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AF | PDBR | CY2013 | PD2013 01307
Original file (PD2013 01307.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX         CASE: PD1301307
BRANCH OF SERVICE: Army  BOARD DATE: 20140219
SEPARATION DATE: 20040130


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (11B/Infantryman) medically separated for heat injury and bilateral foot conditions. The CI had a history of bilateral plantar fasciitis of idiopathic origin. He underwent conservative treatment, being ruled out for surgery. Ultimately, the CI’s bilateral foot condition could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty (MOS), or satisfy physical fitness standards. With respect to the CI’s heat injury, he experienced two heat casualties, both resulting in loss of consciousness, during deployment to Operation Iraqi Freedom in 2003. After return from deployment, he suffered a third heat casualty resulting in loss of consciousness. Subsequent to his placement in a 90-day monitoring program, he suffered yet another heat casualty with loss of consciousness. Despite further testing and attempts at rehabilitation, the CI’s heat injury condition could not meet the physical requirements of his MOS or satisfy physical fitness standards. Due to these conditions, the CI was issued a permanent P3/L3 profile and referred for a Medical Evaluation Board (MEB). The heat injury and bilateral foot conditions, characterized as “multiple episodes of heat exhaustion with syncope and mental changes” and “chronic bilateral plantar fasciitis,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The PEB adjudicated “recurrent heat related loss of consciousness and mental status changes” and “bilateral plantar fasciitis” as unfitting, rated 10% and 0% respectively. With respect to the rating for the bilateral plantar fasciitis, the PEB likely applied the US Army Physical Disability Agency pain policy. The CI made no appeals and was medically separated.


CI CONTENTION: “Veteran was given 10% for feet while suffering other issues which should have been considered.”


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 heat injury and bilateral plantar fasciitis conditions are 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 20031126
 VA - (6 Mos. And 10 mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Heat Injury 7900 10% Residuals of Heat Strokes 8999-8911 NSC 20041109
Bilateral Plantar Fasciitis 5399-5310 0% Bilateral Plantar Fasciitis 5299-5284 10% 20040713
No Additional MEB/PEB Entries
 Other x 14 20040713
Combined: 10%
 Combined: 60%
Derived from VA Rating Decision (VA RD ) dated 200 40914 (bilateral plantar fasciitis) and 20041207 (heat injury).

ANALYSIS SUMMARY: The Board acknowledges the sentiment expressed in the CI’s application regarding the “…suffering other issues which should have been considered” for rating. The Board wishes to clarify that it is subject to the same laws for disability entitlements as those under which the Disability Evaluation System (DES) operates. The DES has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation. That role and authority is granted by Congress to the Department of Veterans Affairs (DVA), operating under a different set of laws (Title 38, United States Code). While the DES considers all of the member's medical conditions, compensation can only be offered for those medical conditions that cut short the member’s career; and the Board’s assessment of fitness determinations is premised on the MOS-specific functional limitations in evidence at the time of separation.

Bilateral Plantar Fasciitis. There are few source documents in evidence, but rather encounter documents with historical summaries of prior treatments. Specific records pertaining to the CI’s bilateral foot condition span from September 2002 to October 2003. The service treatment record (STR) indicated that the CI first experienced bilateral heel and foot pain in February 2002 without history of direct trauma. Under the care of orthopedics and podiatry, his non-surgical conservative treatments of orthotics, assistive walkers, night splints, posterior (day) splints, local steroid injections, casts and physical therapy (PT) brought only temporary relief of his painful symptoms. The CI was able to deploy with no real change in his symptoms upon returning home. At the MEB narrative summary (NARSUM) examination (4 months prior to separation) the CI reported that he is unable to do most of his work and soldier skills required for his MOS due to foot pain. He has difficulty standing for prolonged periods of time in military footwear. The MEB examination revealed pain on the bottom and along the inside and middle portion of both feet. Motor function, vascular, and neurologic examinations were normal. There was no foot edema, erythema or skin ulceration present. There was no comment on range-of-motion (ROM) or painful motion of the feet. The diagnosis was chronic bilateral plantar fasciitis with slight, but constant pain. The examiner noted that the CI is unable to ambulate or stand in military footwear for prolonged periods of time. Although no time was specified as to the wearing of military footwear, the examiner opined that his profiled limitations could jeopardize the CI and others in a field environment and therefore, the condition was determined to be unfitting. The VA Compensation and Pension (C&P) examination on 13 July 2004, (6 months post-separation) was a very limited general examination with an impression of overall joint pain, not specific to his feet. The examiner opined for further evaluation with Orthopedics. There were no follow-up records in evidence. There were no radiographs in evidence pertaining to his bilateral foot condition.

The Board directs attention to its rating recommendation based on the above evidence. The Board first considered whether each foot condition remained separately unfitting, having decoupled them from the combined PEB adjudication. The Board discussed separate left and right plantar fasciitis conditions and determined that in light of the specific entry noting the inability to wear military footwear for prolonged periods of time would indeed create a situation of not meeting service retention standards even with either foot (alone) having the described plantar fasciitis condition. Therefore, the Board agreed that separate conditions of each foot (plantar fasciitis) were independently unfitting and ratable. The record makes clear, in fact, that the CI’s pain from plantar fasciitis (not from any presumably pre-existing “other” condition) was the dominant disability in this case. There is not a specific VA Schedule for Rating Disabilities (VASRD) code for plantar fasciitis. The PEB’s 5310 plantar muscle code is in common use for plantar fasciitis, and is quite acceptable when applied unilaterally; however, its application in this case would entail separate ratings. The Board next considered if a VASRD-compliant bilateral code was applicable, or if the unfitting left foot and unfitting right foot conditions rated separately better depicted the CI’s disability condition IAW VASRD §4.7 (higher of two evaluations).

The Board considered analogous coding of 5022 (Periostitis), 5284 (foot injuries, other, moderate), and 5310 (muscle Group X). Consensus was that in the absence of degenerative disease and painful motion coupled with “slight” depiction of pain on the MEB examination, the 5022 and or 5284 codes would not best describe the CI’s condition. In this case, both feet were considered to fail retention standards; both were implicated by the NARSUM and implied in the commander’s statement; and, both were profiled. Board deliberations focused on the PEB’s analogous coding of 5399-5310 at 0% rating. The higher 10% “moderate” criteria were not met due to the painful condition identification as “slight.” The Board agreed that the underlying pathology and disability picture was best supported by the 5399-5310 coding at 0% for each foot, corresponding to “slight” impairment as described on the pre-separation examination. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends separate disability ratings for each foot of 0% for “slight” muscle disability under the code 5399-5310.

Heat Injury. The STR contained few, but detailed documents with regard to his heat injury. While deployed in 2003, the CI experienced two separate heat-related injuries with an apparent brief loss of consciousness (LOC) with mental status changes and one presumably non-heat related episode LOC. Upon re-deployment, he was evaluated by Internal Medicine. The CI developed no medical complications from these episodes and was placed on a P3 profile secondary to repeat incidents and referred for an MEB in late 2003. At the NARSUM examination, performed on 21 October 2003, (3 months prior to separation) the CI reported recent exertional chest tightness and dizziness with a single episode of syncope (LOC) on 30 September 2003. Records summarized that he was seen in the emergency department and released within 24 hours. The physical examination was normal except for a pulse rate of 108 beats per minute (tachycardia). His blood pressure was 128/75; equating to a normal pulse pressure of 53 ([128 minus 75 = 53] normal range = 40-60). At the VA C&P neurologic examination performed on 9 November 2004, (9 months after separation), the CI complained of “cognitive difficulties” noting no further details. There was no history of seizure activity. His physical and mental status examinations were normal. The examiner stated, “I find no long-term residuals as a result of his multiple episodes of heat stroke.”

The Board directs attention to its rating recommendation based on the above evidence. The PEB rated the condition 10%, code 7900, analogous to hyperthyroidism. The VA rated the condition as not service-connected, coded 8911, analogous to epilepsy. There is not a specific VASRD code for heat-related injury; and, the PEB’s 7900 thyroid code is often analogized for heat-related injuries. Board members considered that in the absence of abnormal functional residuals or significant impact on occupational and social activity, the heat-related condition was of mild severity. Board members agreed that the analogized VASRD 7900 code most accurately depicts the CI’s condition. The Board is unable to find any pathway to a higher rating than the PEBs 10%. The 7900 at 30% criteria is not applicable in this case having evidence of normal blood pressure and pulse pressure. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the heat injury 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. The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. In the matter of the service-combined bilateral plantar fasciitis condition, the Board unanimously recommends that each foot be rated as separately unfitting at 0%, coded 5399-5310, IAW VASRD §4.73. In the matter of the heat injury condition and IAW VASRD §4.119, the Board unanimously recommends no change in the PEB adjudication. 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; Left Foot 5399-5310 0%
Plantar Fasciitis; Right Foot 5399-5310 0%
Heat Injury 7900 10%
COMBINED
 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130910, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




XXXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXXX, AR20140013999 (PD201301307)


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 and hereby deny the individual’s application.
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                                                  XXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary
                                                      (Army Review Boards)

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