RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-02329
BRANCH OF SERVICE:  Army 	BOARD DATE:  20140911
SEPARATION DATE:  20050407

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (92F20/Petroleum Supply Specialist) medically separated for a bilateral foot/ankle condition(s), which could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The MEB forwarded three separate conditions (bilateral plantar fasciitis, bilateral tarsal tunnel entrapment and bilateral ports pedis entrapment) to the Physical Evaluation Board (PEB), each judged to be medically unacceptable IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “bilateral plantar fasciitis with associated bilateral tarsal tunnel syndrome and bilateral ports pedis entrapment” as a single unfitting condition, rated at 0%, specifically referencing the U.S. Army Physical Disability Agency (USAPDA) Policy/Guidance Memorandum #12 (Table of Analogous Codes).  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in his application.  

SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting foot/ankle condition is addressed below and no additional conditions are within the DoDI 6040.44 defined purview of the Board.  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 Board for Correction of Military Records.

RATING COMPARISON:  
   
Service IPEB – Dated 20041018 | VA (5 Mo. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Bilateral Plantar Fasciitis ... [and subsumed tarsal tunnel/ports pedis neuropathies as above] | 5399-5310 | 0% | Plantar Fasciitis, Hallux Valgus, Left Foot | 5276 | 10% | 20050914
| | | Plantar Fasciitis, Hallux Valgus, Right Foot | 5276 | 10% | 20050914
| | | Achilles Tendonitis, Left Ankle | 5271 | 10% | 20050914
| | | Achilles Tendonitis, Right Ankle | 5271 | 10% | 20050914
Other x 0 (Not in Scope) | Other x 18 (Not in Scope) | 20050914
Combined:  0% | Combined:  100%
Derived from VA Rating Decision (VARD) dated 20061016 (most proximate to date of separation).

ANALYSIS SUMMARY:  

Bilateral Foot/Ankle Condition.  The earliest entries in the CI’s service treatment record (STR) dates back to 1997, documenting the onset of bilateral ankle pain (no noted injury), which was diagnosed as an impingement syndrome.  Gait was noted to be normal.  X-rays as well as magnetic resonance imaging (MRI) for the right ankle were negative and the CI was placed on temporary profile.  Bilateral foot pain associated with paresthesias surfaced during a 2001 deployment to Kuwait and an electrodiagnostic study in July 2002 was interpreted as normal with “no electrodiagnostic evidence for tibial nerve entrapment.”  The CI was treated conservatively and resumed a temporary profile.  The first entry in the STR following the above EEG report is a year later and provides a diagnosis of bilateral Achilles’ tendonitis based on suggestive, but mild, X-ray findings.  Per the history related in the commander’s performance statement, “Over the following year and a half [dating to redeployment from Kuwait] his condition has worsened and he has been placed on more restrictive profiles [leading to permanent profile and MEB].”  There is a podiatry consultation and follow-up in July and October of 2003 which note a diagnosis of bilateral plantar fasciitis.  Starting 2 months later, podiatry notes add additional diagnoses of tarsal tunnel and porta pedis entrapment syndromes (for purposes of disability assessment, this is a single entrapment neuropathy [bony nerve impingement] with functional overlap and mostly technical anatomic distinction).  There is a single podiatry entry which lists a separate diagnosis of pes planus (flat foot) and a finding of “mildly decreased medial arch” on MEB foot X-rays, but a specific notation of normal arch (and exclusion of pes planus) on the 1994 service entry examination and the 2004 MEB physical examination (DD Form 2808).  The CI was treated with physical therapy, orthotics and injections with limited success.  Bone scan and MRI of the feet and ankles were normal.  There are various STR entries documenting normal strength (5/5) at the ankle, with no significant sensory deficits.  There are no entries which document gait disturbance or use of a cane until the last entry (podiatry), 2 days prior to the narrative summary (NARSUM), which comments, “…states must use cane to walk.”

The NARSUM was prepared in September 2004 (7 months prior to separation) and notes “constant and moderate” bilateral foot pain rated 8/10, with the comment “points to the instep of the foot as the primary source of pain.”  Limitations were characterized as “can walk 100 yards before he must stop secondary to pain ... can stand for only 10-15 minutes ... relates he requires a cane to assist with ambulation.”  The physical exam did not comment on gait, noted bilateral tenderness over the entire plantar surface “which causes tingling and sharp pain” and described findings consistent with the diagnosed neuropathies (Tinel’s sign and localized bony tenderness at the implicated sites).

The VA Compensation and Pension (C&P) examination (5 months after separation) addressed separate “bilateral ankle” (duration 9 years) and “bilateral feet plantar fasciitis” (duration 4 years) conditions, without documentation of any entrapment neuropathies.  For the ankle conditions, the examiner noted constant “popping, swelling, stiffness and pain”; and for the feet, “pain, weakness, stiffness, swelling and fatigue”; without elaboration of severity; both worsened by standing or walking.  The physical exam documented a normal gait, stating “does not require an assistive device for ambulation.”  The ankle exam documented only non-specific tenderness and recorded range-of-motion (ROM) as bilateral dorsiflexion to 15 degrees (normal 20 degrees) and plantar flexion to 45 degrees (normal).  Specific foot examinations are not in evidence.  There is a VA podiatry note in evidence from April 2006 (12 months after separation) for “rule-out bilateral tarsal tunnel syndrome” which states “has been using a cane occasionally” and documents detailed normal neurologic findings (5/5 strength) except for some decreased sensation to light touch.  No peripheral neuropathy ratings were conferred by the VA.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated analogously to code 5310, the muscle disability code for Group X (movements of forefoot and toes).  This code (derived from the USPDA guidance referenced above) is appropriate to plantar fasciitis and not inconsistent with the Veterans’ Affairs Schedule for Rating Disabilities (VASRD); but, the 0% rating is for “slight” impairment, while the code offers 10%, 20%, and 30% ratings for “moderate,” “moderately severe” and “severe” disability, respectively.  Furthermore, IAW VASRD §4.55 (principles of combined ratings for muscle injuries), each muscle group must be rated separately; thus, bilateral rating under the single code is not VASRD compliant.  The VA’s separate ratings for the feet were under code 5276 (flatfoot, acquired) and for the ankles under code 5271 (limitation of motion).

There were various issues for deliberation in this case prior to selection of a specific coding route.  First it must be settled whether bilateral or separate unilateral ratings are indicated.  VASRD §4.71a offers only two analogous choices for a single bilateral rating which could be applicable to this case.  Code 5279 (metatarsalgia) provides for a bilateral 10% rating, but members agreed that the condition of metatarsalgia is not analogously appropriate to the pathology and degree of disability in this case.  The only other bilateral coding choice is 5276 under which the VA conferred separate ratings; but, the code provides for 30% and 50% bilateral ratings.  The rating descriptions, however, lean heavily on anatomic markers for severe pes planus; none of which were present in this case.  The bilateral 30% description does include “pain on manipulation and use of the foot” which could be considered as analogous to the disability in this case but, a significant objection to the application of code 5276 (even analogously) in this case is that pes planus (to the degree that it was even present) did not make a significant contribution to the pathology or disability in this case and certainly does not satisfy the criteria of VASRD §4.57 (static foot deformities) for acquired flat foot.  Members agreed, therefore, that analogous rating under code 5276 could not be supported in this case.  The next area for deliberation was whether separate ankle and foot ratings, as per the VA, could be supported.  There is, however, little clinical basis for establishing intrinsic ankle pathology or impairment in this case.  There are competing causes for the pain, plantar fasciitis and neuropathy; but, each is applicable to the foot, not the ankle.  It is apparent that it was the foot pain which was the unfitting disability in this case; thus, ankle impairment would be not be appropriate for rating as a disability and that issue aside, would be questionably compliant with  VASRD §4.14 (avoidance of pyramiding).

Having decided that separate (and foot only) ratings were the most VASRD compatible approach; the Board also considered that separate fitness assessments must justify each disability rating.  In this case a bilateral condition was determined to fail retention standards, was profiled and was implicated by the commander’s statement.  Members thus agreed that each foot should be conceded as separately unfitting and, furthermore, that coding and rating features were logically identical.  With regards to the appropriate code for separate ratings, the following are justifiable and were considered: the PEB’s 5299-5210 code as analogous to plantar fasciitis; the nerve code 8799-8725 (tibial nerve neuralgia) as analogous to the tarsal tunnel/ports pedis neuropathies (offering ratings of 10% mild, 10% moderate and 20% severe) and, 5299-5284 (foot injuries, other) as analogous (despite the absence of injury in this case) to the overall disability (offering ratings of 10% moderate, 20% moderately severe and 30% severe).  Although there are separate diagnoses contributing to the pain, the prohibition of pyramiding permits rating under a single code only.  Members agreed that the 5284 code (offering no rating advantage) was less applicable because of the absence of any specific injury to the foot; but, concluded that both tibial neuropathy (code 8725) and plantar fasciitis (code 5310) were significant contributors to the unfitting foot pain.  Since neither rating scale was advantageous, rendering moot the intercession of VASRD §4.7 (higher of two evaluations); deliberations settled on the application of the hyphenated code 8725-5310 (defaulting to PEB rating criteria, but under VASRD compliant separate ratings) for the Board’s recommendations.  Members agreed that “slight” or “mild” did not fairly characterize the disability for each foot in this case and deliberated between “moderate” (10% each foot) or “moderately severe/severe” (20% each foot) recommendations.  After due deliberation, members agreed that the objective functional limitations in evidence (noting the inconsistent presence of gait disturbance and need for assistive device) were fairly characterized as moderate.  Having so decided, with consideration of all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a 10% rating for each foot under code 8725-5310.
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.  The PEB’s reliance on the USAPDA Table of Analogous Codes, as noted above, was not a constraint for the Board’s recommendation.  In the matter of the combined bilateral foot condition, the Board unanimously recommends that each foot be rated as separately unfitting at 10%, coded 8725-5310, IAW VASRD §4.71a.  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, effective as of the date of his prior medical separation: 

UNFITTING CONDITION | VASRD CODE | RATING
Plantar Fasciitis with Entrapment Neuropathy, Right Foot | 8725-5310 | 10%
Plantar Fasciitis with Entrapment Neuropathy, Left Foot | 8725-5310 | 10%
COMBINED (w/ BLF) | 20%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131102, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		
XXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXXXX, AR20150002582 (PD201302329)

1.  I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation.  This decision is final.  

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.   

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						     XXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA

PD-2013-02329