RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04809
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060605

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Infantryman, medically separated for “bilateral plantar fasciitis” with a disability rating of 0%. 

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 - 20060503	VARD - 20070525	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Plantar Fasciitis 	5399-5310	0%	Plantar Fasciitis, Left Foot	5299-5284	10%	20070411	
			Plantar Fasciitis, Right Foot	5299-5284	0%	20070411	
			Residuals of Failed Left Foot Bunionectomy	5280	10%	20070411	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral Plantar Fasciitis (PF).  The PEB combined the left and right foot conditions under a single disability rating, coded analogously to 5310 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’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 foot (including hallux valgus [HV]) and right foot are presented separately, with attendant recommendations regarding separate unfitness, and separate ratings if indicated.

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s bilateral plantar foot pain began without specific trauma in approximately 2002.  He was diagnosed with PF and HV, both worse on the left than right.  He was treated conservatively without improvement, including orthotics and injections. The commander’s statement implicated the CI’s chronic PF as preventing him from running, marching and doing push-ups, which precluded performance of critical duties of his MOS.  The permanent profile listed chronic PF and bunionectomy (repair of HV) pain.  The MEB NARSUM noted complaints of pain in both feet and pain in the left first metatarsophalangeal joint (MPJ – site of bunionectomy) and determined the CI fell below retention standards for refractory plantar fasciitis and left first MPJ arthralgia.

The panel first considered if the left and right foot conditions having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The MEB NARSUM indicated the CI failed retention standards for refractory plantar fasciitis and left first MPJ arthralgia.  Plantar fasciitis was profiled without limiting it to one foot or the other.  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.  The panel next considered if the left foot pain due to PF and the first MPJ pain could each be decoupled from the combined PEB adjudication and remain separately unfitting.  The left first MPJ arthralgia was noted on the profile and by the NARSUM.  However, the unfitting impairment due to each of the left foot conditions was pain and the same symptom or impairment cannot be used to assign more than one rating under different diagnoses IAW VASRD §4.14 (avoidance of pyramiding).  Therefore, the panel recommends that the left foot PF and first MPJ arthralgia remain combined as a left foot condition and not be further unbundled.  The panel next considered a rating for the unfitting left foot condition.  

Left foot.  The CI underwent surgery for PF and bunionectomy on 26 July 2005.  He was doing well post-operatively, but experienced sudden pain in the left first metatarsal (MT) and X-rays on 18 October 2005 showed a new non-displaced fracture of the first MT due to migration of the surgical wire from the bunionectomy.  The CI underwent removal of the wire on 20 October 2005, 7 months prior to separation.

The 14 March 2006 MEB NARSUM examination, 3 months prior to separation, noted complaints of pain on the bottom of the left foot and area of the bunionectomy, with numbness on the lateral aspect of the great toe.  The pain was controlled by medication and rest and aggravated by activity.  Physical examination showed no swelling or redness of the foot or ankle.  There was tenderness of the plantar aspect of the heel of the foot.  The scar on the top of the great toe was well healed, but there was decreased and painful range of motion (ROM) of the first MPJ.  

At the 11 April 2007 VA Compensation and Pension (C&P) examination, 10 months after separation, the CI reported daily pain in the area of the PF surgery.  He also reported numbness and limitation of motion of the first MPJ.  He denied weakness, swelling, fatigability or lack of endurance.  Pain was worse with standing and walking.  There were no flare-ups and he did not use any assistive devices for ambulation.  Corrective shoes and orthotics were tried, but were not helpful.  There were no periods of incapacitation.  He reported he went to work, but was unable to stand for prolonged periods or run.  Physical examination showed no callosities, breakdown or unusual shoe wear pattern.  Gait, posture on standing, squatting, supination, pronation and rising on heels and toes was normal and there was no evidence of swelling or painful motion of the left foot.  However, there was tenderness over the medial arch and heels and 45 degrees of HV (normal 90) with painful motion but no additional loss of ROM after repetitive use. 

The panel directed attention to its rating recommendation based on the above evidence.  The VA rated the left foot condition 10%, coded 5299-5284 (analogous to other foot injury), based on the C&P examination, citing moderate symptoms.

The discrimination between “slight” or “moderate” disability under code 5310 depends on the presence of cardinal signs or symptoms of muscle injury specified as loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination or uncertainty of movement.  A moderate muscle injury has least one sign or symptom and slight has none.  At the MEB NARSUM and VA examinations, the CI reported constant foot pain aggravated by weight bearing activities and examinations noted tenderness of the bottom of the left foot and painful motion of the first MPJ joint.  Therefore, the panel agreed the evidence supported a 10% rating, coded 5399-5310.  The panel also considered rating under VASRD foot codes, including 5284, 5280 (HV) and 5281 (hallux rigidus), 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 recommends a disability rating of 10% for the left foot condition, coded 5399-5310.  

Right foot.  The MEB NARSUM examination, 3 months prior to separation, noted complaints of pain on the bottom of the right foot.  The pain was aggravated by activity.  Physical examination showed no swelling or redness of the foot or ankle.  There was tenderness of the plantar aspect of the heel of the foot.  

At the C&P examination, 10 months after separation, the CI reported daily pain in the area of the right foot arch and heel area.  He denied weakness, swelling, fatigability or lack of endurance.  Pain was worse with standing and walking.  There were no flare-ups and he did not use any assistive devices for ambulation.  There were no periods of incapacitation.  He reported he went to work, but was unable to stand for prolonged periods or run.  Physical examination showed no callosities, breakdown or unusual shoe wear pattern.  Gait, posture on standing, squatting, supination, pronation and rising on heels and toes was normal and there was no evidence of swelling of the right foot.  However, there was tenderness over the medial arch and heels.  There was 20 degrees of HV and normal ROM, without painful motion and no loss of ROM with repetitive use. 

The panel directed attention to its rating recommendation of the right foot condition based on the above evidence.  The VA rated the right foot condition 0%, coded 5299-5284, based on the C&P examination, citing mild symptoms.  Based on the same rating rationale elaborated above for the left foot, the evidence supports a 10% rating for the right foot condition for an analogous “moderate” muscle injury based on tenderness of the bottom of the foot.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the right foot condition, coded 5399-5310.  

BOARD FINDINGS:  In the matter of the bilateral foot condition, the panel recommends a disability rating as follows: an unfitting left foot condition rated 10%, and an unfitting right foot  condition rated 10%, both coded 5399-5310 IAW VASRD §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, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Plantar Fasciitis 	5399-5310	10%	
Right Plantar Fasciitis	5399-5310	10%	
COMBINED	20%	

The following documentary evidence was considered:

[AR NUMBER], XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

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.

Enclosure