RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00982
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20040421

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Security Forces Journeyman, medically separated for “left lower extremity (LLE) cellulitis with lymphedema” with a disability rating of 10%.  

CI CONTENTION:  “Review all conditions.”  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 Medical Evaluation Board (MEB), but determined by the PEB to be not unfitting or non-compensable.  Any conditions outside the panel’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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for the unfitting medical condition(s) at the time of separation.  The panel 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, which operates under a different set of laws.  The panel gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20040105	VARD - 20050718	
Condition	Code	Rating	Condition	Code	Rating	Exam	
LLE Cellulitis with Lymphedema	7121-7199	10%	Chronic Lymphedema Status Post LLE Cellulitis	7199-7121	0%	20050516	
Obesity	Cat III	No VA placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10% 	

ANALYSIS SUMMARY:  

LLE Cellulitis with Lymphedema.  According to service treatment record, the CI’s left foot condition began in September 2001 after having a left foot infection, which was treated with intravenous antibiotics for 3 days followed by oral antibiotics.  An ultrasound dated 16 October 2001, ordered for cellulitis of the LLE with severe swelling, revealed no evidence of deep venous thrombosis.  At a family practice clinic visit on 9 September 2002 the CI reported his foot had been swollen for about a year and he had pain/paresthesias in the toes.  Examination revealed 2-3+ non-pitting edema of the left foot with decreased sensation to light touch of the entire left foot.  There was brisk capillary refill and a full range of motion (ROM).  
At the 1 October 2002 internal medicine clinic visit the CI reported persistent foot swelling, worse in the morning, without any skin changes except that when the foot was swollen it became red.  Examination noted 2+ edema of the left foot to the ankle, which was not tender.  There was full ROM at the ankle with intact strength of the toes and ankle.  Light touch sensation was intact, but blunted compared to the right foot.  There was no difference in temperature between the feet; however, there was profuse perspiration on the dorsum of the feet.  The examiner’s assessment was persistent left foot/ankle edema following a bout of cellulitis with possible early mild reflex sympathetic dystrophy (RSD) versus venous insufficiency status post infection of soft tissues in the lower extremity.  X-rays of the left ankle dated 1 October 2002 were negative except for diffuse soft tissue swelling.  

At a primary care visit on 4 August 2003 the CI noted constant left foot edema since the infection in 2001.  Support stockings did not provide relief nor did elevation.  Examination showed significant edema at the left foot and ankle that was mildly pitted.  Surgical evaluation on 15 August 2003 indicated lower extremity edema of the left foot and ankle without erythema.  The CI was educated on the permanence of the problem and the need for excellent foot care with a compression garment for the remainder of his life as well as a job change.  

At a primary care clinic visit on 17 November 2003 the CI had moderate swelling to the calf, full ROM without pain, and normal strength.  The dorsal pedis pulse was 2+ and there was sweating over the hands and feet.  Compression stockings were continued with the recommendation to elevate the leg when possible.  At a 29 January 2004 surgery clinic visit, 3 months before separation, improvement with compression was noted, although there was still 2+ edema, and the CI continued to need to elevate the extremity.    

A primary care note dated 15 October 2004, 6 months after separation, indicated the CI had recently been medically discharged secondary to lymphedema of the LLE.  He wanted to re-enter the service and denied worsening or improvement of the condition and continued to wear compression stockings and work as a private contractor security guard without difficulties.  On examination he had 1+ edema of the LLE and 2+ dorsal pedis pulses of the lower extremities.  

At the 16 May 2005 VA Compensation and Pension (C&P) evaluation, 12 months after separation, the CI reported off and on swelling of his left foot since 2001 which was worse when out in the heat.  He denied any pain, itching, or burning from the foot swelling or from the hyperhidrosis.  Physical examination showed 0% visible disease of the skin.  The swelling was reported to be on his LLE; however, at the time of the examination, which was completely normal, there was no visible swelling, no cutaneous eruptions, and no diffuse sweating.  The examiner’s diagnosis was chronic lymphedema secondary to superficial skin infection (cellulitis) that occurred in 2001, which appeared asymptomatic at the time of the examination and was well controlled by the pressure stocking.  The examiner opined the hyperhidrosis was unrelated to his military service and was not causing any problems.   

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the cellulitis condition 10%, analogously coded 7121 (post-phlebitic syndrome of any etiology), citing not compatible with the rigors of military service.  The VA rated the skin condition 0%, coded 7199-7121, based on the C&P examination, citing no evidence of continued treatment.  

Members noted that a 10% rating 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,” while a 20% rating requires “persistent edema, incompletely relieved by elevation of extremity, with or without beginning stasis pigmentation or eczema.”  Prior to separation the CI still had lymphedema and even 6 months after separation he still had 1+ edema.  A 30% rating requires “persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration.  However, there was no stasis pigmentation or eczema, and at 12 months after separation, the edema had resolved and LLE skin was clear.  Nevertheless, more proximate to separation the CI had 2+ edema, which still persisted as 1+ edema 6 months after separation.  Therefore, the panel determined the VA examination at 12 months after separation has a less significant probative value than the examinations more proximate to separation.  Since the CI still had persistent edema at 6 months after separation, a 20% rating is warranted. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the LLE cellulitis with lymphedema condition, coded 7199-7121.  

Obesity.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement.  Obesity is not a physical disability.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the left lower extremity cellulitis with lymphedema condition, the panel recommends a disability rating of 20%, coded 7199-7121 IAW VASRD §4.104.  In the matter of the contended obesity condition, the panel recommends no change from the PEB determination as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Lower Extremity Cellulitis with Lymphedema	7199-7121	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160921, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-00982.

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 modification of your assigned disability rating without re-characterization of your 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 direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  This will not result in any change to your separation documents or the amount of severance pay you are entitled to.  Disability severance pay is computed the same regardless of a rating of 0, 10 or 20 percent.

						Sincerely,

								XXXXXXXXXXXXXXXXXX
								Director
								Air Force Review Boards Agency

2 Attachments:
1.  Directive 
2.  Record of Proceedings