RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2013-01930
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20141009
SEPARATION DATE:  20051223

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSgt/E-5 (2T352A/Special Vehicle Maintenance Journeyman, Fire Trucks) medically separated for a right foot condition.  The right foot condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty or satisfy physical fitness standards.  She was issued a temporary L4 profile and referred for a Medical Evaluation Board (MEB).  The foot condition, characterized as “chronic right foot pain following bunion surgery,” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  The PEB adjudicated “right foot pain status post (s/p) hallux limitus and bunion surgery” as unfitting, rated at 10% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The PEB also adjudicated “history of tachycardia” as a Category II condition and “history of anthrax vaccination reaction” as a Category III condition.  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI writes: “I feel that there were more conditions than just my Right Metatarsal condition that should have been considered by the MEB.  Please see the attached 22JAN2013 VA Rating Decision for what these are.”

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 foot condition is addressed below.  Based on the CI’s contention, the tachycardia and anthrax reaction are also being considered; however, no additional conditions were 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 20051108	VA - (2 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
R Foot Pain S/P Hallux Limitus and Bunion Surgery	5299-5280	10%	S/P Right Foot Bunionectomy	5284	10%	20060228	
			Right Foot Surgical Scar, S/P Bunionectomy 	7804	10%	20060228	
History of Tachycardia	Category II	Supraventricular Tachycardia	7010	10%	20060228	
Hx of Anthrax Vaccination Reaction	Category III	Anaphylactic Shock Due To Anthrax Vaccine	6699-6602	NSC		
Other x 0  (Not in Scope)	Other x 5	20060228	
Combined:  10%	Combined:  50%	
Derived from VA Rating Decision (VARD) dated 20060522 (most proximate to date of separation)

ANALYSIS SUMMARY:

Right Foot Pain.  The narrative summary (NARSUM) documented that the CI had foot surgery (base of great toe-first metatarsal surgery for hallux limitus with bunion of the right foot) in February 2002.  After surgery, she had increased pain and paresthesias (numbness) in the foot when wearing steel-toed boots, which was requirement for her job.  Physical therapy and four different types of boots with orthotics were not helpful.  The NARSUM physical examination documented limited range-of-motion (ROM) of the hallux (first toe) with crepitus on ROM at the base of the great toe; first metatarsophalangeal joint (MPJ).  The examiner noted that “The first MTJ reveals a well-healed surgical scar 4 cm medial” and “the right first MPJ with mild edema.”  There were no hammertoes or bunions.  The screw heads (from the surgery) could not be palpated.  The right hallux was 1 cm shorter than the next toe and there was some decreased sensation across the dorsum of the entire foot at the first three digits.  Reflexes were intact/normal (2+) with good ROM at the ankle.  There was no bilateral lower extremities edema noted.

At the VA Compensation and Pension examination dated 28 February 2006 (2 months after separation) the CI was noted to be walking with a slight antalgic gait without any assistance devices.  She had moderate tenderness, with palpation, in the right first MPJ.  She was not able to walk on her toes.  There was pain with manipulation of the first, second and third MCJs.  There was pain with motion of the first MPJ and dorsiflexion of 10 degrees and plantar flexion of 10 degrees with pain.  There was no mention of any paresthesias.  The examiner estimated that the CI lost 0 degrees regarding ROM of the right foot during repetitive use.  VA exam documented a “well healed surgical scar of indeterminate length over the metatarsophalangeal joint which is moderately tender.” 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic right foot pain at 10%, coded 5299-5280 (hallux valgus, unilateral); the 10% rating corresponds to “Operated with resection of metatarsal head” or “Severe, if equivalent to amputation of great toe.”  The VA also rated the right foot pain at 10%, but used VASRD code 5284 (foot injuries, other), the 10% rating corresponds to “moderate” and additionally rated the bunionectomy scar at 10% coded 7804 (painful scar).  In view of the scope of diagnoses and disability covered by VASRD code 5284, to cover all of the disability of the foot, the Board considered that the ideal coding would be under code 5284.

After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend an unfit determination and rating for the foot scar condition.  Any disability from the scar (skin) condition was considered under the foot rating.

The Board majority adjudged that “moderate” best described the level of disability experienced by the CI.  The Board considered the various coding options available, but none provided a higher disability rating than the 10% awarded by the PEB and there was no benefit to the CI for changing the acceptable PEB disability code.  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 chronic right foot condition.

Contended PEB Conditions.  The Board’s main charge was to assess the fairness of the PEB’s determination that history of tachycardia and history of anthrax vaccination reaction were not unfitting.  The Board’s threshold for countering fitness determinations is “a preponderance of evidence,” which is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

History of tachycardia:  As noted in the NARSUM, the CI experience episodic palpations with rapid heart rate (tachycardia) since 2001.  Cardiac evaluation was normal.  In 2004, she declined medication for symptoms.  An MEB for palpitations in 2005 returned the CI to duty and no further treatment was recommended.  There were no applicable duty limitations for this condition noted in the NARSUM, and none were noted on the Physical Profile Serial Report (AF Form 422, dated 27 April 2005).  This condition was not specifically noted in the commander’s statement.  There was no performance-based evidence from the record that this condition significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the history of tachycardia, so no additional disability rating is recommended.

History of anthrax vaccination:  The PEB designated history of anthrax vaccination reaction as a “condition that [is] not separately unfitting and not compensable or ratable.”  Per DoD Instruction 1332.38, Enclosure 5, Medical Contraindication to the Administration of Required Immunizations is specifically characterized as a defect of a developmental nature and does not constitute a physical disability in the absence of an underlying ratable causative disorder.  In this case, the CI had a single reaction to the immunization and suffered no persistent consequence, so there was no physical disability that would limit performance of duty or that could be rated under the Disability Evaluation System.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB assessment of this condition, so no additional disability rating is recommended.

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 right foot condition and IAW VASRD §4.71a, the Board by a majority vote, recommends no change in the PEB adjudication.  The single voter for dissent submitted the appended minority opinion.  In the matter of the contended history of tachycardia and history of anthrax vaccination reaction, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 20131023, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				
MINORITY OPINION.

The minority voter considered that the combination of the foot pain, antalgic gait, foot scar and inability to wear required military foot wear were all part of the CI’s disability.  Given that the CI had onset of foot pain with walking only short distances, her disability picture more nearly approached the “moderately severe" (20%) level under code 5284.  Coding under 5284 better reflects all of the CI’s foot, toe and ankle disabilities.  Considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) and §4.40 (functional loss) the minority voter recommends a disability rating of 20% for the right foot condition.

The minority voter recommends that the CI’s prior determination be modified In the matter of the right foot condition, the minority voter recommends a disability rating of 20%, coded 5284 IAW VASRD §4.71a.

UNFITTING CONDITION	VASRD CODE	RATING	
R Foot Pain S/P Hallux Limitus and Bunion Surgery	5284	20%	
COMBINED	20%	
SAF/MRB

Dear XXXXXXXXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. §  1554a), PDBR Case Number PD-2013-01930.

	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.

Attachment:
Record of Proceedings