RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXXXXXXXXXXCASE: PD-2017-05717 BRANCH OF SERVICE: ARMY SEPARATION DATE: 20070717 -------------------------------------------------------------------------------- SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, UH-60 Helicopter Repairman, medically separated for "bilateral plantar fasciitis" and "right ankle pain," rated 0% each, with a combined disability rating of 0%. -------------------------------------------------------------------------------- CI CONTENTION: Review requested of all conditions as well as an additional condition (sleep apnea) 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 - 20070530 VARD - 20080128 Condition Code Rating Condition Code Rating Exam Bilateral Plantar Fasciitis 5399-5310 0% Plantar Fasciitis, Bilateral 7813 0% 20071219 Chronic Right Ankle Pain 5099-5003 0% Right Ankle 5271 10% 20071219 Left Ankle Mild Degenerative Joint Disease [DJD] Not Unfitting No VA Placement COMBINED RATING: 0% COMBINED RATING OF ALL VA CONDITIONS: 30% -------------------------------------------------------------------------------- ANALYSIS SUMMARY: Bilateral Plantar Fasciitis. The PEB combined the right and left plantar fasciitis conditions under a single disability rating, analogously coded 5399-5310 (Group X muscle injuries) 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 bilateral plantar fasciitis is presented together 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 reported month-long bilateral foot pain at a clinic visit on 15 November 2006. He pointed to the mid-arch as the source of the pain and stated he had been under treatment for ankle pain and pes planus since July 2005. On examination, there was tenderness over the medial arch bilaterally, and plantar fasciitis was diagnosed. Appropriate shoe selection was discussed and calf stretches were demonstrated. Despite physical therapy (PT), the CI had bilateral medial heel pain and tight plantar fasciae on 5 March 2007. Ankle range of motion (ROM) was bilaterally symmetrical with dorsiflexion to 20 degrees (normal) and plantar flexion to 30 degrees (normal 45). The commander's statement dated 6 March 2007 indicated the CI complained of excessive pain in his ankles (see below) and feet. During the 6 March 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported numbness and tingling of both feet. Physical examination revealed normal appearing arches and tenderness on the soles of the feet along the medial border of plantar fascia near the bases of the calcanei (heel bones). At the 28 March 2007 MEB orthopedic consultation, he complained of bilateral foot pain which was worsened by climbing a ladder, road marching, rucking, or running. Despite PT, casting, long-term profiles and limited duty with avoidance of physical training, custom orthotics, and stretching, he had little to no symptom relief. Physical examination showed slight hindfoot valgus bilaterally, and normal longitudinal medial arches. He was able to perform a single-leg heel rise, but had point tenderness about the proximal aspect of the plantar fascia bilaterally, which was the primary area of pain. The 24 April 2007 MEB NARSUM examination, 3 months before separation, recorded complaints of bilateral foot pain, and the examiner noted tenderness along the medial band of the plantar fascia near the base of the calcanei. A permanent L3 profile was issued for bilateral foot pain in May 2007. At the 19 December 2007 VA Compensation and Pension (C&P) examination, 5 months after separation, the CI reported plantar fasciitis for 2 years, which he described as having a "razor blade" under his feet as well as some tingling. Discomfort was palliated by stretching, nonsteroidal anti-inflammatory drugs (NSAIDs), and most so with boot and tennis shoe insert. Physical examination showed a steady gait, tenderness over the plantar heel and medial distal longitudinal arch, and pain in the same location with dorsiflexion of each foot. There was callus formation over the plantar heel to the lateral mid foot to the ball of the foot/metatarsal heads. Bilateral foot X-rays were normal. The panel directed attention to its rating recommendation based on the above evidence. As noted above, the PEB rated the bilateral plantar fasciitis 0%, analogously coded 5310, citing slight muscle injury on both sides. The VA also rated the bilateral plantar fasciitis 0%, but coded 7813 (dermatophytosis (fungal infection)), based on the C&P examination, citing "unless there is disfigurement; limitation of motion or function due to scarring; pain on examination of scars; frequent loss of covering of skin over scars; or dermatitis or eczema affecting at least 5 percent of exposed areas or requiring systemic therapy." Panel members first determined that the left and right foot plantar fasciitis conditions were each unfitting and warranted separate ratings. While the PEB noted a slight disability, the panel agreed that the extent of the pain, recalcitrance to treatment, and the limitations in duty and physical training performance, favored each foot disability to be at least moderate in severity. Therefore, a 10% rating for plantar fasciitis of each foot is appropriate. Panel members noted the VA's 0% rating using a fungal infection code, and that its rationale was disparate from and not related to the plantar fasciitis. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% each for the left and right foot plantar fasciitis, coded 5399-5310. Right Ankle Pain. According to the STR and MEB NARSUM, the CI's right ankle condition began in the winter of 2003 with increased running, ruck marching and climbing in and out of helicopters. At an aviation clinic visit on 19 July 2005, the CI reported ankle pain "most of the time." On examination, he had 1+ arches with overpronation, and tenderness bilaterally inferior to the lateral malleoli. Ankle X-rays on 25 August 2005 demonstrated intact osseous structures and joint spaces with well-maintained ankle mortises. There was a bilateral os trigonum and os peroneum (accessory ossicles), a small bilateral Achilles enthesophyte (bony projection at the site of tendon or ligament attachment), and mild bilateral soft tissue swelling around the distal fibulas. At a podiatry clinic visit on 20 September 2005, the CI had bilateral tenderness of anterior talofibular and calcaneofibular ligaments, and at a follow-up on 15 November 2005, a right ankle MRI revealed a strain of the right anterior talofibular ligament; left ankle findings were normal. Treatment consisted of crutches and immobilization of the right foot/ankle. Ankle bone scans on 8 December 2006 showed increased uptake overlying bilateral os trigonum likely representing sequelae of stress reactions, but noted that degenerative change or remote trauma could present similarly. At a sports medicine clinic visit on 2 January 2007, the CI reported spraining both ankles his "entire life." When he worked on aircraft and jumped down and landed too hard or fast, his ankles would "invert, pop and hurt" with pain and instability described as "60% right ankle and 40% left ankle." He felt better when assigned to desk work. The provider noted bilateral tenderness over the sinus tarsi and anterior talus. Anterior drawer and talar tilt tests were negative, although he had significant internal pain with forced plantar flexion and dorsiflexion. Despite temporary profiles, NSAIDs, and ankle splints/braces, the pain persisted. The MEB examination revealed bilateral talus tenderness, decreased ankle ROM, and lower extremity sensation intact to light touch. On 7 March 2007, PT ROM measurements showed average dorsiflexion of 11 degrees (lacking an average of 9 degrees) and average plantar flexion of 40 degrees (normal 45), both limited by stiffness. At the MEB orthopedic consultation, the CI complained of ankle pain for more than 3 years, which was worsened by the activities mentioned above; conservative treatment had provided minimal relief. Physical examination showed the ability to perform a single-leg heel rise on his bilateral lower extremities, and tenderness over the anterior joint line as well as the medial and lateral malleoli. Dorsiflexion was to -5 degrees and plantar flexion to roughly 20 degrees bilaterally. Sensation to light touch was intact, and anterior drawer and talar tilt tests were negative. The MEB NARSUM examination noted complaints of right ankle pain, and the examiner noted decreased ROM bilaterally with tenderness along the lateral aspects. At the VA C&P examination, the CI reported right ankle pain. Physical examination showed "dorsiflexion to 88 degrees and plantar flexion to 120 degrees," after repetition. There was right ankle pain with instability maneuvers as well as with inversion, and tenderness over the anterior lateral ankle and proximal foot in the same region. The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the right ankle condition 0%, analogously coded 5003 (arthritis, degenerative), citing application of the US Army Physical Disability Agency pain policy. The VA rated the right ankle condition 10%, coded 5271 (ankle, limited motion of), based on the C&P examination, citing pain and moderate limitation of motion. Panel members agreed that the ROM examinations proximate to separation were consistent with the "moderate" limitation of motion required for a 10% rating under this code, based on PT and MEB consultation measurements, and therefore a higher rating of 20% was not indicated in the absence of "marked" limited ROM. There was no ankylosis of the ankle or subastragalar (sub-tarsal) joints, no malunion of the os calcis (calcaneus) or astragalus (talus), and no astragalectomy for consideration under the respective diagnostic codes (5270, 5272, 5273 or 5274). The panel also noted that the VA right ankle ROM measurements were inconsistent with prior measurements and significantly outside VASRD standard measurements, and were therefore given no probative value. 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 ankle condition, coded 5271. Contended PEB Condition: Left Ankle Mild DJD. The panel's main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting. The contended condition was not profiled and did not fail retention standards. The commander's statement indicated the CI was grounded from flight due to complaints of excessive ankle pain. At a sports medicine visit, the provider documented 60% involvement of the right ankle and 40% of the left ankle. On 25 January 2006, X-rays ordered for a twisted left ankle, noted an incidental os trigonum, Achilles spur, and significant soft tissue swelling about the lateral malleolus; however there was no radiographic evidence of an acute osseous abnormality. The 8 December 2006 bone scan demonstrated increased uptake overlying the bilateral os trigonum which likely represented sequelae of stress reactions, but also noted degenerative change or remote trauma may have had a similar presentation. A left ankle MRI dated 27 February 2007 showed a mild degenerative signal abnormality involving opposing bony margins of os trigonum and adjacent posterior talus with some intervening tissue T2 hyperintensity. During the MEB examination, the CI reported bilateral ankle pain, and the examiner documented decreased ROM of both ankles and tenderness of the talus bilaterally. Left ankle PT ROM measurements showed dorsiflexion average of 17 degrees and plantar flexion with a full ROM. At the MEB orthopedic consultation, the CI complained of ankle pain for more than 3 years. Dorsiflexion was to -5 degrees and plantar flexion to roughly 20 degrees in the bilateral lower extremities. Panel members noted the CI was grounded from flight duties and then assigned desk duty due to his ankle condition, and therefore determined the condition was unfitting, albeit MRI findings were more subtle on the left ankle than the right. The panel agreed that the ROM examinations proximate to separation were consistent with the "moderate" limitation of motion required for a 10% rating under this code, and therefore a higher rating of 20% was not indicated in the absence of "marked" limited ankle ROM. There was no ankylosis of the ankle or subastragalar (sub-tarsal) joints, no malunion of the os calcis (calcaneus) or astragalus (talus), and no astragalectomy for consideration under the respective diagnostic codes (5270, 5272, 5273 or 5274). After due deliberation, the panel agreed the preponderance of the evidence with regard to the functional impairment of left ankle mild DJD favors its recommendation as an additionally unfitting condition for disability rating. It is appropriately coded 5271 and meets the VASRD §4.71a criteria for a 10% rating. -------------------------------------------------------------------------------- BOARD FINDINGS: In the matter of the left foot plantar fasciitis, the panel recommends a disability rating of 10%, coded 5399-5310 IAW VASRD §4.71a. In the matter of the right foot plantar fasciitis, the panel recommends a disability rating of 10%, coded 5399-5310 IAW VASRD §4.71a. In the matter of the right ankle condition, the panel recommends a disability rating of 10%, coded 5271 IAW VASRD §4.71a. In the matter of the contended left condition, the panel agrees it was unfitting and recommends a disability rating of 10%, coded 5271 IAW VASRD §4.71a. 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 Left Plantar Fasciitis 5399-5310 10% Right Plantar Fasciitis 5399-5310 10% Right Ankle Pain 5271 10% Left Ankle Mild Degenerative Joint Disease 5271 10% COMBINED w/ BLF 40% -------------------------------------------------------------------------------- XXXXXXXXXXXXXXXXXXXXXXXX Dear XXXXXXXXXXXXXXXXXXXX: I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a permanent disability retirement with the combined disability rating of 40% 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 permanent 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),. A copy of this decision has also been provided to the Department of Veterans Affairs.