RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04493
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080131

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Health Care Specialist, medically separated for “sacroiliac pain” rated 10%, and “chronic left knee pain” and “chronic plantar fasciitis,” rated 0% each, with a combined disability rating of 10%.  

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 - 20071116	VARD - 20081014	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Sacroiliac Pain	5236	10%	Lower Spine Strain	5237	10%	20080404	
Chronic Left Knee Pain	5099-5003	0%	Left Knee S/P Anterior Cruciate Ligament [ACL] Reconstruction with Well Healed Scar and Degenerative Joint Disease	5260	10%	20080404	
Chronic Plantar Fasciitis	5399-5310	0%	Left Foot Plantar Fasciitis with Pes Planus S/P Gastrocnemius Resection and Subtalar Joint Arthrodosis	5276	10%	20080404	
			Right Foot Plantar Fasciitis with Pes Planus	5276	0%	20080404	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Sacroiliac (SI) Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s SI condition began in 1998 after supporting a syncopal patient.  She underwent a MEB and PEB in 2004 but was found fit and returned to duty.  At the 10 July 2007 MEB physical therapy (PT) range of motion (ROM) evaluation, goniometric measurements revealed average thoracolumbar flexion to 89 degrees (normal 90).  The 17 October 2007 MEB NARSUM addendum, 3 months prior to separation, noted CI complaints of occasional back pain at the left SI joint with radiation into the buttocks but not down the legs.  When the SI pain occurred, it lasted for a short while, and occasionally she used heat/ice/or a TENS unit but took no pain medication.  Physical examination showed she was able to touch her toes and there was no lumbar spine or SI joint tenderness and no paralumbar muscle spasms.  Bilateral straight leg raising was to 80 degrees with no radicular symptoms, and neurovascular function was intact.  

At the 4 April 2008 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported lower middle back pain and radiation to the left buttock with left leg numbness or tingling when getting out of a car.  Physical examination showed an antalgic gait, but normal posture, and no muscle spasms or tenderness.  Range of motion measurements showed flexion to 90 degrees, and extension to 30 degrees (normal), with painful motion during forward and lateral flexion.  The 6 May 2008 clinic examination showed full ROM with no pain, lumbosacral spine tenderness, and muscle spasms.  There was no numbness or radiation and upper extremity strength was normal.  The CI took a narcotic and a muscle relaxant for pain.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the SI condition 10%, coded 5236 (SI injury and weakness), citing tenderness and flexion to 90 degrees not limited by pain.  The VA rated the lower spine strain condition 10%, coded 5237 (lumbosacral strain), based on the C&P examination, citing painful motion on flexion.  Panel members agreed that the VA examination was more detailed and compliant with VASRD rating guidelines and thus more probative for rating.  Although there was insufficient limitation of motion to support minimum rating, the panel agreed a 10% rating was justified for the presence of painful motion.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  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 SI condition.  

Chronic Left Knee Pain.  According to the STR and MEB NARSUM, the CI’s left knee condition began in 2004 after being pushed from the side during physical training.  Swelling occurred immediately, and an MRI showed an ACL tear for which she underwent a reconstruction in January 2006.  At the MEB PT ROM evaluation, goniometric measurements revealed average left knee flexion to 120 degrees, limited by pain.  The MEB NARSUM addendum noted CI complaints of occasional locking which was relieved by forcing the knee into flexion.  Standing was difficult after 45 minutes but was partially attributed to a recent left foot surgery.  She took no medications for pain and was doing administrative work.  Physical examination showed no effusion or laxity.  There was loss of definition over the left medial quads, and thigh circumference was 45 cm on the left compared to 47 cm on the right.  There was some lateral joint line pain and patellar crepitus as well as significant pain with lateral and posterior patellar movement. 

At the C&P examination, the CI reported left knee stiffness and bilateral knee pain with no swelling or instability; she took a non-steroidal anti-inflammatory drug (NSAID) daily.  Physical examination showed a well-healed, non-tender and non-adherent scar, and no swelling, deformity, crepitus or laxity.  Left knee flexion was to 120 degrees (normal 140) with pain, while right knee ROM was full and pain-free.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 0%, coded 5099-5003 (analogous to degenerative arthritis), citing minimal and constant pain IAW the US Army Physical Disability Agency pain policy.  The VA rated the left knee condition 10%, coded 5260 (limitation of flexion of the leg), based on the C&P examination, citing flexion limited to 120 degrees by pain.  Panel members agreed there was no limitation of flexion or extension (5260, 5261), evidence of ligamentous instability or laxity (5257), or history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) to support ratings under the respective codes.  Additionally, there was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  However, there was evidence of painful motion with functional loss to support a 10% rating (based on §4.59, §4.40 and §4.45).  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 left knee condition, coded 5099-5003.  

Chronic Plantar Fasciitis.  The PEB combined the right and left foot conditions under a single disability rating, coded analogously to 5310 (muscle Group X injury) and rated 0%.  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 noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  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 left and right foot conditions is presented below, with attendant recommendations regarding separate unfitness, and separate rating if indicated. 

According to the STR and MEB narrative summary, the CI’s foot pain began sometime in 2003 with no specific injury or trauma, and she had recurrent foot pain that was always greater on the left than the right.  The pain was the worst when deployed to Iraq and also related to increased activities.  She was diagnosed with bilateral plantar fasciitis and pes planus and received left heel steroid injections in March 2005 and March 2006 without pain relief.  She subsequently had left foot surgery on 1 March 2007 to loosen the Achilles tendon and insert an arch implant.   Post-operatively, she had regular podiatry follow-ups and was prescribed shoe inserts.  

The MEB NARSUM addendum noted CI complaints of bilateral foot pain, greater on the left than the right, and worst when taking her first steps in the morning.  The pain was aggravated by prolonged walking and standing.  Physical examination showed prominent pes planus and tenderness at the calcaneal insertion of the plantar fascia bilaterally.  Neurovascular findings were intact, and she could stand on her toes but had difficulty on her heels “probably more in reference to the recent left foot surgery.”  Sensations over the medial and lateral aspects of the feet were comparable and good, and lower extremity reflexes were normal.  

The C&P examination noted pes planus deformity, bilateral plantar fasciitis and residuals of left foot surgery.  The CI reported stiffness and swelling in both feet with pain on standing and walking, and wore a splint for plantar fasciitis at night.  Pain was relieved with steroid injections, NSAIDs, and rest.   She wore shoe inserts, which helped, and could stand for one hour and walk 2 miles.   Her foot pain had no effect of activities of daily living and she had not missed any work or had any flare-ups.  Physical examination showed no evidence of painful motion, edema, swelling, instability, weakness or tenderness.  There was a small scar in the left Achilles area with no tenderness or adhesion to the skin.  The Achilles tendon was normally aligned with no valgus or pain on manipulation.  Pes planus was present bilaterally.  

The panel noted that the PEB, in an unsigned TDRL document on 2 September 2008 (due to inability to contact and acquire the CI’s concurrence), rated the plantar fasciitis 10% for the left foot and 0% for the right foot, analogously coded 5399-5310, citing bilateral tenderness along the central step of the plantar fasciitis and radiologic studies documenting moderate bilateral pes planus deformity.  The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the plantar fasciitis 0%, coded 5399-5310, citing normal ROM, tenderness, and moderate bilateral pes planus deformity.  The VA rated the left foot plantar fasciitis 10%, coded 5276 (flatfoot, acquired), based on the C&P examination, citing treatment for pain on manipulation and use of the left foot; and rated the right foot plantar fasciitis 0%, also coded 5276, citing no evidence that the weight bearing line was over or medial to the great toe with inward bowing of the tendo-achillis and pain on manipulation and use of the feet.  

The panel first considered if each of the foot conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Plantar fasciitis of both feet was judged to fail retention standards.  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, members agreed that each foot was reasonably justified as separately unfitting.  Since the relevant evidence for rating was identical for both feet, the panel considered the rating of the left and right foot conditions together.  

Panel members adjudged that code 5310 represented the best coding option and noted that the NARSUM examination documented prominent pes planus and tenderness of the calcaneal insertions bilaterally.  There was pain on manipulation and use of the feet, greater on the left than right, and the CI could stand on her toes, but not the heels, which was likely attributed to her left foot surgery.  Panel members agreed the left foot met criteria for a 10% rating, while the right foot met criteria for a 0% rating.  There was no evidence of weak foot (5277), claw foot, (5278) or malunion/nonunion of the tarsal or metatarsal bone (5283), and no evidence of injury of either foot (5284) to warrant ratings under the respective codes.  After due deliberation, considering all of evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the plantar fasciitis condition, coded 5399-5310.  

BOARD FINDINGS:  In the matter of the sacroiliac condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the left knee condition, the panel recommends a disability rating of 10%, coded 5003 IAW VASRD §4.71a.  In the matter of the plantar fasciitis, the panel recommends a disability rating of 10%, coded 5399-5310 IAW VASRD §4.71a/4.73.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Sacroiliac Pain	5236	10%	
Chronic Left Knee Pain	5099-5003	10%	
Chronic Plantar Fasciitis	5399-5310	10%	
COMBINED	30%	

The following documentary evidence was considered:

AR20190006904, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs.