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AF | PDBR | CY2013 | PD-2013-02465
Original file (PD-2013-02465.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXX       CASE: PD-2013-02465
BRANCH OF SERVICE: air force     BOARD DATE: 20141209
SEPARATION DATE: 20050618


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSgt/E-5 (3E671/Operations Management Craftsman) medically separated for a bilateral foot condition, which could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty or satisfy physical fitness standards. He was issued an L4-T profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded “chronic Achilles enthesitis [inflammation of tendon insertions] bilaterally,” as the sole condition to the Physical Evaluation Board (PEB) IAW AFI 48-123 and AFI 44-113. The Informal PEB adjudicated “bilateral Achilles tendonitis,” as a single unfitting condition, rated at 20% “IAW D epartment o f D efense and VA Schedule for Rating Disabilities (VASRD) regulation.” The PEB also adjudicated “hypertriglyceridemia” as a Category III condition. The CI made no appeals and was medically separated.


CI CONTENTION: “The original condition was, and has been a life changing medical condition. In addition, the original MEB teams failed to rate or recognize other well documented conditions that contributed to being unfit for service. Those conditions are lower back disk problems, and same Achillies [sic] condition on my right foot. It was only not operated on because of limited improvement resulting from left foot surgeries. It has not allowed me to do anything physical since discharge, further creating new health challenges, and reducing overall quality of life for my family. The rating seems inconsistent.”


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 bilateral foot condition is addressed below. The contended lumbar disc disease was not identified by the MEB or PEB and is therefore not within the DoDI 6040.44 defined purview of the Board. The Category III triglyceride condition does not constitute a ratable disability and will not be addressed by 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 (BCMR).


 RATING COMPARISON :

Service IPEB – Dated 20050419
 VA - (7Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Bilateral Achilles Enthesitis (Tendonitis) 5024-5099-5003 20% Left Achilles Tendonitis 5099-5024 10% 20060118
Right Achilles Tendonitis 5099-5024 10% 20060118
Other x 1 (Not in Scope)
 Other x 4 20060118
Combined: 20%
 Combined: 40%
Derived from VA Rating Decision (VA RD ) dated 200 60130 (most proximate to date of separation)



ANALYSIS SUMMARY:

Bilateral Achilles Tendon Condition. There are multiple entries in the service treatment record (STR) detailing the earlier course of this condition, but a paucity of source evidence in the 12-month period preceding separation. The narrative summary (NARSUM) and podiatry addendum in March 2005 (3 months prior to separation), provides the evidence most probative to separation; and, the clinical histories from these sources are corroborated by the earlier STR entries. The CI developed bilateral heel pain in 1996 (left > right) without specific trauma. He was found to have heel spurs with associated Achilles tendonitis and, in November 1997, he underwent surgery on the left foot (exostectomy [removal of heel spur]). Without relief, he underwent left foot surgical revision (debridement, re-attachment of Achilles tendon); in March 2000, but results were inadequate, and further conservative management (physical therapy, orthotics, and [steroids injections]) was unsuccessful in providing sufficient relief. Imaging (magnetic resonance imaging) noted post-surgical changes and mild tendonitis of the left foot and was normal for the right foot. A podiatry note from November 2004 (7 months prior to separation) documented equal right and left heel pain with “minimal improvement ... pain mostly with running,” and a MEB was initiated.

The NARSUM (primarily derived from the podiatry addendum) documented the above clinical course and noted bilateral heel pain (without detailing severity or consistency) interfering with running, jumping, and climbing. The physical examination noted bilateral heel and Achilles tenderness with significantly decreased dorsiflexion of the ankle bilaterally (4-6 degrees, normal 20 degrees) and painful motion. The examiner noted that the CI was “doing fairly well now that he does not have to run;” and, an addendum of 21 March 2005 opined that the he “is able to perform his duty ... as long as it doesn’t require him to run or jump ... should be transferred to another unit that does not require running.”

A VA Compensation and Pension examination was performed in January 2006 (7 months post-separation). The VA examiner noted “left greater than right” heel pain limiting standing to “15-30 minutes” and walking to “more than ¼ mile but less than 1 mile;” and, opined that there was “no significant effect” on occupational activities, but noted an occasional need to sit and “rest to relieve pain” (documenting full time employment as a project manager). The VA physical exam noted an antalgic gait, bilateral heel tenderness, and normal bilateral range-of-motion (ROM): 20 degrees dorsiflexion and 70 degrees plantar flexion.

The Board directed attention to its rating recommendation based on the above evidence. The PEB’s 20% bilateral rating was coded analogously to 5003 (degenerative arthritis) and, must be assumed to constitute de facto separate 10% ratings; since, two or more major joints under 5003 yields a 10% rating (barring incapacitating episodes, which were not in evidence). The VA’s separate 10% ratings were under analogous code 5024 (tenosynovitis) which defaults to code 5003 criteria. Separate 10% ratings under code 5003 criteria are appropriate, conceding painful motion. A combined rating higher than 20% cannot be supported by any applicable bilateral foot code under VASRD §4.71a. The Board considered separate ratings analogously under code 5299-5284 (foot injuries, other); but, members agreed that the “moderately severe” characterization for each foot to meet the 20% criterion of that code could not be supported, given the relatively intact functioning. Consideration was also given for rating analogously under code 5299-5271 (ankle, limited motion) as “marked” limitation meeting the 20% criterion of that code. The significantly compromised dorsiflexion documented in the NARSUM offers support for this route; but, members agreed that this approach could not be adequately justified; since, the normalized ROM at the VA exam and the lack of any clinical correlation for severe ROM restriction argue strongly against higher rating based on ROM limitation. 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 Achilles tendonitis condition and IAW VASRD §4.71a, 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 20131108, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record



                          
XXXXXXXXXXXX
President
DoD Physical Disability Board of Review

SAF/MRB
Dear XXXXXXXXXXXX:

 Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2013-02465.
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,



 XXXXXXXXXXXX
Director
Air Force Review Boards Agency
Attachment:
Record of Proceedings

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