RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2013-02662
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150203
Separation Date:  20070529

SUMMARY OF CASE:  The available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Avionic Systems Specialist) medically separated for bilateral foot pain.  The condition could not be adequately rehabilitated to meet the requirements of his Air Force Specialty or physical fitness standards.  He was issued a L4 profile and referred for a Medical Evaluation Board (MEB).  The bilateral foot pain condition, characterized as “bilateral foot pain, metatarsalgia, plantar fasciitis,” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated the bilateral foot pain (right and left foot separately rated) condition as unfitting, rated 20%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  Although neither the narrative summary (NARSUM) nor MEB Board Proceedings forwarded an obesity condition to IPEB, the IPEB determined obesity to be a Category III condition (conditions which are not a physical disability and not compensable).  The CI made no appeals and was medically separated.

CI CONTENTION:  “My rating should be changed because they were increased shortly after my discharge from the Air Force.  Also, despite the Air Force being aware of my knee disability, it was not included in my rating but added once again by the VA.”  “I am directly implying the Air Force Medical Evaluation Board intentionally omitted disabilities in order to grant me a lower rating. (20%)  I was advised to not challenge their decision because it would result in a lower rating than 20%.  My medical issues that would have contributed to my MEB rating increase but were also omitted includes, back pain.  Please understand, the disabilities I had while in service were increased immediately after I was discharged with an effective date of June 1^st 2007. (This does not include back pain and my knee)   “The intent of the evidence I have provided is to show disabilities I had while on active duty were not included in my Medical Evaluation Board.  I was told a lower rating would occur if I appealed the board’s decision.  My appeal would have included the omission of my knee, hearing, back pain, and mental health.  All of which (minus back pain) I am currently service connected for according to veterans affairs.  All of my service connected disabilities have resulted in an award of (SSDI) benefits from social security.”

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:

Service IPEB – Dated 20070413 | VA - (3 days Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Bilateral Foot Pain (Right & Left foot separately rated 10% each) | 5284 | 20% | Bilateral Plantar Fasciitis | 5099-5020 | NSC* | 20070601
Other x 1 (Not in Scope) | Other x 2
Rating:  20% | Rating:  30%
Derived from VA Rating Decision (VARD) dated 20070801 most proximate to date of separation (DOS)
*VARD dated 20081119 granted service connection and rated 10% effective 20070530

ANALYSIS SUMMARY:

Bilateral Foot Pain Condition.  The Board noted that the PEB rated the bilateral foot pain condition under the single code 5284 (other foot injuries).  The AF Form 356, Findings and Recommended Disposition of Formal USAF Physical Evaluation Board, annotated that the right and left foot were adjudicated as separately unfitting and rated at 10% each.  The bilateral factor was applied IAW VASRD §4.26.  After reviewing the evidence present for review, members agreed that coding and rating features for each foot were logically identical and therefore will be presented together.

The CI developed bilateral foot pain in February 2006 with initial reports of right foot pain worse than the left foot.  A bilateral foot X-ray showed bilateral pes planus.  A civilian Podiatrist documented bilateral foot pain with acute pain on pronation.  The physical therapist documented a 7-month history of bilateral plantar fasciitis with an increase in symptoms over the past 3 months secondary to running 3 times per week.  The Podiatrist documented that the CI wore custom orthotics, which did not relieve the pain.  There were physical exam findings of pain with palpation through the plantar fascia in the arch region; palpable pain at the plantar fascia origin left greater than right; and bilateral palpable pain at the tendo-Achilles insertion as well as the retro calcaneal bursa region.  An X-ray performed at this visit showed bilateral foot calcaneal spurring and changes consistent with pes planus.  The CI underwent orthotic casting for bilateral shoe orthotics.  The MEB NARSUM exam, approximately 2 months prior to separation, documented that the CI was under the care of a civilian Podiatrist and a second set of orthotics was ordered.  He had failed physical therapy and the initial cortisone injection had provided some slight pain relief.  The Orthopedist noted physical exam findings of fallen arches, excessive pronation of the feet, tenderness to palpation of both feet, plantar fasciitis testing in both feet revealed pain in the heel.

The VARD dated 1 August 2007 documented that the CI reported he woke up with arch and ankle pain, he needed to stretch his feet while he was in bed, on awakening, the pain was 7/10 and it would never drop below that in any 24 hour period.  By noon daily, he was unable to stand on the ground due to pain at 9/10.  The VARD also contained the following statement regarding the physical exam:

“There are no findings on the plantar surfaces.  The skin is fully normal, smooth, and quite consistent with your age.  Muscle strength is 5/5.  Range of motion testing revealed dorsiflexion is greater than 10 degrees and plantar flexion is greater than 30 degrees with no restriction and no grinding.  There was no crepitus with any of the motion through the ankle.  Range of motion across the metatarsophalangeal joints is greater than 20 degrees for all toes for dorsiflexion and plantar flexion with no grinding and no pulling.  Examination along the plantar fascial bands was fully normal.  You have normal arches and the Achilles tendons are straight.  X-rays showed the bones and joints are normal.  Your feet were shown to be normal on your VA examination with no diagnosis of a chronic disability of either foot shown on the examination.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the bilateral foot condition as 5284 and rated each foot separately at 10% each.  The VA coded the bilateral plantar fasciitis as 5099-5020 (synovitis) initially determined to be not service-connected.  A subsequent VARD dated 19 November 2008 granted service-connection and rated both feet at 10%, utilizing the code 5279-5276 (bilateral or unilateral) effective the day after separation.  There was ample evidence in the service treatment record that the CI had bilateral foot pain, which was most frequently diagnosed as plantar fasciitis with no distinction of one foot consistently being worse that the other.  The Board considered the alternate coding/rating scheme for plantar fasciitis of 5310 (Group X muscle function) for its rating recommendation.  The rating criteria for code 5310 requires a subjective determination of slight, moderate, moderately severe, or severe disability to assign a 0, 10, 20 or 30% rating, respectively.  In order to promote uniformity across the Board, the follow guidelines are used as a starting point for deliberations in an attempt to use objective evidence for applying subjective rating criteria:

Severe disability connotes debilitating pain with functional limitations on most occupational tasks, many domestic chores, and at least some essential activities of daily living.

Moderately severe disability connotes significant joint muscle etc damage or deformity and pain with minimal use, imposing limitations on some critical tasks mobility and routine activities.

Moderate disability connotes significant or near constant pain with functional limitations on some occupational tasks and domestic chores; but little interference with routine activities, and no interference with essential activities of daily living.

Mild or Slight disability is a reasonable characterization for impairment or pain not resulting in at least moderate functional limitations as described above; generally interfering only with relatively strenuous or non-essential activities.

After deliberations, Board members agree that the CI’s bilateral foot disability was most appropriately designated as “moderate.”  The “moderate” rating criteria under code 5310 grants a 10% rating to each foot and is of no benefit to the CI.  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 bilateral foot 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 bilateral foot condition, 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, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131216, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			
XXXXXXXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2013-02662.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

	I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

XXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

PD-2013-02662