RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2013-01752
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150331
SEPARATION DATE:  20040702

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Chaplain Service Support Journeyman) medically separated for major depressive disorder (MDD).  The mental health (MH) condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty (AFS).  She was issued a temporary S4 profile and referred for a Medical Evaluation Board (MEB).  “Major depressive disorder, moderate” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  The MEB also identified and forwarded major reconstructive jaw surgery for PEB adjudication.  The Informal PEB (IPEB) adjudicated MDD and pes planus as Category II conditions (conditions that can be unfitting but not compensable or ratable).  The PEB determined the depressive disorder existed prior to service (EPTS) based on the 180-day rule (DODI 1332.38, E3.P4.5.4.1) and was deemed not permanently aggravated by military service and the bilateral pes planus was also an EPTS condition; and, both were incompatible with long-term service.  The CI requested a Formal PEB (FPEB).  The FPEB concurred with the IPEB that the depressive condition was noted prior to the CI’s entry on active duty and the 180-day rule applies.  The FPEB determined the CI’s condition was incompatible with the long-term rigors of military life and that the MH condition was not aggravated by service.  The CI appealed to a Secretary of the Air Force Personnel Council (SAFPC) who non-concurred with the previous board’s recommendations and opined the CI was unfit for MDD.  A rating of 10% (mild) was assigned, but then applied a rating deduction of 10% for the Category III non-compensable adjustment disorder, equaling a 0% rating.  Pes planus was determined to be a Category II EPTS.  The CI was medically separated.

CI CONTENTION:  “Medical records and subsequent ratings from the VA present objective evidence for a higher evaluation by the board for the diagnosed psychiatric condition and as well as the bilateral foot condition.”

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 SAFPC PEB – Dated 20040513	VA - (5 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive Disorder	9434	0%	Major Depressive Disorder	9434	10%	20050204	
Pes Planus, EPTS	CAT II	Bilateral Pes Planus w/ Plantarfasciitis	5276	20%	20050211	
Other x 1  (Not in Scope)	Other x 0 	
Rating:  0%	Combined:  30%	
Derived from VA Rating Decision (VARD) dated 20050715 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Major Depressive Disorder Condition.  Among the earliest notes in the service treatment record (STR) dated 12 August 1998 indicated the CI sought MH assistance about concerns of an upcoming deployment, had recently been treated with Zoloft (sertraline-an anti-depressive medication) and had a Global Assessment of Function (GAF) score of 60 (moderate symptoms).  Additionally, she had problems with her feet, which also caused her concern and affected her training and duty requirements to become a member of the security forces.  Over several months she noted improvement with Zoloft, which when discontinued in December 1998, she again became depressed and it was reintroduced.  In June 1999, she became overwhelmed by a move to a new duty station and felt isolated, tearful, disheveled with a depressed mood.  Over the next several months she attended therapy and group sessions for her life circumstance problem; and, by August 1999 and confirmed on 14 September 1999; notes indicated the CI had an adjustment disorder with depressed mood that had resolved.  She was continued on the Zoloft and was cleared for TDY (temporary duty) in April 2000.  In December 2002, the CI sought care for depression “I thought it was gone but it is here again.”  An S-1 profile was issued in December 2002 for recurrent moderate MDD with a GAF of 65 (mild symptoms).  With individual therapy over the following 6 months, the CI showed improvement and the GAF increased to 68 (mild symptoms).  After noting the Zoloft “was not working anymore like it used to,” she decided to be weaned off the medication.  In August 2003, she was referred for a command-directed MH evaluation because of concerns about her emotional state.  Scales measuring depression and anxiety were subclinical; however, because of “her ongoing difficulties and limited treatment gains,” an MEB was required.  She was placed on an S4-T profile and was not world-wide qualified.  A goal oriented patient treatment plan was developed in September 2003.  She was symptomatic while on a lower dose of Zoloft and improved when a higher dosage was restored.  After 5 years on Zoloft she “just quit” and developed withdrawal symptoms of headaches, nausea, vomiting, diarrhea and body aches necessitating resumption of the medication in January 2004.  In February 2004, Zoloft was discontinued since the CI was pregnant.  Her diagnosis was then determined to be an adjustment disorder with mixed emotional factors, which resolved and she had a GAF of 80 (transient symptoms, which are expectable reactions to psychological stressors.)  With treatment from March through June of 2004 the CI remained stable with her GAF increasing from 68 to 71 (mild to transient symptoms).

The narrative summary (NARSUM) dated 23 September 2003, 9 months prior to separation noted the CI reported a history of depressive symptoms spanning across her career beginning with physical challenges during basic training, foot problems, and stress secondary to apparent suicide attempts of other security personnel as well as job stress, which was based on her opinion that she felt unprepared and improperly trained for her duties as a chaplain’s assistant.  Despite fairly extensive psychotherapy and pharmacotherapy, she continued to experience emotional difficulties, which were perceived as “[her] overly emotional state and [her] inability to accept constructive criticism.”  A psychiatric addendum dated 11 November 2003 indicated the “MEB Narrative and OP (outpatient) medical record were reviewed—without need for Psychiatric input to MEB.”  The commander’s statement dated 20 October 2003 indicated the CI could not deploy and she had not risen to her NCO responsibilities and when given taskings, she attributed her failure to accomplish them on others.  That commander’s statement is in contrast to a commander’s statement dated 10 May 2002, which indicated there were no duty requirements as a chaplain’s assistant that the CI was unable to satisfy due to her condition and she was performing all of her normal duties.  On 17 December 2003 the CI addressed her various approaches to learning and responding as well as performing her NCO duties under the guidance of her mentor, who returned from deployment, a chaplain, her supervisor, and her medical and psychological support team.  A renewal of a prior S4-T profile was issued on 1 April 2004 with restrictions of not world-wide qualified and not mobility qualified.

At the VA Compensation and Pension (C&P) examination dated 4 February 2005, 7 months after separation, the CI reported the depression, which began in 1998 when she was experiencing severe feet problems, was treated with Zoloft through January 2004.  She had three periods of depression in 1998 after her feet collapsed, in 2003 when she was overwhelmed with work, and in 2004 when her husband left her.  However, the depression was in full remission since that time.  During the examination she showed a wide range of affect with an otherwise unremarkable examination except noting a history of moderate depression and stomach cramps of an unknown etiology.  She had no social or occupational impairment due to MH issues and had a GAF of 75 (transient symptoms; expectable reactions to psychosocial stressors).  In October 2005, 14 months after separation, the CI felt overwhelmed and wondered whether she was depressed again, not having been so since 2004.  Interim stressors included divorce and loss of her job.  The examiner’s impression was an adjustment disorder with a depressed mood and a history of a MDD with a GAF of 70 (mild symptoms).  A repeat GAF almost three weeks later was 60-65 (mild symptoms) due to her inability to get employment.

The Board directed attention to its rating recommendation based on the above evidence.  The Board first deliberated whether VASRD §4.129 (for any “mental disorder that develops in service as a result of a highly stressful event”) was applicable to this case.  All members agreed that the depression was not related to a highly stressful event; and, therefore, VASRD §4.129 is not applicable in this case.  The Board turned to deliberation of a fair rating recommendation at the time of separation derived from criteria of VASRD §4.130 and based on the disability at the time of separation.  The PEB assigned a net 0% rating using code 9434 for a MDD, social and industrial adaptability impairment mild.  The rating assigned was 10%; however, a reduction of 10% was applied based on a Memorandum for HQ AFPC/DPPDS dated 13 May 2004 for “contributing/aggravating factors” related to an adjustment disorder that was a Category III condition, which is not separately unfitting and not compensable or ratable IAW DoDI 1332.39 §6.1.8 “In such instances, the overall rating of psychiatric impairment will be reduced to the impairment rating that would be warranted in the absence of the influence of the non-compensable condition according to generally accepted medical principles.”  The VA assigned a 10% rating using code 9434 for MDD.  A 10% rating requires occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication.  While the CI clearly met the criteria for a 10% rating, the Board discussed whether she had sufficient symptomatology at separation to warrant a 30% rating that requires occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal) with symptoms of a depressed mood,  anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and  mild memory loss (such as forgetting names, directions, recent events).  She certainly had multiple episodes of a depressed mood, but few instances of anxiety, and no evidence of significance in the STR of panic attacks, chronic sleep impairment or mild memory loss.  Therefore, the Board favors a 10% rating and finds that an adjustment disorder was not only intermittent, but resolved on each occasion it was mentioned in the STR, whereas the MDD had been ongoing and was treated with medication and therapy for years.  Although DoDI 1332.29, in effect at the time of separation and subsequently cancelled, gave the PEB the option to reduce the CI’s rating, the Board determined there was significant objective medical evidence to support the depressive disorder as a distinct and separate unfitting condition for which no deduction is warranted.  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 major depressive disorder condition.

Pes Planus Condition.  At the CI’s Military Entrance Processing Station examination performed on 12 July 1996, the CI was noted to have asymptomatic, moderate to severe pes planus of the feet with some pronation.  In March 1998 the CI complained of a 5-month history of bilateral mid tarsal (a bone of the hind foot) joint pain, which was asymptomatic and did not exist prior to enlistment.  The pain developed when she increased her activity with heavy military equipment, including a 50 caliber machine gun, while she was training to be a security forces gunner.  In May 1998 the CI, who was diagnosed with bilateral plantar fasciitis (pain at the bottom of the feet), was recommended to obtain properly fitting shoes and inserts and was treated with Indocin (indomethacin, a nonsteroidal anti-inflammatory medication).  The CI subsequently changed her AFS to Chaplain’s assistant; and adjustment of her custom orthotics was ordered along with continued strengthening and stretching.  X-rays of the feet in December 1999 revealed bilateral pes planus and hallux valgus (bunions).  Pain persisted and the orthotics were replaced in February 2001.  A NARSUM dated 8 May 2002 indicated the CI was requested to be a security forces augmentee; however, it noted that she had severe bilateral pes planus and chronic bilateral plantar fasciitis and had a profile that limited standing and marching to 30 minutes.  A Medical Board Report was issued on 8 May 2002 for the aforementioned conditions and noted the conditions did not exist prior to service.  The CI twisted her left foot on 4 May 2002 at which time X-rays revealed no fractures; however, repeat X-rays on 15 May 2002 revealed stress reactive changes in the bones of the left mid foot.  A bone scan on 30 May 2002 was consistent with a fracture of the 5th metatarsal, which was confirmed by an X-ray study.  Treatment was with regular shoe wear and activity as tolerated.  The bilateral pes planus was initially profiled L3 in 1997 and again in 2001 (L4), 2002 (L4 and L2), and 2003 (L4 and L2), but was not explicitly implicated in the commander’s statement.  The NARSUM of 23 September 2003 noted the CI had periodic pain associated with flat feet and the condition addressed in a prior MEB resulted in a cross train from security forces to be a chaplain’s assistant.  Custom orthotics were again prescribed in December 2003.

At the VA C&P examination dated 4 February 2005, 5 months after separation, examination of both feet revealed no obvious arch with outward bulging of the medial (inner) aspect of the foot; and the collapsed arch was sensitive to touch.  The CI’s gait was normal without varus or valgus angulation.  The examiner’s assessment was severe bilateral pes planus with chronic severe plantar fasciitis and a history of an old right (should be left) foot fracture still with significant pain along with constant and obvious deformity of the arch of the foot due to collapse of the arches.  She only tried to wear Birkenstock sandals, which were very supportive.  In May 2005, 10 months after separation, the CI complained of right foot pain.  Examination revealed flat feet and plantar fasciitis more so on the right that the left, which was treated with indomethacin.  A podiatry examiner noted bilateral medial arch collapse and ankle adduction (inward) as well as a slight left leg shortening by 1/4 inch and was prescribed orthotics.  Temporally remote (almost 9 years after separation) VA C&P examinations were reviewed; however, they offered very limited or no probative after separation evidence of any significant value although they did indicate the CI underwent left and right foot reconstruction in 2011 and 2012 respectively.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB determined the [bilateral] pes planus were EPTS “Category II-conditions that can be unfitting but are not currently compensable or ratable.”  The VA assigned a 20% rating using code 5276 (bilateral severe) based on a 30% rating with a 10% reduction for the EPTS moderate to severe pes planus with some pronation, albeit asymptomatic.  The Board’s first task is to analyze the PEB EPTS determination and its second task is to address the PEB’s consolidation of the bilateral foot conditions.  Although there is no doubt the pes planus existed prior to enlistment, the record is replete with (clear and unmistakable) evidence that it was aggravated by military service and manifested by bilateral plantar fasciitis and bilateral arch collapse with anatomical foot deformity requiring multiple treatments, medication, profiles and a change of AFS.  The Board members agreed that the service aggravation is supported by a preponderance of medical evidence (the standard at the time of separation) that the natural progression of the pre-existing condition was altered by military service.  Although VASRD §4.71a permits combined ratings of two feet, it also allows separate ratings for each separately compensable foot.  IAW DoDI 6040.44 if the PEB combined adjudication is not compliant with combined rating criteria, each condition subsumed under the single disability rating must be reasonably justified as separately unfitting in order to remain eligible for rating.  

The Board’s charge in this case was directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  The evidence for both feet was presented together since the STR notes regularly referred to the conditions as bilateral pes planus and plantar fasciitis.  The Board determined by performance based fitness criteria that the conditions are reasonably justified as separately unfitting and are separately ratable.  Although VASRD §4.7 (higher of two evaluations) offers the opportunity for separate ratings, the VASRD using code 5276 (flatfoot acquired) has ratings for both unilateral and bilateral conditions.  Therefore, the Board discussed the options of using a 10% rating for either unilateral or bilateral moderate flatfoot and either a 20% rating for severe unilateral flatfoot or a 30% rating for severe bilateral pes planus.  Since the CI entered the service with moderate to severe pes planus and the condition was aggravated by the service, a severe rating is more applicable.  Although the CI’s left foot sustained a fracture, which did not require surgical intervention, both feet were anatomically altered and manifested plantar fasciitis.  Therefore, a 30% rating for bilateral pes planus is applicable; however, the Board also must take in account the status of the condition on entrance to determine whether a reduction is appropriate.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20%, which represents a 30% rating reduced by 10% for the pre-existing bilateral pes planus 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 PEB relied on DoDI 1332.39 for rating the MDD in this case; and that condition and the bilateral pes planus were adjudicated independently of that instruction by the Board.  In the matter of the MDD condition, the Board unanimously recommends a disability rating of 10%, coded 9434 IAW VASRD §4.130.  In the matter of the bilateral pes planus condition, the Board unanimously recommends a disability rating of 20%, coded 5276 IAW VASRD §4.71a.  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 her prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Major Depressive Disorder	9434	10%	
Bilateral Pes Planus	5276	20%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131002, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

Dear XXXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2013-01752.

	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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.

	I have carefully reviewed the evidence of record and the recommendation of the Board.    I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

	As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at (210) 565-2273 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.  

Attachment:
Record of Proceedings

cc:
SAF/MRBR
DFAS-IN