RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-04536
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080610

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E3, Cavalry Scout, medically separated for “bilateral plantar fasciitis” with a disability rating of 0%.  

CI CONTENTION:  Review requested of additional conditions (hypertension, knees, shoulder) 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 - 20080407	VARD - 20081121	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Plantar Fasciitis, Right Foot	5399-5310	0%	Plantar Fasciitis/Calcaneal Spur, Right 	5284	10%	20080728	
Plantar Fasciitis, Left Foot	5399-5310	0%	Plantar Fasciitis/Calcaneal Spur, Left 	5284	10%	20080728	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Bilateral Plantar Fasciitis.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI developed bilateral foot pain in 2007, about a year before separation, without specific injury but in the context of running and other physical demands of early training.  He was diagnosed with bilateral plantar fasciitis by podiatry and treated with orthotics and injections.  The symptoms did not respond adequately to conservative measures, and he reasonably declined a more invasive shock wave treatment.  Clinical STR entries documented bilateral arch and heel tenderness and normal range of motion (ROM) of the feet without pain on manipulation.  There were no STR entries that noted gait disturbance or serious functional impairment and none that documented any additional VASRD-ratable findings.  

The 15 January 2008 MEB NARSUM examination, 5 months prior to separation, documented persistent bilateral foot pain rated 4-5/10 that prohibited running and other general soldiering requirements.  The physical examination recorded a normal gait, the absence of swelling or deformity, and bilateral arch and heel tenderness.  The examiner stated, “Foot motion is normal and there is no pain elicited by motion of the foot.”

Physical therapy measurements of ankle ROM were conducted on 10 March 2008.  The examiner documented a normal gait, “no signs of loss of coordination,” and normal (5/5) strength bilaterally for plantar flexion and dorsiflexion.  Dorsiflexion was to 9 degrees on the right, and 16 degrees on the left (normal 20), and plantar flexion to 42 degrees on the right, and 43 degrees on the left (normal 45), specifying painful motion in some planes.

At the 28 July 2008 VA Compensation and Pension (C&P) examination, 6 weeks after separation, the CI reported “occasional” pain rated at 6-7/10, with no pain on some days, that limited prolonged standing and walking.  The physical examination recorded a normal gait (no cane, brace, or orthotics), the absence of “deformity, swelling, crepitus or laxity,” and bilateral arch and heel tenderness.  The examiner specifically excluded the presence of pes planus and all other VASRD-coded foot diagnoses.  Modest (and unratable) ROM limitations of the toes were charted, but forefoot, hindfoot and ankle ROM were not addressed.  The VA X-ray interpretation was “prominent bilateral calcaneal spurs [but] otherwise normal” (no service X-rays in evidence). 

The panel directed attention to its rating recommendations based on the above evidence.  The PEB rated each foot 0%, analogously coded 5399-5310 (muscle disability code for Group X, movements of forefoot and toes).  This code is commonly applied and appropriate for plantar fasciitis and the PEB cited the 0% criterion of “slight” muscle disability.  Code 5010 offers higher ratings of 10% for “moderate,” 20% for “moderately severe” and 30% for “severe” disability.  The VA rated each foot 10%, coded 5284 (foot injures, other), referencing the C&P evidence and citing the applicable criterion of “moderate” disability.  Code 5284 offers higher ratings of 20% for “moderately severe” and 30% for “severe” disability.

Both coding options above are reasonably applicable to this case.  The panel agreed that separate ankle and foot ratings would violate VASRD §4.14 (avoidance of pyramiding), and further agreed that alternative rating for ankle limitation of motion (code 5271) was neither sufficiently defensible (no ankle pathology or diagnosis in evidence) nor advantageous (10% for moderate limitation).  There was no evidence for any ratable criterion or separately coded foot diagnosis that would justify a rating higher than 10% under any other applicable code available in VASRD §4.71a.  The panel was therefore left to deliberate whether any rating higher than the PEB’s 0% could be justified under codes 5399-5310 or 5234. 

Although both of the above codes are  defensible, member consensus was that code 5299-5284 (analogous application given the absence of discrete injury) offers more latitude in rating criteria and was thus favorable IAW VASRD §4.7 (higher of two evaluations).  Code 5310 for muscle disability is dependent upon the VASRD §4.56 specified cardinal signs, for which there was insufficient and inconclusive evidence in this case.  Having reached consensus that code 5299-5284 was indicated, members deliberated whether the 10% criterion for moderate disability was justified.  A 0% rating under code 5284 requires failure to meet the minimum 10% for moderate impairment; and, a consensus of members ultimately agreed that the minimum 10% rating for each foot should be conceded.  Although the CI was faring well with general mobility and routine activities, he was still limited with prolonged standing and walking, and strenuous activities.  This would have imposed fairly significant occupational limitations at the time of separation.  The panel agreed that no rating higher than 10% for either foot was supported under 5284 or any other code.  After due deliberation, considering all the evidence and conceding VASRD §4.3 (reasonable doubt), the panel’s consensus recommendation for the plantar fasciitis condition is a 10% rating for each foot under code 5299-5284.

BOARD FINDINGS:  In the matter of the bilateral plantar fasciitis condition, the panel majority recommends a disability rating of 10% for each foot, coded 5299-5284 IAW VASRD §4.71a.  The single voter for dissent recommends no change and did not elect to submit a minority opinion.  There are no other conditions within the panel’s scope of review for consideration.

The panel recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Plantar Fasciitis, Right Foot	5299-5284	10%	
Plantar Fasciitis, Left Foot	5299-5284	10% 	
COMBINED	20%	

The following documentary evidence was considered:

[AR Number], XXXXXXXXXX

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 to 20% 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 and to the counsel you listed on your application; [name and address].