RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-05445
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20050710

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Health Care Specialist, medically separated for “bilateral chronic plantar fasciitis” with a disability rating of 10%.

CI CONTENTION:  The CI was given a rating increase from 10% to 40% for the bilateral foot condition by the VA.  The CI requested review of an additional condition 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 - 20050329	VARD - 20050823	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral, Chronic Plantar Fasciitis	5399-5310	10%	Chronic Bilateral, Plantar Fasciitis	5284	10%	20050502	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Bilateral Chronic Plantar Fasciitis (PF).  The PEB combined the right and left foot conditions under a single disability rating, coded analogously to 5310 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 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 bilateral PF is presented below, with attendant recommendations regarding separate unfitness, and separate rating if indicated. 

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s bilateral PF began in 2002 and was associated with running.  The CI denied any specific injury or trauma.  Podiatry treated her with anti-inflammatory medications, steroid injections, icing, elevation and exercises with limited improvement.  Podiatry offered surgery but she declined.  

The 25 January 2005 MEB NARSUM examination, 6 months prior to separation, noted complaints of shooting pains from her posterior arch over the heel to the back of the heel.  She reported constant pain that she rated at 9/10 at rest.  She also reported she walked on the balls of her feet.  Symptoms increased with walking and trying to run.  She wore night splints at night but her heels had worsened over the past 5 months.  She was working in her MOS and could provide bedside care for patients but could not be on her feet all day or carry patients on a litter.  She had inserts for her shoes but her boots hurt her feet.  Physical examination showed marked tenderness on the bottom surface of both heels with no bruising, swelling or skin changes.  There was no pain on the Achilles tendon.  She could heel-to-toe and duck walk with some discomfort on the duck walk.  

The 29 January 2005 MEB NARSUM specialty care consult examination, 5 months prior to separation, noted complaints of severe foot pain on the bottom of each heel with any prolonged weight activity.  She could not tolerate rigid orthotic inserts, so she wore a soft arch support with additional cushion under her heel.  She could stand or walk for very brief periods and could not wear Army boots.  The condition had neither worsened nor improved over the last several months.  Physical examination showed both feet were unremarkable with a normal range of motion.  She had normal strength at her ankles and feet but was extremely tender at the plantar aspect of each heel.  Plantar fascial bands were bilaterally palpable and taut medially.  The neurovascular examination was unremarkable bilaterally.  Bilateral weight bearing X-rays showed normal foot structure.  

At the 2 May 2005 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported pain, swelling and fatigue whether at rest, standing or walking.  She could not walk or stand for prolonged periods and could not run but she did not lose any time from work.  
Physical examination showed tenderness of both feet and no pes planus.  She did not have any limitation with standing or walking and did not require any type of support.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral PF 10%, coded analogously as 5310 (Group X. Function: movements of forefoot and toes), citing tenderness on the plantar aspect of each heel and taut plantar fascial bands, normal range of motion, strength, neurological examination and radiographic studies.  The VA also rated the bilateral PF 10%, coded 5284 (other foot injury), citing moderate symptoms.

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.  PF of both feet was profiled and 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 the feet, the panel next considered the rating of the left and right PF together.  

Panel members agreed that the NARSUM examination was more detailed and complete than the C&P examination and therefore, more probative.  The panel also considered if VASRD code 5310 was the most appropriate code and represented the best coding option.  The NARSUM noted extreme tenderness in each heel with palpable and taut plantar fascial bands bilaterally to warrant a 10% rating for each foot under 5310.  She could stand and walk for only brief periods and the commander’s statement noted impairment to duty.  There was no evidence of a “moderately severe” condition to warrant a higher 20% rating.  There was no evidence of flatfoot (5276), weak foot (5277), claw foot, (5278) or malunion/nonunion of the tarsal or metatarsal bone (5283) for higher ratings under these codes.  There was no evidence of injury of either foot (5284) to warrant a rating under that code.  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 foot and 10% for the right foot PF conditions, coded 5399-5310.  

BOARD FINDINGS:  In the matter of the bilateral PF condition, the panel recommends a disability rating of 10%, coded 5399-5310 for the right foot and a disability rating of 10%, coded 5399-5310 for the left foot IAW VASRD §4.73.  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 the date of the prior medical separation:  

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

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170707, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180007406, 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. 

Sincerely,					      
						      					
Enclosure