RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXX                		                                                   CASE:  PD-2014-02287
BRANCH OF SERVICE:  AIR FORCE	SEPARATION DATE:  20070416

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Communication Computer System Operations Journeyman) medically separated for “deep venous thrombosis times three on recently removed from chronic anticoagulation with persistent leg edema,” rated at 20%. 

CI CONTENTION:  His conditions continue to worsen and negatively impact his daily activities.  His complete submission is at Exhibit A. 

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 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:  

IPEB - Dated 20070301	VA* - (~4 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Deep Venous Thrombosis Times Three on Recently Removed from Chronic Anticoagulation with Persistent Leg Edema	7199-7121	20%	Deep Vein Thrombosis of the Left Lower Extremity	7120	0%	20070820	
			Deep Vein Thrombosis of the Right Lower Extremity	7120	0%	20070820	
Plantar Fasciitis	Cat II	Bilateral Pes Planus	5276	0%	20070820	
Other MEB/PEB Conditions x 0 	Other x 3	
RATING:  20%	RATING:  0%	
*Derived from VA Rating Decision (VARD) dated 20071015 (most proximate to date of separation [DOS]).  
ANALYSIS SUMMARY:  

Deep Venous Thrombosis.  The service treatment record (STR) supplements and substantiates the MEB narrative summary (NARSUM) dated 4 December 2006 and the addendum NARSUM dated 8 February 2007.  While the NARSUM indicated the CI had three deep vein thromboses (DVTs) in the prior 2 years, the STR addressed only two DVTs.  The first DVT was marked by 3 days of increasing calf pain of the right leg and was confirmed on 28 April 2006 following surgery (a gastrocnemius recession and subtalar implant) of the right foot performed on 19 April 2006 for significant equinus (inadequate dorsiflexion of the foot) with medial column (bones of the inner portion of the foot) collapse bilaterally.  Treatment consisted of Fragmin (dalteparin, an anti-coagulant) intramuscularly and Coumadin (warfarin, an anti-coagulant) orally with INR monitoring (to determine anti-coagulant efficacy) thereafter.  Hematologic work-up for many clotting risk factors was negative, but Factor VIII activity, an independent risk factor for venous thrombosis was high.  A subsequent procedure was performed on the left foot and the Coumadin was temporarily replaced with injections of Lovenox (enoxaparin, an anti-coagulant) preoperatively and 6 days post-operatively.  Post surgery, which was performed on 16 August 2006, the CI had left leg pain.  An ultrasound study dated 26 August 2006 showed evidence of thrombus (blood clot) within the left paired peroneal veins and the dose of the Coumadin was increased.  A follow-up chest X-ray to rule out a pulmonary embolus was negative.  The CI did not take pain medication on a chronic basis, but had Percocet (hydrocodone, a narcotic and acetaminophen, a pain reliever) and cyclobenzaprine (a muscle relaxer) for break-through pain.  Other than some numbness in the left foot, both surgical procedures healed.  By 15 February 2007, the CI had residual symptoms of left ankle joint swelling and pain in both feet.  The NARSUM examiner noted swelling of the right foot without erythema or warmth and a well-healed incision on the right foot, while a hematologist recommended the CI stay on anti-coagulant therapy until February 2007, repeat the laboratory tests 2 weeks after completion, and follow-up prior to discontinuing therapy.

The commander’s statement dated 12 January 2007 indicated the CI could not perform all primary in-garrison military duties without restrictions because his foot needed to be elevated at all times, but he was able to perform his duties on a networked computer system, although he could not be deployed.  A revised temporary P4L4 profile was issued on 15 February 2007 with limitations of no prolonged standing, carrying and firing a weapon, marching, and wearing a protective mask and all chemical defense equipment.  Additionally the CI could not do any bending, pulling, climbing, working at heights, working outside, or physical fitness training and had to elevate his foot at all times.  

At the VA Compensation and Pension (C&P) examination dated 20 August 2007, performed 4 months after separation, the CI reported no lower extremity numbness, tingling, or paresthesias or residual swelling or skin breakdown in either foot subsequent to the surgeries and the deep venous thromboses.  He did not wear any type of Jobst or TED stockings (to prevent DVTs) and was on no anticoagulation medication in relation to his history of recurrent DVTs.  The examination was silent on whether there were any skin changes other than scars of the right and left calves and feet.  

The Board directed attention to its rating recommendation based on the above evidence.  The Air Force PEB assigned a 20% rating using code 7199-7121 (Post-phlebitic syndrome) for “deep venous thrombosis times three on recently removed from chronic anticoagulation with persistent leg edema.”  The VA assigned a 0% rating using code 7120 (Varicose veins: Asymptomatic palpable or visible varicose veins) for deep vein thrombosis of the left lower extremity and a 0% rating using code 7120 for deep vein thrombosis of the right lower extremity.  

Board Approach to PEB Consolidated Rating.   The PEB seemingly combined the left and right deep venous thrombosis conditions when it determined the rating.  However, VASRD §4.25 (b) states:  “Except as otherwise provided in this schedules, the disabilities arising from a single disease entity . . . are to be rated separately as are all other disabling conditions, if any.” Furthermore, DoDI 6040.44 states “Assignment of disability rating is based on the VASRD.  An individual with more than one unfitting condition receives a disability percentage rating for each condition.”  The Board then sought a route to a higher rating.  Using code 7121 requires “Intermittent edema of extremity or aching and fatigue in leg after prolonged standing or walking, with symptoms relieved by elevation of extremity or compression hosiery.”  At the time of separation the aforementioned had credence for each leg independently.  Therefore, a 10% rating for each leg is not unreasonable.  However, at the time of separation, no examination noted “persistent edema, incompletely relieved by elevation of extremity, with or without beginning stasis pigmentation or eczema,” although the NARSUM examination did refer to “swelling of the right foot” and the left ankle joint had swelling 2 months prior to separation, but 4 months post-separation the CI reported no residual swelling nor did the VA C&P examination note any swelling.  Therefore, Board members agreed that there was insufficient evidence to warrant a 20% rating for either the left or right leg DVT.  To rate each leg separately IAW with the VASRD and DoDI 6040.44 warrants a 10% rating for each condition.  However, combining the ratings of each including the bilateral factor would be 21%, which rounds down to 20% and is the same rating the CI received on separation.  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 deep venous thrombosis condition.

Contended PEB Condition-Bilateral Plantar Fasciitis.  The Board’s main charge is to assess the fairness of the PEB’s determination that the Category II bilateral plantar fasciitis conditions were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The bilateral plantar fasciitis conditions were profiled based on a note dated 12 April 2006, which indicated the CI had been on profile for over a year.  However, the conditions were not explicitly implicated in the commander’s statement and were not judged to fail retention standards, although it was the bilateral plantar fasciitis manifesting bilateral heel pain, not responsive to conservative therapy including semi-rigid orthotics and injections to the heels, that were factors for surgery on the right and left feet/ankles that anteceded the bilateral DVTs that occurred as a result of the surgery on each foot/ankle.  However, despite the DVT’s, postoperatively, both feet healed.  MRIs of both the left and right feet dated 2 December 2005 noted no evidence of plantar fasciitis or enthesopathy (a disorder of the attachment of a tendon or ligament to bone).  At the VA C&P examination the CI complained of bilateral persistent foot pain, which increased with weight-bearing, with walking on any uneven surface, and increased standing greater than 15 minutes.  Activities of daily living and work were unaffected and he walked without any assist device.  Examination revealed a mild 5 degree pes planus deformity, more pronounced on the right than on the left, with a 3 degree pes planus deformity on the left.  There was no evidence of calluses, breakdown, or atypical shoe wear and no evidence of a high arch.  There was a very minimal flat foot deformity noted in the right foot and left foot, and there was no evidence of definite forefoot or midfoot malalignment with weight bearing and non-weight bearing and no evidence of pain with ROM of the ankle or forefoot; the Achilles tendon did not appear significantly abnormal.  The VA assigned a 0% rating using code 5299-5276 (Flatfoot, acquired), which can be used for either bilateral or unilateral conditions, for bilateral pes planus.

The aforementioned was reviewed and considered by the Board.  There was no performance based evidence from the record that the bilateral plantar fasciitis conditions significantly interfered with satisfactory duty performance post surgery and post resolution of the bilateral DVTs.  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 any of the bilateral plantar fasciitis contended conditions and so no additional disability ratings are recommended.

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 20140520, 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 XXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-02287.

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,

Attachment:
Record of Proceedings