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AF | PDBR | CY2014 | PD-2014-01418
Original file (PD-2014-01418.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2014-01418
BRANCH OF SERVICE: ArmY  BOARD DATE: 20140911
SEPARATION DATE: 20080713


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (25U10/Signal Support Systems Specialist) medically separated for her back and feet conditions. These conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards. She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The CI’s chronic bilateral foot pain, chronic low back pain (LBP), plantar fasciitis and pes planus conditions were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded to the PEB adjustment disorder with depressed mood as meeting retention standards. The Informal PEB (IPEB) adjudicated chronic foot pain (bilateral) and chronic LBP, without neurologic deficit conditions as unfitting, each rated at 10% respectfully, citing application of the US Army Physical Disability Agency (USAPDA) pain policy. The IPEB did not address the remaining conditions (plantar fasciitis, pes planus and adjustment disorder) . The CI appealed to the Formal PEB (FPEB) which reaffirmed the IPEB’s findings for the chronic low back condition as unfitting, rated at 10%, but changed the chronic foot pain (bilateral) diagnosis to bilateral plantar fasciitis (to include chronic bilateral foot pain and pes planus) as unfitting, rated at 0%. The remaining condition (adjustment disorder) was not addressed. The CI may no further appeals and was medically separated.


CI CONTENTION: “I really do not care because I am considered to be 100% VA rating on all my conditions that the military did not care for when discharging me from duty, so pointless because there is nothing else I can ask the Arm Force (sic) ”.


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. In addition, the CI was notified by the Army that her case may be eligible for review of the military disability evaluation of her mental health (MH) condition in accordance with Secretary of Defense directive for a comprehensive review of Service members who were referred to a disability evaluation process between 11 September 2001 and 30 April 2012 and whose MH diagnoses may have been changed during that process. The CI is eligible for PDBR review of other conditions evaluated by the PEB and has elected review by the PDBR. The rating for the unfitting back and feet conditions are addressed below along with the contended MH condition.






RATING COMPARISON :

Service FPEB – Dated 20080305
 VA* - (~ 5 & 6 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Low Back Pain 5299-5237 10% Lumbosacral Strain 5237 10% 20081219
Bilateral Planar Fasciitis (Chronic Bilateral Foot Pain; Pes Planus) 5399-5310 0% Bilateral Plantar Fasciitis 5276 10% 20081219
Adjustment Disorder… Not Unfitting Panic Disorder… 9434-9412 30% 20090106
Other x 0 (Not in Scope)
 Other x 7 20081219
Combined: 10%
 Combined: 60%
*Derived from VA Rating Decision (VARD) date 20090810 (most p roximate to date of separation )


ANALYSIS SUMMARY:

Chronic Low Back Pain. A primary care evaluation dated 19 September 2006 documented a medical history of a non-traumatic, chronic midline (L5-S1) LBP without radiculopathy for a period of 5 years; pain was initially noted while in high school, but had worsened since entering the military. During examination the CI reported a 2-month history of sharp pain in the low back region, while the examiner noted lumbar spine tenderness to palpation to both the midline and along the paraspinous muscles, there was no evidence of muscle spasms or abnormal spinal contour and the neurologic evaluation was normal. Lumbar spine X-ray images obtained 19 September 2006 were unremarkable as well. The CI’s condition was diagnosis as lumbago and was ineffectively treated with physical therapy, chiropractic care as well as anti-inflammatory medications. Neuroimaging of the lumbar spine obtained on 8 January 2008 showed mild hypertrophic bilateral facet joints between L4-L5 and L5-S1. The CI was given a permanent L3 profile for her LBP/degenerative disc disease L5-S1 and feet stress fractures condition and referred for MEB.

At the MEB narrative summary (NARSUM) examination on 6 August 2007 (approximately 11 months prior to separation), the CI reported no interventions relieved her back pain. On physical examination, the examiner noted that the back was tender to very light palpation in the lumbar spine and there was increased thoracolumbar pain with axial compression on her shoulders. The examiner also observed that the CI had reversal of the normal lumbar lordotic curve. The examiner concluded that the CI’s back pain was slight and constant.

At the VA Compensation and Pension (C&P) examination for low back pain, obtained on 
19 December 2008 (approximately 5 months post separation) the examiners observed that the CI’s gait was normal, but she complained of [back] pain with motion and tenderness to palpation. The CI’s straight leg raise was negative, normal sensory/motor evaluations; she was without guarding and no [muscles] spasms. There was slight straightening of the lordotic curve as shown by diagnostic radiographic imagines.

The Board directs attention to its rating recommendation based on the above evidence. The FPEB adjudicated the chronic LBP as unfitting coded 5299-5237 while the VA coded it 5237, (lumbosacral strain), both rated it 10%. The Board concluded the multiple treatment notes documented lumbar tenderness that did not result with an abnormal gait nor an abnormal spinal contour, were consistent with the 10% criteria under VASRD §4.71a, General Rating Formula for the Spine. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded there was insufficient cause to recommend a change in the PEB adjudication for the chronic low back pain.

Bilateral Plantar Fasciitis to include Chronic Bilateral Foot Pain and Pes Planus. The CI reported sudden onset of bilateral foot pain while marching, running and walking that initially occurred during basic training, January 2006.
In spite of a sustaining a possible ankle and foot injury by leaping across an obstacle and landing awkwardly, she was still able to continued and complete her basic training. An orthopedic examination performed on 13 February 2006, documented acquired deformity (hammer toe) of the feet 5th toes, bilateral. Radiographic imagines of the left foot obtained on 16 May 2007 reveal stress reactions of the 2nd and 3rd metatarsals as well as pes planus. The right foot [images] also reveals stress reactions of the 2nd and 3rd metatarsals, pes planus and a heel spur with swelling at the Achilles tendon and ankle, consistent with plantar fasciitis. The CI’s feet condition was treated with customizes boots, digital pads and anti-inflammatory medication. A bone scan dated 19 June 2007 demonstrated stress changes of the right mid-foot. Again, the CI was treated with custom orthotics, ice, stretching, activity modification and non-narcotics medications, without relief of her bilateral foot pain. At a podiatric care evaluation, dated 10 October 2007, the examiner concluded that the CI was not a surgical candidate. Another podiatrist’s examination obtained on 11 December 2007 stated that “her pes planus is hereditary and the plantar fasciitis is military aggravated”.

At the MEB NARSUM examination on 6 August 2007 (approximately 11 months prior to separation), the CI reported no interventions relieved her feet pain. Physical examination documented the applicant wore soft shoes and was mildly uncomfortable while ambulating and transfers. On examination of the feet, the examiner observed [that the CI was] flat footed with valgus deformity of the left ankle; complaints of foot pain when the right foot was 12 degrees dorsiflexion and 25 degrees plantar flexion; and left foot 15 degrees dorsiflexion and 30 degrees plantar flexion. Pain was rated moderate and constant.

At the VA C&P examination on 19 December 2008 (approximately 5 months post separation), the CI reported that she injured her feet in a fall during basic training. She reported pain, weakness, fatigability, swelling and lack of endurance of her feet while standing or walking. The CI reported that she could only stand for a duration of 15 minutes and could only tolerate walking a few yards; nonetheless she was enrolled as a college student and attended school full-time. The used of corrective shoes, orthotic inserts and a cane were noted. The VA’s examiner noted that the CI complained of feet pain, weakness, instability, abnormal weight bearing, tenderness and bilateral 5th hammer toes; but did have normal motion.

The Board directs attention to its rating recommendation based on the above evidence. The FPEB combined the bilateral foot pain conditions into a single unfitting condition characterized as “Bilateral plantar fasciitis,” coded as 5399-5310, plantar fasciitis and rated at 0%. The VA similarly combined the right and left foot as bilateral plantar fasciitis, coded as 5276 and assigned a rating of 10%. The Board evaluated whether or not it was appropriate for the two chronic foot pain conditions to be “bundled” together. The Board must determine if the PEB’s approach of combining the conditions under a single rating was justified in lieu of separate ratings. The Board may apply separate codes and ratings in its recommendations if compensable ratings for each condition are achieved IAW the VASRD. If the Board judges that two or more separate ratings are warranted, it must satisfy the requirement that each “unbundled” condition in and of itself, was separately unfitting. The feet were profiled for stress fractures; there was radiographic evidence of bilaterally stress reaction and there were hammer toes on her feet.

Chronic bilateral foot pain was implicated in the commander’s statement. The Board reviewed VASRD codes 5282 (hammer toe); 5276 (pes planus (acquired)); 5399-5310 (analogous to muscle injury); and 5284 (foot injuries). The Board determined that the criteria for VASRD code 5276 (pain on manipulation) and use of the feet, most closely reflected the CI’s functional impairment as described by the PEB (permanent service aggravation of her congenital pes planus which contributed to her plantar fasciitis). VASRD code 5276 rates bilateral or unilateral pes planus.
After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the bilateral plantar fasciitis.

Contended Mental Health Condition. At the MEB NARSUM examination (performed 8 months prior to separation) CI reported she initially sought treatment at the Behavioral Health clinic in 2005 due to work related stressors. The CI reported that she had difficulty controlling her anger which led to personal conflicts, including a fight with an individual in her barracks. She was assigned to attend anger management classes, but only attended a few classes. A social worker diagnosed her with an adjustment disorder with depressed mood in September 2007. Treatment notes document that the CI’s moods varied with both work and home stress. At the time of the NARSUM examination, she was geographically separated from her spouse and their marriage was strained. There were no documentation of hospitalization, nor were there any reports of the CI having any suicidal or homicidal ideations. The mental status exam (MSE) was normal. A diagnosis of adjustment disorder with depressed mood was rendered with a Global Assessment of Function (GAF) of 70 (mild). The condition was profiled as S1 and was not implicated in the commander’s statement or judged to fail retention standards by the MEB.

At the VA C&P behavior health examination performed 6 January 2009 (6 months post separation), the CI reported the she was a full-time college student, studying to be a diagnostic medical technician. During this evaluation the CI reported a past history of suicidal ideation while in the military and a suicide attempted by [drug] overdose in 2006. The examiner observed that the CI appeared isolative, withdrawn, ruminated over issues, not engaged in leisure pursuits, noted reports of panic attacks with duration of 15 minutes and occurred every 2 weeks. The CI reported that her psychotropic medications (Bupropion and Temazepam) and individual [talk] therapy [sessions] were not helpful and she reported going to the emergency room in fear of having a heart attack. The MSE was notable for ruminations, persecutory delusions, insomnia, depressed mood, lethargy, slow speech and a guarded attitude. Stressors included financial difficulties, finding employment and providing financial support for her younger sister. Diagnoses rendered included panic disorder with agoraphobia, generalized anxiety disorder (GAD) and depressive disorder, not otherwise specified (NOS) with a GAF of 48 (serious).

All available evidences were reviewed by the action officer and considered by the Board. There was no performance based evidence from the service treatment records that the adjustment disorder with depressed mood had significantly interfered with satisfactory duty performance. Although there was a diagnosis of anxiety disorder, NOS, listed on multiple treatment notes as a medical problem; there was no evidence of medical care associated with this diagnosis. The MEB forwarded adjustment disorder with depressed mood as meeting retention standards. The CI appealed the MEB findings. The PEB requested a psychiatry addendum (findings stated above) which rendered a diagnosis of adjustment disorder with depressed mood, medically acceptable. Neither the IPEB nor FPEB addressed the adjustment disorder condition.

The Board reviewed the records for evidence of inappropriate changes in diagnosis of the MH condition during processing through the DES. Adjustment disorder with depressed mood was the sole mental health diagnosis rendered. The MEB forwarded adjustment disorder as medically acceptable to the PEB. The VA diagnoses of panic disorder with agoraphobia, GAD and depressive disorder, NOS were appropriately not adjudicated by the PEB due to these conditions were diagnoses post separation and documentation of (her declining mental health stability) symptoms that was not evident during the DES process. However, because the IPEB and the FPEB did not consider the adjustment disorder with depressed mood, this case appears to have met the inclusion criteria in the Terms of Reference of the MH Review Project. All Board members agreed that the preponderance of evidence did not support an unfit determination for any MH disorder.


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 low back pain was operant in this case and the condition was adjudicated independently of that policy instruction by the Board. In the matter of the chronic LBP condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the chronic bilateral fasciitis condition and IAW VASRD §4.73, the Board unanimously recommends a disability rating of 10%, coded 5276. In the matter of the MH review, the Board unanimously agreed that a MH condition did not rise to the level of unfitting. 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 her prior medical separation:

UNFITTING CONDITION VASRD CODE RATING
Bilateral Plantar Fasciitis Condition 5276 10%
Chronic Lower Back Pain 5299-5237 10%
COMBINED (w/ BLF) 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20140319, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record







XXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXX, AR20150006604 (PD201401418)


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              XXXXXXXXXXXXXXX
                           Deputy Assistant Secretary of the Army
                           (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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