RECORD OF PROCEEDINGS

PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXX BRANCH OF SERVICE: Army

CASE NUMBER: PD1100926 SEPARATION DATE: 20041214

BOARD DATE: 20120815

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was a mobilized Reserve Major/O4 (38A, Civil Affair Officer), medically separated for onset of celiac disease with associated enthesopathy symptoms of plantar fasciitis and trapezius myofasciitis. He did not respond adequately to treatment and was unable to perform within his Military Occupational Specialty (MOS) or meet physical fitness standards. He was issued a permanent P3/U3/L3 profile and underwent a Medical Evaluation Board (MEB). Celiac disease, bilateral plantar fasciitis, left ulnar neuropathy and bilateral trapezius myofasciitis were forwarded to the Informal Physical Evaluation Board (IPEB) as medically unacceptable IAW AR 40-501 on the DA Form 3947. However, the MEB narrative summary (NARSUM) notes that the left ulnar neuropathy was medically acceptable. The IPEB adjudicated the celiac disease condition as not service-connected and the other three conditions to be not unfitting. The CI appealed to the Formal PEB (FPEB) which adjudicated the celiac disease condition with associated esthenopathy symptoms of plantar fasciitis and trapezius myofasciitis as unfitting, and rated 10% with application of the Veterans Administration Schedule for Rating Disabilities (VASRD). The celiac disease was considered to be an EPTS (existed prior to service) condition with permanent service aggravation. No deduction for the EPTS component was made. The ulnar neuropathy was determined to be not unfitting. The CI made no further appeals and was medically separated with a 10% combined disability rating.

CI CONTENTION: “The Department of the Army incorrectly and unfairly rated my service connected disability too low, I continue to have substantial medical problems associated with my disability and believe the rating should have been substantially higher.”

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. In this case, the Board considered if the associated conditions of bilateral plantar fasciitis and trapezius myofasciitis were separately unfitting at the time of separation. 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 the Correction of Military Records.

RATING COMPARISON:

ANALYSIS SUMMARY: The IPEB combined the celiac disease with associated enthesopathy symptoms of plantar fasciitis and trapezius myofasciitis as a single unfitting condition, coded analogously to 7319 and rated 10%. The Board first evaluated the IPEB coding approach of combining the conditions under the single analogous 7319 code. The Board’s initial charge in this case was therefore directed at determining if the IPEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings. The Board must apply separate codes and ratings in its recommendations if compensable ratings for each condition are achieved IAW VASRD §4.71a. If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each ‘unbundled’ condition was unfitting in and of itself. Not uncommonly this approach by the PEB reflects its judgment that the constellation of conditions was unfitting; and, that there was no need for separate fitness adjudications, not a judgment that each condition was independently unfitting. Thus the Board must exercise the prerogative of separate fitness recommendations in this circumstance, with the caveat that its recommendations may not produce a lower combined rating than that of the IPEB.

Celiac Disease Associated with Plantar Fasciitis and Trapezius Myofasciitis. The CI enjoyed excellent overall health until he deployed to Indonesia in May 2003 when he developed a gastroenteritis illness. Persistent diarrhea after treatment prompted further evaluation leading to diagnosis of celiac disease (gluten sensitive enteropathy) in July 2003. He was placed on a gluten free diet with symptom improvement. In addition, possible extra-intestinal manifestations were noted including neck and back pain, arthralgias of knees and hands, and bilateral plantar fasciitis. The gastroenterologist treating the CI attributed the musculoskeletal symptoms to the celiac disease. His symptoms recurred when he was unable to maintain a gluten free diet during subsequent deployments. Upon return to his home station from deployments, he resumed the gluten free diet with resolution of most gastrointestinal symptoms over a period of four weeks, but with persistence of the extra-intestinal manifestations. In June 2004, he was determined to no longer be deployable, given a P3 profile and referred to MEB. The Board considered each unbundled condition separately.

Celiac Disease. Service treatment records reflect resolution of diarrhea with adherence to a gluten free diet. The condition did not interfere with performance of duties in garrison, however the inability to follow a special diet while deployed significantly interfered with fulfillment of the duty requirements of his military job which required frequent overseas travel to locations not supported by military services. A 24 August 2004 memorandum from his gastroenterologist states the CI was non-deployable due to dietary limitations. Board members agreed this gastrointestinal disease rendered the CI unfit for continued military service and turned its attention to its disability rating recommentdaion for the gastrointestinal condition at the time of separation. The FPEB and VA both adjudicated the celiac disease analogous to irritable bowel syndrome (7399-7319). The 5 May 2004 gastroenterology appointment noted the CI did well at home on a gluten free diet, but diarrhea recurred when he deployed and was unable to follow his diet. His weight was 235.9 pounds, unchanged from the weight recorded at the clinic appointment on 18 November 2003. The MEB NARSUM, dated 27 August 2004, stated that most of his GI symptoms resolved within four weeks on a gluten free diet after returning from a deployment. Intermittent diarrhea occurred depending on the availability of a gluten free diet. The abdominal examination was normal. At the time of the VA Compensation and Pension (C&P) examination on 31 March 2005, 3 months after separation, the CI reported experiencing four loose bowel movements per day. The abdominal examination was normal, and his weight was 237 pounds, essentially unchanged from the MEB NARSUM weight. Laboratory testing was normal including blood count and chemistry, showing no signs of malabsorption due to celiac disease. In its rating decision, the VA cited the C&P examination recording the CI report of four loose stools a day. The Board notes that while there was an initial weight loss during the acute illness in May and June 2003, the CI had regained the lost weight by November 2003, 3 months after diagnosis and initiation of a gluten free diet. The CI’s weight remained stable after November 2003 consistent with good control of gastrointestinal disease by diet. The Board determined that the condition was no worse than the description of the 10% disability rating for “moderate, frequent episodes of bowel disturbance with abdominal distress” under VASRD diagnostic code 7319. The service treatment records indicated that, while on a diet, his gastrointestinal symptoms were resolved or mild and did not interfere with duties in garrison more nearly approximating a zero percent rating. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 0% for celiac disease condition.

Trapezius Myofasciitis. The CI developed trapezius myofascial pain in the fall of 2003 without a history of injury. A physical medicine and rehabilitation evaluation on 31 December 2003 recorded left trapezius tightness and tenderness associated with neck stiffness and pain. There was no weakness of the arms, however a left ulnar neuropathy due to cubital tunnel syndrome (unrelated to the trapezius/neck pain condition) was diagnosed. X-rays of the cervcal spine showed minimal loss of disc space at C4-5 and X-rays of the shoulders were normal. A physical therapy note from 14 January 2004 noted the neck pain interfered with physical activity. The CI’s gastroenterologist, at the 5 May 2004 appointment, noted that the CI did not participate in physical training due to neck and back pain. The physical medicine and rehabilitation MEB NARSUM, 14 June 2004, noted the CI had not been seen since the December 2003 evaluation due intervening deployments. The trapezius myofascial/neck pain persisted with “little improvement.” On examination there was full cervical range-of-motion (ROM) without signs of radiculopathy. There were multiple tender points in the upper trapezius muscle. Strength of the upper extremities was normal with normal reflexes. The MEB NARSUM noted the CI was unable to take the physical fitness test due to trapezius neck pain. On physical examination he was noted to have pain to palpation over the left trapezius. The Board considered if the trapezius myofascial pain was a separately unfitting condition. Treating physicians recorded that the trapezius / neck pain interfered with performance of the physical fitness test. The condition was considered to be medically unacceptable by the physical medicine and rehabilitation physician and was referred by the MEB as a separate medically unacceptable condition. The Board noted that there was a paucity of information for review, but concluded that the preponderance of available evidence supported a conclusion that the trapezius myofasciitis condition was separately unfitting and turned its attention to its rating recommendation at separation. In addition to the service treatment record, the Board also considered the the VA C&P examination, 31 March 2005, three months after separation. The C&P examiner recorded that the trapezius/neck pain was mild during the day, but disturbed his sleep at night. The CI was not taking any medication for the trapezius/neck pain. On examination, the CI was observed to have a normal posture and gait. Examination of the neck showed tenderness of the left trapezius with reduced range of motion. Neurological examination was normal. An X-ray of the cervical spine demonstrated loss of normal lordosis suggesting of muscle spasm although the examiner did not note its presence. The VA adjudicated a 10% rating for the condition based on this examination. The Board noted the physical medicine examination documenting full neck ROM, however, agreed there was evidence of tenderness and painful motion supporting a 10% rating. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) and VASRD §4.59 (painful motion), the Board recommends a disability rating of 10% for the trapezius condition, coded 5299-5237, analogous to cervical strain.

Bilateral Plantar Fasciitis. The CI developed intermittent bilateral heel pain in the fall of 2003. The physical medicine and rehabilitation evaluation 31 December 2003 recorded the CI experienced “first step” heel pain after getting out of bed in the morning and after prolonged sitting. Plantar fasciitis was diagnosed and orthotics prescribed. A physical therapy evaluation

14 January 2004 recorded three months of intermittent heel pain with initial steps after arising in the morning or after sitting for more than 15 minutes. The heel pain occurred with the first 10 to 15 steps then subsequently resolved. Symptoms were were independent of type of foot wear. Imaging was normal bilaterally. He was treated conservatively with stretching, orthotics and braces at night to maintain a stretch position. The physical therapist noted that the CI had not participated in physicial activity for six months mostly due to neck pain. There was tenderness at the proximal insertion of the plantar fascia at the heel (medial calcaneal tubercal). The gastroenterologist, on 5 May 2004, recommended no “PT” (physical training) secondary to back and neck pain without mention of the heel pain. There were no other visits in the service treatment records specifically for the plantar fasciitis. The physical medicine and rehabilitation MEB NARSUM, 14 June 2004, recorded CI report that the plantar fasciitis condition had worsened without further elaboration. On examination, there was tenderness at the insertion of the plantar fascia bilaterally. An orthopedic surgery evaluation on 29 June 2004 also noted the history of plantar fasciitis manifested by “AM pain” at the heel and advised continued stretching and orthotics. At the MEB history and physical examination, 29 June 2004, the CI indicated a history of foot problems on DD 2807 and reported having experienced pain in the back, shoulder, neck and elbow without mentioning foot pain, but indicated being prescribed orthotics. The examiner, on DD 2808, noted orthotics for plantar fasciitis without elaboration. The MEB NARSUM, 27 August 2004, stated the CI had “severe” plantar fasciitis without description of symptoms. The NARSUM stated the CI was unable to do the PT test due to neck and foot pain. On physical examination he was noted to have pain to palpation both plantar areas. The Board considered if the bilateral plantar fasciitis condition was a separately unfitting condition. Prior to the onset of the celiac disease, the CI had no complaints related to his feet other than an infection eight years earlier. In a letter, dated 30 September 2004, from the CI to the IPEB describing his health prior to 26 May 2003, he wrote “I jogged every other day and participated in tennis league and went on 8-mile walks around Diamond Head twice a week.” The two MEB NARSUMS indicated that the condition interfered with performance of the physical fitness test and was considered to be medically unacceptable. The Board considered the clinical descriptions, that the heel pain resolved after 10 to 15 steps of walking, were consistent with a minimal problem, but observed that treating physicians indicated that running in physical training aggravated the symptoms and advised the CI to avoid running. The Board concluded that the preponderance of evidence supported a conclusion that the plantar fasciitis condition was separately unfitting and turned its attention to its rating recommendation at separation, utilizing the evidence just reviewed and the C&P examination. The VA C&P examination on 31 March 2005 recorded that the CI had reported pain in his feet since August 2003 and could not participate in sports as a result. He was not taking any medication, but continued to wear the braces at night “with some relief of pain.” On examination, gait and posture were observed to be normal. There was marked tenderness of both feet without deformity. ROM of the feet and ankles were normal. The VASRD does not have a specific code for plantar fasciitis and it must be rated analogously. The VA adjudicated its ratings using the analogous code 5284 other foot injuries, assigning 10% each for moderate severity. The 5284 code, other foot injuries, assigns ratings based on assessment of severity as moderate (10%), moderately severe (20%), and severe (30%) applicable to each foot. The Board also considered 5299-5276, analogous to pes planus, but noted that the arches were normal on multiple exams. It also considered 5284, other foot injuries, and determined that this best described the underlying disability. The Board discussed whether each foot more nearly approximated the 0% level or the 10% under 5284. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) and VASRD §4.59 (painful motion), the Board recommends a disability rating of 10% each for left and right plantar fasciitis, coded 5284.

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. In the matter of the combined celiac disease and trapezius myofasciitis, and plantar fasciitis, the Board unanimously recommends that the conditions be separately adjudicated as follows: unfitting celiac disease 0% coded 7399-7319 IAW VASRD §4.114 and unfitting trapezius myofasciitis 10% coded 5299-5237 IAW VASRD §4.71a. The Board unanimously determined the bilateral plantar fasciitis was unfitting and recommended, by a vote of 2:1, that the right and left foot plantar fasciitis be separately rated at 10% and coded 5284 IAW VASRD §4.71a. The single voter for dissent (who recommended a 0% rating for each foot) 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 his/her prior medical separation:

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20111016, w/atchs

Exhibit B. Service Treatment Record

Exhibit C. Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXX

President

Physical Disability Board of Review

SFMR-RB

MEMORANDUM FOR Commander, US Army Physical Disability Agency

(TAPD-ZB / ), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXX, AR20120016393 (PD201100926)

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 reject the Board’s recommendation and hereby deny the individual’s application. There is insufficient justification to support the Board’s recommendation in accordance with Army and Department of Defense regulations.

2. The PDBR divided (unbundled) the applicant’s unfitting condition, celiac disease, into its component parts and rated them separately. This is a legitimate method of calculating a disability percentage but the individual conditions, i.e. diarrhea (celiac disease), trapezius myofasciitis, bilateral plantar fasciitis must each be individually unfitting in order to be ratable separately. In other words, he can only receive a rating of 10% for plantar fasciitis of the right foot if the evidence is clear that if plantar fasciitis of the right foot were his only malady that failed to meet retention standards, it would have been deemed to be unfitting and resulted in a premature termination of his military career. The evidence cited involves multiple examiners and is not descriptive of maladies that have failed therapeutic management and fail to meet retention standards. The record does not support a conclusion that his neck pain (trapezius fasciitis) or his foot pain (plantar fasciitis) prevented him from performing the duties of his MOS. Because they are not shown to be independently unfitting, they are not ratable.

2. This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

BY ORDER OF THE SECRETARY OF THE ARMY:

Encl XXXXXXXXXXXXXXXXXXX

Deputy Assistant Secretary

(Army Review Boards)

CF:

( ) DoD PDBR

( ) DVA