RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1200900 SEPARATION DATE: 20020312 BOARD DATE: 20130208 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4, (92A10/Automated Supply and Logistics Specialist), medically separated for chronic bilateral plantar fasciitis. The CI developed pain in both feet when she was doing sprints during physical training. Despite extensive physical therapy (PT), podiatry consults, orthopedics consults, custom orthotics and steroidal injections, the CI failed to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. She was issued a permanent L3 Profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded chronic bilateral plantar fasciitis on DA Form 3947 to the Physical Evaluation Board (PEB). The MEB forwarded no other conditions for PEB adjudication. The PEB adjudicated the chronic bilateral plantar fasciitis as unfitting, rated 0%, with likely application of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals, and was medically separated with a 0% disability rating. CI CONTENTION: “My ankle condition is more severe than previous accounted for because I have decrease in my range of motion and I can neither walk nor stand or sit for any prolonged period of time. The same with my lower back and knees.” The CI attached a 3-page statement to her application (contending related lower back pain, hip and knee pain, anxiety and depression) which was reviewed by the Board and considered in its recommendations. SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings for unfitting conditions will be reviewed in all cases. The unfitting bilateral plantar fasciitis condition will be considered by the Board as this condition meets the criteria prescribed in DoDI 6040.44. The ankle condition will be considered by the Board as it relates to the unfitting bilateral plantar fasciitis condition. The other requested conditions (lower back pain, hip and knee pain, anxiety and depression) are not within the Board’s purview. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Army Board for Correction of Military Records. RATING COMPARISON: Service FPEB – Dated 20011218 VA (*18 Mos. Post-Separation) – All Effective Date 20020313 Condition Code Rating Condition Code Rating Exam Chronic Bilateral Plantar Fasciitis 5399-5310 0% Bilateral Plantar Fasciitis 5299-5278 10% 20030918 Left Calcaneal Heel Spur 5299-5271 10% 20030918 Right Calcaneal Heel Spur 5299-5271 10% 20030918 .No Additional MEB/PEB Entries. Lumbosacral Sprain/Strain 5237 20% 20030918 Hypertension 7101 10% 20030918 L & R knee conditions 4x 10% 20050211 Urinary Incontinence 7599-7512 60% 20050211 0% X 4 / Not Service-Connected x 7 Combined: 0% Combined: 90%* * All claims denied (NSC) in original 20020701 VARD due to missed VA exams; DRO decision of 20040827 granted feet, back, and HTN ratings above (combined 50%); DRO decision of 20050316 added 4x knee ratings, Individual unemployability and 7512 60% rating as above, all retroactive to 20020313. ANALYSIS SUMMARY: The Board acknowledges the sentiment expressed in the CI’s application regarding the significant impairment with which her service-incurred condition continues to burden her. It is a fact, however, that the Disability Evaluation System (DES) has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation. This role and authority is granted by Congress to the Department of Veterans Affairs (DVA). The Board utilizes DVA evidence proximal to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12- month interval for special consideration to post-separation evidence. The Board’s authority as defined in DoDI 6044.40, however, resides in evaluating the fairness of DES fitness determinations and rating decisions for disability at the time of separation. Post-separation evidence therefore is probative only to the extent that it reasonably reflects the disability and fitness implications at the time of separation. Chronic Bilateral Plantar Fasciitis Condition (including associated Ankle limitations). The CI had a well-documented history of bilateral foot pain in the service treatment record (STR). X-rays of both feet indicated bilateral bone spurs (heels). Throughout the STR, there was documentation of exquisite tenderness to palpation (TTP) along the plantar arch, antalgic gait, with heel toe walking, almost no heel contact, bone spurs and plantar fascia tenderness. The CI was offered surgery multiple times, however she declined. In August 2001, a permanent L3 profile was granted for chronic bilateral plantar fasciitis. The MEB examination, 5 months prior to separation, noted constant bilateral feet aching, and inability to tolerate 24 hour duty despite wearing special orthotic boots with soft padding, due to bone spurs and painful plantar fascia. The CI was advised to wear tennis shoes when off duty. Exam showed tenderness in the plantar fascia of both feet and also the sides of the heel and pain on movement of the under joints. There was no motor weakness or muscle atrophy. “She can't walk on her heels due to the pain and also on her toes with difficulty.” “Range of motion of both ankles done on 22 October 2001 showed right dorsiflexion lacks 20° (normal 0- 20°), plantar flexion 30° (normal 0-45°), inversion 0°, eversion 0°; left dorsiflexion lacks 20°, plantar flexion 30°, inversion 0°, eversion 0°. No active range of motion due to the pain and patient will not move feet.” Bilateral heel X-rays documented bilateral calcaneal spurring left greater than right. There was CT imaging for “Eval (of) symptomatic tarsal bony vs. fibrous coalition, with significant limitation of Range of Motion, R » L” with “a demonstrated fibrous coalition of the posterior facet of the subtalar joint best seen on image #9, on the right.” A podiatry exam 6 months prior to separation documented normal ROMs with the exception of lacking 10° of plantar flexion with contracture of the tendo-achilles soleus-gastroc R>L; bone spurs; increased bilateral heel pain with palpation on weight bearing and normal strength. The examiner recommended surgery. The assessment was “Plantar Fasciitis, Exostosis R calcaneous and Functional Equinus.” The commander’s statement also indicated a diagnosis of severe chronic plantar fasciitis spurs causing the CI to be placed on quarters several times due to swelling feet and intense pain. The VA Compensation & Pension (C&P) examination 18 months post separation documented ankle pain along with chronic bilateral tarsal and plantar pain due to bilateral plantar bone spurs and plantar fascia tenderness which was aggravated with standing and walking more than ten to fifteen minutes. The examiner stated: “There is only 10-15 degrees of plantar flexion in the bilateral ankles without any other passive or active range of motion due to guarding and pain. No other abnormal findings were noted.” The Board directs attention to its rating recommendations based on the above evidence. The PEB and the VA chose different coding options for the CI’s bilateral foot condition which materially impacted the level of disability rating. The PEB used the VA Schedule of Ratings per §4.73-4 Diagnostic Code 5310 Group X (muscle) Function: Movements of forefoot and toes; propulsion thrust in walking, and consolidated both feet into a single rating of 0% (Slight). The general application of the VASRD prescribes evaluations should be for single extremities unless otherwise specified in the code or condition for muscle injuries or nerve injury. If more than one extremity is evaluated separately, ratings are combined (under §4.25), using the bilateral factor (§4.26) where applicable. The VA considered the CI’s foot conditions as bilateral plantar fasciitis analogous to Code 5278 [Claw foot (pes cavus)], which includes a bilateral consideration within the 10% coding criteria; and also for left and right calcaneal heel spur analogous to 5271, ankle limited motion, at 10% for each foot IAW VASRD §4.71a. The STR noted that bilateral foot pain was caused by tender plantar fascia. The CI clearly met 5310 criteria of Movements of forefoot and toes; propulsion thrust in walking as was evidenced by the MEB documentation that the CI would not move her feet due to pain, she had an inability to walk on heels or toes with tenderness in plantar fascia and sides of her heels, and pain on movement of the under joints. The CI required special orthotic boots with soft padding during duty hours and tennis shoes off duty. The Board deliberated over the level of the CI’s bilateral foot conditions and considered analogous coding options under 5099-5310 (Group X, IAW §4.73, Schedule of Ratings–Muscle Injuries), or under VASRD §4.71a—Schedule of ratings– musculoskeletal system coding options of 5299-5271 (Ankle, limited motion), 5299-5278 (Claw foot [pes cavus] and/or 5299-5284 (Foot injuries, other), as well as §4.57, Static foot deformities. Given the CI’s underlying pathology and disability picture of foot pain with limited ankle dorsiflexion particularly on the right, the Board majority considered the disability picture was closest to that depicted by 5299-5278 for the bilateral condition at 30%. The Board also took into consideration the tenants of §4.7 (higher of two evaluations). Alternative rating of 20% unilateral for the right and 10% unilateral for the left was considered, but not predominate. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 30% (Moderate) for the chronic bilateral plantar fasciitis condition. BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. As discussed above, PEB reliance on the USAPDA pain policy for rating chronic bilateral plantar fasciitis was likely operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the chronic bilateral plantar fasciitis condition, the Board, by a vote of 2:1, recommends a disability rating of 30%, coded 5099-5278 IAW VASRD §4.71a. The single voter for dissent (who recommended a disability rating of left foot coded 5999-5284 rated 10% and right foot coded 5999-5284 rated 10%) did not elect to submit a minority opinion. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of her prior medical separation: UNFITTING CONDITION VASRD CODE RATING Chronic Bilateral Plantar Fasciitis (with Heel Spurs) 5099-5278 30% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120612, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record XXXXXXXXXXXXXX, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxx, AR20130006240 (PD201200900) 1. Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to recharacterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay. 2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum: a. Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay. b. Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay. c. Adjusting pay and allowances accordingly. Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay. d. Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options. 3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures. BY ORDER OF THE SECRETARY OF THE ARMY: Encl xxxxxxxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)