RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-04142
BRANCH OF SERVICE:  AIR FORCE	SEPARATION DATE:  20061106

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Integrated Avionics Systems) medically separated for migraine headaches and chronic right foot and ankle pain, rated 10% and 10%, respectively.

CI CONTENTION:  The applicant has asked for consideration of all her conditions.  Her complete submission is at Exhibit A.

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 based upon a 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:  

IPEB - Dated 20060912	VA* - (~6 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Migraine Headaches	8100	10%	Migraine Headaches	8100	30%	20070504	
Chronic Right Foot and Ankle Pain Associated with Plantar Fasciitis and Chronic Ankle Sprain	5310	10%	Right Plantar Fasciitis With Strain and Surgical Scar From Neuroma Removal and Calcaneal Spur	5284	10%	20070504	
			Right Ankle Strain	5271	0%	20070504	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 3 (equals SC, NSC & deferred)	
RATING:  20%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20071031 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY: 

Migraine Headaches Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s headache condition began at puberty.  During college, she was treated by her primary care physician and also noted that these were bad enough to interfere with work at time.  She denied the history of headaches and treatment on her entrance history date 10 March 2003.  Three months later, she began her enlistment.  She noted recurrent headaches during basic training with gradual progression.  MRIs in 2004 were normal other than an incidental finding which did not show pathology on further evaluation.  She was begun on a prophylactic medication by neurology with some improvement, but noted side effects from the medication.  A repeat MRI on 4 January 2005 showed that the previously noted lesion was unchanged and continued observation recommended.

The MEB NARSUM examination was performed on 3 May 2005.  It noted that she had enjoyed prolonged resolution of her headaches after the addition of nortriptyline (Pamelor).  She had not returned to full duty, but this was related to ongoing orthopedic issues (below). 

The commander’s letter was written on 14 July 2005, over 1 year prior to separation and prior to the initiation of nortriptyline for prophylaxis (below).  It noted the loss of over 21 days to convalescent leave and quarters, but did not apportion the loss to the different medical conditions.  Over the course of the preceding year, various medications were tried with some success, but also had side effects which were not acceptable to the CI until she was begun on nortriptyline for headache prophylaxis in November 2005.  She was also on modified duty during this time.  The Board noted that the CI continued to perform well and was recommended for immediate promotion on the fitness reports which closed out on 15 January 2005 and 15 January 2006.  The CI was entered into the MEB process for headaches, ankle, and foot issues.  

Around May 2006, 6 months prior to separation, the CI and her husband began consideration of conception.  She was advised in a telephone call to her neurologist on 9 May 2006 that some medications would need to be discontinued and that these should be tapered (to avoid rebound headaches).  On 7 June 2006, she was seen in a civilian acute care clinic and then placed on 48 hours quarters the next day for her headaches.  The Board noted that this was the only urgent care visit documented in the records and also the only documented occasion that she was placed on quarters for her headaches.  A follow-up neurology appointment on 23 August 2006 noted an increase in her migraine headaches to 1-2 times per month and noted that she took Valium for the “bad” migraines which knocked her out.  The CI was seen several more times for various issues prior to separation; the last clinical entry was dated 18 October 2006, less than 3 weeks prior to separation.  There were no additional acute care or emergency room visits or placement on quarters after the 7 June 2006 entries. 

At the VA Compensation and Pension (C&P) evaluation performed on 4 May 2007, 6 months after separation, the CI reported 3-4 migraines per month.  The examiner did not record that these were prostrating or that they required bed rest.  The neurological examination was normal.  

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the migraine headache condition at 10%, coded 8100 (migraine headaches).  The VA rated the migraine condition at 30%, also coded 8100 citing post-separation clinical visits.  The  Although the CI continued to endorse frequent headaches, her performance was excellent as evidenced by the fact that she was promoted during the 2 years she was under treatment for the headaches and that she was recommended for immediate promotion twice during this period.  Review of the records in evidence shows that she was seen on an urgent basis for the headaches once in the 12 months leading up to separation and that this visit was associated with the only placement on quarters documented in the records.  The requirement for a higher 30% rating is that the CI have prostrating attacks averaging once a month for the prior several months.  The Board did not find evidence to support this.  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 migraine headache condition.  

Chronic Right Foot and Ankle Pain Condition.  According to STR and the MEB NARSUM, the first record in evidence for these conditions is a foot center note dated 24 March 2005.  The CI reported that she fell off of a ladder in December 2004 and twisted her right ankle.  She then began physical therapy in January 2005.  No contemporaneous records were in evidence.  She reported that she now had severe pain under the heel and arch of the right foot.  On examination, the plantar fascia and outside of the ankle were both tender to palpation.  The ankle range of motion (ROM) was limited, but not painful.  Instability was not present.  X-rays showed a small heel spur.  She was thought to have plantar fasciitis and a lateral ankle sprain.  She was then begun on physical therapy (PT).  At an orthopedic appointment on 5 December 2005, it was noted that an MRI on 5 August 2005 was normal.  A bone scan was consistent with plantar fasciitis.  On examination, the plantar fascia insertion was tender, but the remainder of the examination normal.  Stretching was recommended.  At a foot center evaluation on 12 January 2006, she was noted to have minimal ankle pain, but persistent pain from the plantar fasciitis as well as pain over the balls of the right foot.  She was subsequently diagnosed with a neuroma of the second interspace of the right foot.  The NARSUM was dated 3 May 2006.  The CI was noted to have ongoing pain of the right ankle which was under treatment.  On 23 June 2006, the neuroma was excised.  She did well in rehabilitation over the next 2 months.  The final clinical note in evidence was dated 30 August 2006, 2 months prior to separation.  The CI noted that she had not taken medications for several days and that her pain had not increased.  The neuroma was well healed and only slightly tender.  The heel (plantar fasciitis) pain was almost completely resolved.  On examination, the area of the excision had minimal tenderness, there was no tenderness along the plantar fascia, and no pain involving the lateral ankle ligaments.  The VA C&P evaluation recorded that the foot and ankle pain persisted.  On examination, the gait was normal.  The ROM of the ankle was full and pain free.  Tenderness was present near the ankle.  Plantar fascia tenderness was not documented.  Tenderness at the excision site was not documented.  Laxity (instability) was not present.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic right foot and ankle pain associated with plantar fasciitis and chronic ankle sprain as a single condition at 10%, coded 5310 (moderate impairment of movements of the forefoot and toes including the plantar fascia).  The VA separated the foot and ankle conditions for rating.  It rated the plantar fasciitis condition at 10%, coded 5284 (other foot injuries at the moderate level) and the right ankle strain at 0%, coded 5271 (limitation of motion).  The Board noted that objectively, both conditions were essentially resolved in the examinations proximate to separation and found no route to a rating for the foot and ankle conditions, combined or separately, higher than that adjudicated by the PEB and VA.  Accordingly, further deliberation to determine if the conditions were separately unfitting is rendered moot as there is no advantage to the CI.  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 and ankle pain condition.  

BOARD FINDINGS:  In the matter of the migraine headaches condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic right foot and ankle pain associated with plantar fasciitis and chronic ankle sprain condition and IAW VASRD §4.71a and 4.73, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  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 w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR

Dear 

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-04142.

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