RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXX 	CASE:  PD-2017-04448
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090331

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Human Intelligence Collector, medically separated for “left plantar fasciitis” with a disability rating of 10%.    

CI CONTENTION:  Review requested of the left plantar fasciitis as well as 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 – 20090126	VARD - 20090609	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Plantar Fasciitis	5299-5284	10%	Left Foot Plantar Fasciitis	5020	10%	20090407	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Left Plantar Fasciitis (PF).  According to the service treatment record and MEB narrative summary (NARSUM), the CI initially experienced left foot pain in March 2006 during basic training and was diagnosed with bilateral tibial stress fractures at the time.  In October 2006, she developed left foot pain and swelling during a 6-mile run, and X-rays showed stress fractures of the second, third, and fourth metatarsals (MTs).  She was treated with a controlled ankle motion (CAM) walker and crutches, but after advanced individual training, the foot continued to hurt.  Foot X-rays in January and April 2007 showed no abnormality of the third or fourth MTs and there was evidence of good positioning and healing of the second MT.  An MRI on 30 April 2007 showed periosteal reaction of the second MT suggestive of a stress fracture.  Subsequently, the CI was treated for recurrent stress fractures with profiles and use of a CAM walker boot and crutches.  She continued to report persistent foot pain, but an MRI on 5 June 2008 showed no abnormalities of the feet.  A bone scan on 10 July 2008 showed increased activity within the left ankle that may have been post-traumatic injury or stress change and mild left foot PF, but no other foot abnormalities, and she was given a CAM walker and crutches to use again.  At an orthopedic examination on 17 July 2008, the CI reported left foot pain, and the physical examination revealed mild tenderness of the dorsal foot over the second and third MTs.  The provider indicated that a recent MRI and bone scan were negative for active stress fractures, and diagnosed “recurrent stress injury, not active on bone scan, but chronically recurrent.”  

At the 28 August 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, the CI was using a CAM walker.  At a podiatry visit on 28 October 2008, 5 months before separation, the examiner thought the left foot pain was due to mechanical problems or possibly a third interspace neuroma.  Initially strapping and padding of the foot was tried without improvement, and at a follow-up visit on 20 November 2008, the third interspace was injected with steroids which provided significant improvement.  Surgery for neuroma removal was considered but could not be performed until early February 2009 due to the podiatrist’s schedule, and the CI was given a second steroid injection.  

The 5 December 2008 MEB NARSUM examination, 4 months prior to separation, noted complaints of chronic foot pain.  Physical examination showed a slow uneven gait with a CAM walking boot and use of a cane, and tenderness across the medial aspect of the top of the foot.  Left foot ROM was dorsiflexion (DF) of 22 degrees (normal 20) and plantar flexion of 35 degrees (normal 45), with painful motion, and increased pain with repetition.  

At the 7 April 2009 VA Compensation and Pension (C&P) examination, 1 week after separation, the CI reported continued left foot pain, with occasional heel pain, worsened by prolonged standing and walking.  She treated the pain with rest and daily anti-inflammatory medication.  Physical examination showed a normal gait and symmetrical feet with mild flatfoot and hallux valgus (bunion) on each side with no tenderness.  The CI was able to rise on the heels and toes, walk heel to toe, and rise up on one foot without apparent discomfort.  Foot and ankle ROM was normal in all planes with no evidence of discomfort, loss of mobility, function or instability, and there was no change with repetitive use.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left PF 10%, analogously coded 5299-5284 (foot injuries, other), citing moderate disability.  The VA also rated the left foot PF condition 10%, but coded 5020 (synovitis), based on the C&P examination, citing painful or limited motion of a major joint or group of minor joints.  Panel members noted the CI’s left foot pain was due to metatarsal fractures/stress reactions with development of PF, but at the VA examination, which was closest to separation, she had a normal gait and physical examination,    Although she reported continued foot and occasional heel pain, the panel agreed that the disability due to the foot condition was best characterized as a moderate foot injury for a 10% rating, with no evidence of a severe foot injury for a higher rating under code 5284.  The panel considered other VASRD foot and analogous codes, but all were less applicable 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 foot condition.  

Contended PEB Condition:  Chronic Left Foot Pain With Plantar Fasciitis And Non Healing Stress Fractures.  The panel’s main charge is to assess the fairness of the PEB determination that the contended non-healing left stress fractures were not unfitting.  The contended condition was profiled and the December 2008 NARSUM noted that chronic left foot pain with multiple contributing diagnoses, including non-healing stress fractures, caused the CI to fail retention standards.  However, as noted above, imaging in June and July 2008 showed no evidence of active stress fractures, and the PEB Form 199 also stated that despite the NARSUM and MEB diagnosis of “non-healing stress fractures,” they appeared to have resolved.  The VA examiner also documented a normal gait and left foot examination.   The panel agreed that an additional rating for residual foot pain cannot be assigned IAW VASRD §4.14 (avoidance of pyramiding), which states “the evaluation of the same disability under various diagnoses is to be avoided.”  All contributions to the CI’s disability due to foot pain are subsumed in the panel’s §4.71a rating recommendation for the left foot PF.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the left plantar fasciitis and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended left foot non-healing stress fractures, the panel agrees it cannot recommend it for additional disability rating.  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:

AR20190011897, XXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXX

	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.