RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-05639
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080327

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Power Generator Equipment Repairer, medically separated for “bilateral plantar fasciitis” and “bilateral Achilles tendonitis,” each rated 0%, with a combined disability rating of 0%.   

CI CONTENTION:  The conditions have worsened.  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 - 20080329	VARD - 20080331	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Plantar Fasciitis 	5399-5319	0%	Bilateral Achilles Tendonitis and Bilateral Plantar Fasciitis	5024-5276	0%	20080331	
Bilateral Achilles Tendonitis	5024	0%					
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Bilateral Plantar Fasciitis.  The PEB combined both the bilateral plantar fasciitis, coded 5399-5319, and the bilateral Achilles tendonitis, coded 5024, as single unfitting conditions.  The approach by the PEB commonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  However, the panel in the analysis that follows determined whether the combined conditions were separately unfitting and whether separate ratings were warranted.  

Panel members discussed whether the PEB’s separation of the plantar fasciitis and Achilles tendonitis evoked pyramiding in violation of VASRD §4.14.  The panel noted that plantar fasciitis involves the heel bone and is a condition of the foot involving a ligament-type structure which supports the longitudinal arch and extends to the toes.  Whereas the Achilles tendon connects the calf muscles of the posterior leg to the heel bone and is involved in plantar flexion of the foot.  Therefore, based on different anatomy and functions of the plantar fascia and Achilles tendon, pyramiding is not an issue in this case.

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s bilateral foot conditions became symptomatic after she “fell from a wedge” while attending AIT in 2004.  In November 2004, the CI was prescribed soft orthotics, referred to physical therapy (PT) and issued a profile “to run at her own pace and distance.”  The CI experienced periodic exacerbations lasting several months interspersed with periods of improvement.  Each occurrence was worse than the preceding one.  

At a podiatry clinic visit on 12 April 2006, the CI reported a 2 month history of bilateral heel pain (after a 5 month remission of symptoms).  On examination, there was tenderness over the plantar aspects of the calcanei (heel bones) bilaterally.  There was no pain with active range of motion (ROM) and no inflammation, visible deformity or visible pain with weight bearing.  Spenco inserts were dispensed to replace the orthotics she was using and prednisone (an oral steroid) was prescribed.  Custom inserts were made in October 2006.  X-rays of the feet in May 2007 revealed bilateral calcaneal spurs with no evidence of fractures.  A note dated 25 July 2007 indicated that all previous treatment attempts did not provide relief and the CI was evacuated from deployment for the condition.  On 31 July 2007 foot arch supports and AFOs (ankle foot orthoses) were dispensed.    

During the 1 November 2007 MEB examination (recorded on DD Forms 2807 and 2808) 4 months prior to separation, the CI reported using night splints and shoe inserts with arch supports.  Physical examination showed tenderness at the medial calcaneus and over the arches bilaterally.  
The 18 December 2007 MEB NARSUM examination, 3 months prior to separation, noted the complaint of foot pain.  Physical examination showed normal ankles and a basic gait.  Muscle testing was normal for power and strength.  The ROM of the ankles and subtalar, midtarsal and metatarsophalangeal joints was normal bilaterally.  She was tender over the plantar fascia bilaterally.  Pain was elicited in the plantar fascia bilaterally with passive dorsiflexion of her ankles.  The examiner noted the chronic pain interfered with the CI’s ability to perform her military duties, but was likely recalcitrant secondary to the demands of the military and would be expected to improve as a civilian.  

At the 31 March 2008 VA Compensation and Pension (C&P) evaluation, 4 days after separation, the CI reported 6-7/10 pain in the feet.  Physical examination showed no deformities of the toes.  There was tenderness in the medial plantar arch extending to the Achilles tendon bilaterally.  Dorsiflexion was 10 degrees (normal 20), planter flexion was 20-25 degrees (normal 45), inversion was 20 degrees and eversion was 10 degrees with slight end-range pain.  There was no change in the ROM with repetition.  

The panel directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB rated the bilateral plantar fasciitis 0%, coded 5399-5310 (Group X. Function:  Movements of forefoot and toes), citing “rated as slight bilaterally.”  The VA combined the bilateral Achilles tendonitis and bilateral plantar fasciitis as a single condition rated 0% and coded 5024-5276 (tenosynovitis-flatfoot, acquired), based on the C&P examination, citing a noncompensable evaluation for mild symptoms relieved by built-up shoe or arch support.

The panel’s initial charge in this case was directed at determining if the PEB’s approach of combining the bilateral plantar fasciitis under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each foot, the panel considers each foot 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 plantar fasciitis, presented above, indicated the bilateral plantar fasciitis was profiled; it was implicated by the NARSUM; and it was implicitly referred to in the commander’s statement based on the profile.  Members agreed that each foot condition was separately unfitting and that identical coding and ratings were applicable. 

Panel members noted the CI had the plantar fasciitis for several years which flared from time to time, but was not responsive to medication, physical therapy, insoles, orthotics or temporary profiles.  Furthermore, the condition caused the CI to be evacuated during deployment.  Therefore, panel members considered the condition to be a moderate disability thereby warranting a 10% rating for the plantar fasciitis of each foot.  While code 5399-5310 is the accepted VA analogous code for plantar fasciitis, panel members did consider use of code 5299-5284 (foot injuries, other) since repeated running caused pain in the feet and ankles; however, plantar aponeurosis is distinctly mentioned in the VASRD; therefore, use of code 5399-5310 was felt to be the better option.  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 right foot plantar fasciitis and a disability rating of 10% for left foot plantar fasciitis, both coded 5399-5310.  

Bilateral Achilles Tendonitis.  According to the STR and the MEB NARSUM, the CI’s bilateral foot pain began in July 2004 as noted above.  At a physical therapy visit on 6 February 2005 the CI reported she had essentially no pain in the right Achilles tendon and only mild to moderate tenderness in the left.  She wanted to start a running program and she felt insoles with increased cushioning and arch support had been helpful.  On examination she had a normal ROM of the ankles and tenderness over the right Achilles.  On 29 March 2005, the CI reported she ran three to four miles three times a week, but the following morning after a run she was fairly sore.  On 30 June 2005, the CI noted pain secondary to increased running greater than 20 miles weekly.  On examination, she had a non-antalgic gait with tenderness over the distal Achilles tendons and the posterior plantar heels.  X-rays of the right ankle dated 12 July 2005 were normal.  At a primary care clinic visit on 20 July 2005, the CI complained of right ankle pain as a result of twisting it while marching in formation.  The pain was improved by wearing a brace and shoe insert.  On examination, there was swelling along the right lateral ankle and tenderness.  Treatment consisted of cryotherapy cold packs and exercises to increase the ROM.  

During the 1 November 2007 MEB examination (recorded on DD Forms 2807 and 2808) 4 months prior to separation, the CI reported wearing night splints and shoe inserts with arch supports.  Physical examination showed tenderness over the bilateral Achilles tendons.  The 18 December 2007 MEB NARSUM examination, 3 months prior to separation, showed normal ankles and a basic gait.  Muscle testing was normal for power and strength.  ROM of the ankles and subtalar, midtarsal and metatarsophalangeal joints was normal bilaterally.  She was tender over the Achilles tendons bilaterally.  A small enlargement was present in the left Achilles tendon.  Pain was elicited in the Achilles tendon bilaterally with passive dorsiflexion of her ankles.  

At the C&P evaluation there was tenderness in the medial plantar arch extending to the Achilles tendon bilaterally.  Dorsiflexion was 10 degrees (normal 20); planter flexion 20-25 degrees (normal 45) with slight end-range pain.  There was no change in the ROM with repetition.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral Achilles tendonitis 0%, coded 5024 (tenosynovitis), citing normal ROM (per podiatrist); this interferes with the performance of her duties.”  The VA rated the bilateral Achilles tendonitis and bilateral plantar fasciitis conditions together as noted above.  
 
The panel’s initial charge in this case was directed at determining if the PEB’s approach of combining the bilateral Achilles tendonitis under a single rating was justified in lieu of separate ratings.  In this case, the bilateral tendonitis condition was profiled, implicated by the NARSUM and implicitly referred to in the commander’s statement based on the profile.  Members agreed that both the right and left Achilles tendonitis were separately unfitting and that identical coding and ratings were applicable. 

Panel members noted that at a PT visit the CI indicated she was able to run greater than 20 miles a week and had tenderness the following morning.  ROMs of the ankles, subtalar, midtarsal and first metatarsophalangeal joints were normal bilaterally and there was tenderness over the Achilles tendons bilaterally.  Pain was present in the Achilles tendons with passive dorsiflexion and no more than slight pain at the end of ROM at the VA examination.  There was insufficient evidence of painful motion during active ROMs.  A 10% rating for either ankle using code 5099-5003, which is the code 5024 uses for rating, is not applicable in the absence of objectively confirmed swelling, muscle spasm, or satisfactory evidence of painful motion nor was a 10% rating applicable using code 5271 (ankle, limited motion of) in the absence of moderate disability.  Therefore, use of code 5024 or 5271 for each ankle only warrants a 0% rating.  Use of code 5284 was considered since the Achilles tendon inserts on the calcaneus.  However, neither the right nor the left Achilles tendonitis rose to a moderate level.  However, a 0% rating for each ankle offers no benefit to the CI.  After due deliberation, considering all of 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 bilateral Achilles tendonitis.

BOARD FINDINGS:  In the matter of the bilateral plantar fasciitis, the panel recommends the following adjudication:  a disability rating of 10%, coded 5399-5310 IAW VASRD §4.73 for the right foot and a disability rating of 10%, coded 5399-5310 IAW VASRD §4.73 for the left foot.  In the matter of the bilateral Achilles tendonitis, the panel recommends no change in the PEB adjudication.  There were 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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Bilateral Plantar Fasciitis, Right Foot	5399-5310	10%	
Bilateral Plantar Fasciitis, Left Foot	5399-5310	10%	
Bilateral Achilles Tendonitis	5024	0%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170601, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record
AR20180008228, 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 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