RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01129
BRANCH OF SERVICE:  AIR FORCE	SePARATION DATE:  20081103

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5, Air Traffic Control Apprentice, medically separated for “bilateral pes planus, moderate,” with a disability rating of 10%.  

CI CONTENTION:  The CI elaborated no specific contention in his application.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 PEB – 20080912	VARD - 20090508	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Pes Planus	5276	10%	Pes Planus	5276	30%	20081002	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:

Bilateral Pes Planus.  A note in the service treatment record (STR) dated 7 June 2007 indicated the CI reported a history of foot pain and fallen arches with pain during activities involving running.  Examination confirmed fallen arches and pes planus without swelling, erythema, or abnormal warmth.  No pain was elicited with motion.  Podiatric evaluation in June 2007 noted the CI had significant subtalar joint subluxation and pes planus with secondary shin splints and ankle pain.  In spite of the use of orthotics, he was recommended to be profiled as not being able to participate in heavy heel impact activities and running.  The CI was reassessed by the podiatrist in October 2007, who put a medial post wedge on the back aspect of his orthotics to try to keep his foot from rolling in.  Valium (diazepam, a muscle relaxant) was prescribed for cramps and spasms within the mid arch of each foot; and, it afforded significant improvement.  However, when the CI stopped the Valium the pain recurred.  By November 2007 persistent bilateral mid arch pain was unresponsive to conservative therapy, but was subjectively improved with Valium, which was not compatible with continued controlling use.  X-rays of the ankles showed no significant bony, articular, or soft tissue abnormality.  Bilateral posterior tibia (PT) tendon dysfunction and tendinitis with secondary compensation was treated with steroid injections about the ankles in January 2008.  Orthopedic evaluation in February 2008 found flexible pes planovalgus deformities with tight gastrocnemius muscles and tendons.  Surgery was recommended along with limiting squatting with weightlifting, which was putting a lot of pressure on his feet.  The CI was disqualified from continued ATC [Air Traffic Control] duties and sought another career field.  Naproxen (a nonsteroidal anti-inflammatory drug (NSAID)) for pain relief was added to the Valium for muscle spasm relief.  A physical therapy evaluation in April 2008 noted collapse of the arches bilaterally with marked/severe calcaneovalgus (flexible flatfoot) position especially in loading.  The CI had 3 degrees past neutral dorsiflexion on the left and 3 degrees short of neutral dorsiflexion on the right.  The CI had some benefit from electric stimulation treatments.  At an orthopedic examination in May 2008 the CI still had discomfort in the medial aspect of both feet, but the lateral foot started to have more pain.  On examination he had severely flat feet on standing with an almost rocker bottom deformity of his foot with tenderness of the calcaneocuboid and cuboid metatarsal joints (an area of the mid and hind foot).  Magnetic resonance imaging (MRI) of the right foot in June 2008 demonstrated a pes planus deformity with no evidence of a post tibial tendon tear, inframalleolar peritendinitis (inflammation below the lateral ankle bone) of the peroneal tendon complex, no osseous stress injury or macro-fracture and low-grade intermetatarsal (spaces between the toes) bursitis.  A physical therapist noted persistent cramping and diffuse left greater than right foot especially with more involved activities.  On examination in October 2008 there was swelling of both feet and ankles with pes planus and fallen arches bilaterally and tenderness on palpation and pain on motion bilaterally.  At the final podiatry visit prior to separation the CI still had the same pain and symptoms as he had previously with pain around the posterior tibial tendon.  With gait and stance the CI showed significant and pronounced mid column collapse, with subtler joint subluxation and rear foot pronation.  

An revised temporary L2 profile was issued on 5 October 2007, which exempted the CI from running, cycle ergometry, stationary bike, elliptical machine and intramural/squadron sports.  A duty limiting condition report dated 2 January 2008 restricted the CI from running distances greater than 110 yards, no repetitive trauma to the feet, no standing for greater than 10 minutes in formation, and no duties consistent with an air traffic controller rating.  At the MEB narrative summary (NARSUM) examination dated 10 March 2008, approximately 8 months before separation, the CI reported painful bilateral flat feet for a number of years not responsive to range-of-motion (ROM)/strengthening exercises, activity modification, injections and Valium, which had been the only significant effective intervention, but its use was not consistent with his duties.  Elective surgery was deferred and recovery time, if the surgery were pursued was predicted to be 8-10 months under ideal circumstances.  On examination the CI had flattened feet and midfoot/forefoot abduction deformity with tightness in the calf muscle.  With the hind foot in a neutral position, he had 0 to -5 degrees dorsiflexion.  There was weakness in the posterior tibial tendon and tenderness along the lateral sinus tarsi (entry point to the subtalar joint).  There was also a midfoot and forefoot abduction deformity with a fixed forefoot varus.  Sensory examination was unremarkable.  The NARSUM author opined the CI could most likely run 100 yards, if he had to, but he would not be able to multi-task in the deployed environment secondary to the pain in his feet associated with prolonged standing, walking, running, or carrying heavy weights.  A NARSUM addendum dated 27 June 2008 indicated the condition had not changed since the original NARSUM and the final diagnosis was pes planus, bilateral, which was recalcitrant to all conservative management except Valium for muscle relaxation.  The commander’s statement dated 12 June 2008 indicated the CI was medically disqualified from his primary career field as an ATC due to the medication he took.  However, he served as a deployment manager without any restrictions, limitations, or work-a-rounds.  The commander noted that if deployed, the CI would be limited in the amount of time he could remain on his feet and would be restricted in performing any load bearing functions.  Nevertheless, the commander recommended the CI be allowed to retrain.

At the VA Compensation and Pension (C&P) examination dated 2 October 2008, approximately a month before separation, the CI reported the pain began 2 years earlier and his left foot was more painful than the right.  Pain began with weight bearing and had been treated with Valium and electrical stimulation.  Pain ranged from 3-6/10 (10 being the worst pain) with flares from 7-8/10 when he did cardiovascular exercise.  On examination there was no swelling, edema, instability or weakness.  He had a normal gait and mild pain on the plantar surface/arch area (along the sinus tarsi) and tenderness on pressure to the cuboid bone area (mid foot).  There were no callosities, no skin breakdown or changes, no vascular changes, and no unusual shoe wear.  The CI was able to walk on his heels and toes and was able to tandem gait. Valgus angulation was mild at 3-5 degrees with a mild forefoot varus abnormality.  After separation in July 2009, alternative medications including the muscle relaxers, cyclobenzaprine and baclofen, were considered to replace the Valium, which was felt to have too many side effects to warrant its use.  In July 2010 the CI reported he took the Flexeril (cyclobenzaprine) for 3 months and thought it was too sedating. Valium was resumed as needed; baclofen was considered for future use. 

The Board directed its attention to its rating recommendation based on the above evidence.  The Air Force PEB assigned a 10% rating using code 5276 (flatfoot, acquired) for bilateral pes planus, moderate.  The VA assigned a 30% rating using code 5276 for pes planus (flat feet) based on evidence that showed pain on manipulation and use with marked deformity both non-weight bearing and weight bearing.  The Board noted that Valium relieved the CI’s spasms bilaterally, but because of bilateral pes planus with marked deformities evidenced by rocker bottom appearing feet and mid column collapse and the offer for moderately extensive surgery as well as pain on manipulation and use accentuated with intermittent swelling, a 30% rating for bilateral involvement is more applicable.  The Board was unable to find a route to a higher rating of 50% in the absence of pronounced; marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement, and severe spasm of the Achilles tendon on manipulation, not improved by orthopedic shoes or appliances  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the bilateral pes planus condition.  

BOARD FINDINGS:  In the matter of the bilateral pes planus condition, the Board unanimously recommends a disability rating of 30%, coded 5276 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  

The Board, therefore, recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:

CONDITION	VASRD CODE	RATING	
Bilateral Pes Planus, Severe	5276	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140303, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record
SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-01129.

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.

Sincerely,

Attachment:
Record of Proceedings 

cc:
SAF/MRBR 
DFAS-IN