RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXX	CASE:  PD-2017-06082
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040902

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve W2, Warrant Officer, medically separated for “irritable bowel syndrome [IBS]” “migraine headaches” and “chronic bilateral foot pain due to plantar fasciitis,” rated 10%, 0% and 0%, respectively, with a combined disability rating of 10%.   

CI CONTENTION:  Review requested of his unfitting conditions, which were rated higher by the VA; and additional conditions not identified by the Medical Evaluation Board (MEB) and/or Physical Evaluation Board (PEB) was requested.  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 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 - 20040430	VARD - 20041206	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Irritable Bowel Syndrome	7319	10%	Irritable Bowel Syndrome, Gastroesophageal Reflux Disease, and Hiatal Hernia	7399-7319	0%	20041028	
Migraine Headaches	8100	0%	Migraine Headaches	8100	10%		
Chronic Bilateral Foot Pain due to Plantar Fasciitis	5399-5310	0%	Bilateral Plantar Fasciitis	5299-5279	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30% 	

ANALYSIS SUMMARY:  

Irritable Bowel Syndrome (IBS).  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI had a history of reflux and underwent a Nissen fundoplication procedure in 2001.  He began experiencing chronic diarrhea in 2002, which was treated with fiber, and at a gastroenterology visit on 22 August 2003, he reported 2-3 diarrhea stools on some days, and constipation on other days.  The provider noted the abdomen was soft, non-tender, and non-distended, and bowel sounds were present in four quadrants; a rectal examination was deferred.  During the 19 December 2003 MEB NARSUM examination, 9 months prior to separation, the CI complained of IBS symptoms.  Physical examination showed a normal abdomen and bowel sounds with no costovertebral tenderness.  The 10 March 2004 MEB addendum, 6 months before separation, noted the CI had IBS, which responded to fiber and exercise that included usually walking twice daily.  At a primary care visit on 7 May 2004, he reported five plus bowel movements in the morning and diarrhea and abdominal discomfort after any meal.

At the 28 October 2004 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported explosive diarrhea with cramps and bloating approximately 4 times a month, but he had no abdominal pain during the examination.  Physical findings revealed a soft abdomen, normal bowel sounds, and no masses or enlargement of the organs.  Well-healed scars were present from the fundoplication surgery.  Abdominal X-rays were within normal limits with a bowel gas pattern, and a small mass was noted in the left pelvic cavity.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the IBS 10%, coded 7319 (irritable colon syndrome).  The VA rated the IBS, GERD, and hiatal hernia condition 0%, analogously coded 7399-7319, based on the C&P examination, citing medical evidence showing disturbances of bowel function with occasional episodes of abdominal distress.  Panel members agreed noted a 10% rating was warranted for a moderate condition marked by frequent episodes of bowel disturbance with abdominal distress, but a 30% rating was not justified without sufficient evidence of severe disability with diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress.  Furthermore, there was no indication that the CI was prescribed medication for severe diarrhea.  After due deliberation, considering all 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 IBS.  

Migraine Headaches.  According to the STR and MEB NARSUM, the CI began experiencing migraines in 2001 during flight training as a result of tension.  He stopped flying in 2002, and treatment consisted of an antidepressant and Maxalt for abortive therapy in 2003.  The MEB NARSUM examination noted a minimum of weekly migraine headaches, which caused incapacitation and loss of duty time.  With medication, he improved, but still lost time from work. Physical examination showed a blood pressure of 119/81 and pulse of 72 beats/minute, and his pupils were equal and reactive to light and accommodation with extraocular movements intact.  No further neurologic evaluation was recorded.  

The MEB addendum documented headaches about 1-3 times a week for which he took Zomig (serotonin receptor antagonist).  He was allowed to drive home when these occurred, and was able to rest in a quiet, dark environment with the headaches usually relieved in approximately 1 hour with a feeling of fatigue afterwards.  He seemed to be stable for several months and had no nausea or vomiting.  At the May 2004 primary care appointment, the CI reported a bad headache weekly which required him to take Zomig and lie down.  He took Advil 2-3 times a week for less severe headaches.  The provider noted he lost 5 or more duty a week.  

At the VA C&P examination, the CI reported headaches that occurred 2-4 times a month.  Physical examination showed intact cranial nerves and pupils with no stated visual field defect; fundoscopic evaluation was normal as was motor strength and sensation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the migraines 0%, coded 8100 (migraine), citing weekly occurrence and not considered prostrating.  The VA rated the migraines 10%, coded 8100, based on the C&P examination, citing characteristic prostrating headaches averaging 1 in 2 months over the previous several months.  Panel members agreed that while the CI was permitted to drive home when experiencing a headache, he nevertheless had to lie down in a quiet dark room and lost 5 or more hours of work per week.  However, there was no headache log or objective evidence of how often he had to lie down, and thus it was speculative to presume justification for a rating higher than 10%.  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 migraines, coded 8100.  

Chronic Bilateral Foot Pain due to Plantar Fasciitis (PF).  According to the STR and MEB NARSUM, the CI’s foot condition began in 1999, and treatment consisted of physical therapy and shoe inserts.  During the 13 February 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, the CI reported plantar fasciitis, and the examiner documented normal arches and plantar keratosis of the fifth metatarsophalangeal (MTP) joint and plantar big toes.  The MEB NARSUM examination noted complaints of chronic plantar fasciitis, and physical findings showed tenderness along the arches of the feet but no heel spurs.  The MEB addendum recorded slight improvement of the plantar fascial inflammation and that the CI could walk with frequent changes in shoes, but had increased pain if he ran even short distances.

At the VA C&P examination, he endorsed chronic bilateral foot pain in the heels and bottom of the feet (right worse than the left) for which he took Motrin.  Physical examination showed a normal gait, but there was heel and plantar pain on palpation as well as tenderness and muscle spasm.  Foot X-rays showed mild hallux valgus deformities and no pes planus. 

The panel directed attention to its rating recommendation based on the above evidence.  The Formal PEB rated the bilateral plantar fasciitis 0%, analogously coded 5399-5310 (group X. Function:  plantar aponeurosis), citing slight pain with likely application of the US Army Physical Disability Agency pain policy.  The VA rated the bilateral plantar fasciitis 10%, analogously coded 5299-5279 (metatarsalgia, anterior (Morton’s disease), unilateral, or bilateral), based on the C&P examination, citing pain to palpation of both feet.  Panel members noted that each foot had, at the most, a slight disability since the condition was present for years with minimal references to it in the STR and no documentation of podiatry or orthopedic visits.  Therefore, the panel determined that code 5399-5310 was more applicable than code 5279 since the tenderness was on the bottom of the feet in the area of the heels rather than toward the metatarsal areas.  Thus, ratings of 0% each, and no higher, are applicable for the right and left foot conditions.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% each for the right and left plantar fasciitis, both coded 5399‑5310.  

BOARD FINDINGS:  In the matter of the irritable bowel syndrome and IAW VASRD §4.114, the panel recommends no change in the PEB adjudication.  In the matter of the migraine headaches, the panel recommends a disability rating of 10%, coded 8100 IAW VASRD §4.124.  In the matter of the bilateral foot pain, the panel recommends disability ratings of 0% each for the right and left foot plantar fasciitis, both coded 5399-5310 IAW VASRD §4.73.   

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

CONDITION	VASRD CODE	PERMANENT RATING	
Irritable Bowel Syndrome	7319	10%	
Migraine Headaches	8100	10%	
Chronic Right Foot Pain due to Plantar Fasciitis	5399-5310	0%	
Chronic Left Foot Pain due to Plantar Fasciitis	5399-5310	0%	
COMBINED	20%	

The following documentary evidence was considered:

AR20200004840,XXXXXXXXX 

Dear XXXXXXXXXXX

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 been provided to the Department of Veterans Affairs.