis of the flexor tendons.  The permanent profile dated 21 October 2008 listed bilateral shin splints and bilateral stress fractures.  The commander’s statement did not implicate a specific medical condition or conditions as impairing the CI’s duty performance.  

At the 13 March 2009 VA Compensation and Pension (C&P) examination, 5 months before separation, the CI reported pain in the arches that occurred three times per week and lasted for 2 hours.  She reported at rest she had no pain, the pain was precipitated by walking or standing. She reported at the time of pain she could function without medication.  Treatment was icing and stretching.  The CI reported no functional impairment from the condition.  Physical examination showed a normal gait.  There were no signs of abnormal weight bearing, callosities or unusual show wear pattern.  There was no painful motion, weakness, or instability of either foot.  Ankle range of motion (ROM) was dorsiflexion of 12 degrees (normal 20) and plantar flexion of 45 degrees (normal).  There was no hallux valgus or rigidus.  There was slight tenderness of the plantar fascia and under the metatarsal heads of both feet.  There was normal alignment of the Achilles tendons.  The CI was noted to have claw feet.  There was slight contraction and shortening of the plantar fascia and mild eversion and varus deformity bilaterally.  Dorsiflexion of the toes did not produce pain on either foot.  The VA examiner noted the CI did not have any limitation with standing or walking or require any type of support in her shoes.  Bilateral foot X-rays on 13 March 2009 showed no evidence of healing stress fractures.  The joint spaces appeared fairly well maintained.  There was no soft tissue swelling.  

The 24 April 2009 MEB NARSUM examination, 4 months prior to separation, noted complaints of bilateral PF.  Physical examination showed tenderness over the top of the left mid-foot, with segmental restriction in the area.  The left arch had an asymmetrically higher cavus orientation than the right foot.  The MEB NARSUM determined the CI fell below retention standards due to chronic bilateral foot pain plantar fasciitis.  The permanent profile listed “bilateral stress fractures” which included only the left foot stress fracture.  The MEB NARSUM determined the CI fell below retention standards due to “chronic bilateral foot pain plantar fasciitis.”  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 military occupational specialty performance, members agreed that each foot was reasonably justified as separately unfitting.

The panel then directed attention to its rating recommendation based on the above evidence.  The CI’s case was processed according to the Department of Defense/VA Disability Evaluation System Pilot Program.  The DES Proposed Rating for bilateral PF with pes cavus was 10%, coded 5299-5278 (claw foot [pes cavus]), based on the STR and C&P examination, citing pain on the bottom of both feet.  The PEB and VA rated the bilateral PF condition 10%, analogously coded 5278 as recommended in the DES Proposed Rating. 

There was no evidence of all toes tending to dorsiflexion, ankle dorsiflexion limited to neutral, or marked tenderness under the metatarsal heads for a higher rating of either foot or the bilateral feet under 5278.  There was no other foot or toe deformity of either foot to support a higher rating.  The panel considered if rating the PF conditions under 5310 analogous to Group 10 muscle injury (includes the plantar fascia) provided a higher rating for one or both feet.  The panel agreed that a 0% rating for each foot was supported analogous to slight muscle injury.  The PF conditions did not meet the threshold for moderate level of disability under 5310 based on the pre-separation VA examination, the most proximate examination to separation, which documented the CI had no pain at rest and only intermittent foot pain, approximately 6 hours per week.  There was therefore no higher than a 10% rating supported for the bilateral PF condition under any applicable VASRD code.  After unbundling the foot conditions the panel found there was no ratings benefit to the CI.  Therefore, no change to the PEB’s combined adjudication is recommended.  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 PF condition.  

Left Ankle DJD and Achilles Tendonitis.  According to the STR and MEB NARSUM, the CI’s left ankle condition began in December 2007 after an ankle sprain during basic training.  Ankle MRI on 21 November 2008 showed arthritic changes and mild tendonitis of the flexor tendons as they passed behind the medial malleolus.  The 24 April 2009 MEB NARSUM examination noted complaints of left ankle pain.  Physical examination did not address the left ankle.  

At the 13 March 2009 VA C&P examination, 5 months before separation, the CI reported left ankle pain three times per week that lasted for 45 minutes.  The pain was localized and increased with activity and was relieved by rest, ice and massage.  She reported pain, swelling, weakness and locking, and denied giving way or dislocation.  At the time of pain the CI reported she could function with medication.  She was not receiving treatment for the condition and denied any functional impairment due to the condition.  Physical examination showed a normal gait.  There was tenderness, but no swelling, weakness, guarding of movement, subluxation, or deformity of the ankle.  Ankle ROM was dorsiflexion of 12 degrees (normal 20) and there was normal plantar flexion, with pain at end ROM.  There was increased pain after repetition, without additional loss of ROM.  Left ankle X‑rays were normal.

As noted above, the VA DES Proposed Rating for left ankle tendonitis was 10% coded 5024-5271 (tenosynovitis-ankle, limited motion), based on the STR and C&P examination, citing painful, limited motion.  The PEB and VA rated the left ankle condition 10%, coded 5024-5271 as recommended in the DES Proposed Rating.  

A 10% rating was supported for painful limited motion of the ankle coded 5024, or for limitation of ankle motion that was moderate under 5271.  There was no evidence of marked limitation of ankle ROM for a higher rating under 5271.  The panel considered other VASRD ankle codes, but all were less applicable and/or not advantageous for 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 ankle condition.  

BOARD FINDINGS:  In the matter of the bilateral plantar fasciitis condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the left ankle degenerative joint disease and Achilles tendonitis 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:

	PD-2017-04148

AR20190011736, XXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXXX

	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-2017-04148