RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00599
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20080112

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Voice Network Systems Craftsman, medically separated for “right foot pain” and “right shoulder pain,” each rated 10%, with a combined disability rating of 20%.   

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 - 20071207	VARD - 20080131	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Foot Pain	5399-5310	10%	Status Post (S/P) Exostectomy of First Metatarsal Cuneiform Joint of the Right Foot	5299-5284	10%	20071010	
Right Shoulder Pain	5099-5003	10%	Chronic Right Shoulder Strain S/P Surgery of Right Shoulder for Repair of Superior and Anterior Labral Tears 	5299-5203	NSC		
Obstructive Sleep Apnea	Cat II	Sleep Apnea	6847	50%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Right Foot Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent two surgeries for exostosis (benign bony outgrowth on surface of bone) removal at the first metarsocuneiform joint (joint where first metatarsal meets foot bone) in 1999 and 2001.  In August 2006 he also underwent an endoscopic fasciotomy (fascial release) of the right foot for right heel pain (plantar fasciitis).  He did not obtain sufficient pain relief and in January 2007 he underwent a plantar fasciectomy (removal of the plantar fascia), which also did not fully resolve his foot pain.  A change of duty form in record indicated work restrictions from 30 April 2007 to 30 May 2007 for Tailor buniectomy (bunion of the fifth metatarsal head) without noting the right or left foot.  However, the only other note which addressed Tailor bunions was dated 19 December 2005 and the podiatrist indicated X-rays of the left foot showed a Tailor’s bunion.  There were no other notes in record regarding this surgery and it is unclear if it took place, but discussions of the right foot in later notes in the STR as well as the CI’s letter to the MEB dated 8 August 2007 do not indicate a Tailor bunionectomy of the right foot was performed.  Podiatry notes in May and June 2007 discuss only the right heel condition.  

At the 12 April 2007 physical therapy evaluation, 9 months before separation, the CI reported heel pain graded 3/10 when standing.  Physical examination showed normal appearance of the feet.  There was tenderness of the medial midfoot.  Right foot, talus, cuboid, metatarsal and ankle range of motion (ROM) were all normal.  Foot strength was graded 5/5.  

The 16 May 2007 MEB NARSUM examination, 8 months prior to separation, noted complaints of right plantar foot pain causing problems with running, walking short distances, standing more than 5 minutes or jumping.  Physical examination listed the same findings as the physical therapy evaluation above using the exact same language.  

At the 10 October 2007 VA Compensation and Pension (C&P) evaluation, 3 months before separation, the CI reported constant right foot pain.  He denied weakness, stiffness, swelling or fatigue.  Physical examination showed painful motion and tenderness of the right foot, but a normal gait.  There was no swelling, circulation problems, weakness or muscle atrophy.  There was active motion in the metatarsophalangeal joint of the great toe, but no measurement was provided.  There was no pes planus or pes cavus.  On the right he had hammertoes of the fourth and fifth toes.  There was no metatarsalgia, hallux valgus or hallux rigidus.  The CI required the use of orthotics but the corrective shoe wear did not relieve the foot pain.  Right ankle ROM was dorsiflexion of 20 degrees (normal 20) and plantar flexion of 45 degrees (normal 45).  There was no painful motion of the ankle noted.  The examiner recorded the CI did not have any limitation with standing and walking.  Right foot non-weight bearing X-rays showed hammertoes of the right fourth and fifth toes but were otherwise unremarkable. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right foot condition 10%, coded 5399-5310 (analogous to group X muscle injury, which includes the plantar fascia), citing normal strength and no atrophy or impaired joint function.  The VA rated the right foot condition 10%, coded 5299-5284 (analogous to other foot injury), based on the C&P examination, citing pain and tenderness with motion and X-rays positive for hammertoe deformities of the fourth and fifth digits.

The rating criteria of 5399-5310 are subjective, with a 0% rating for “slight,” 10% rating for “moderate,” 20% for “moderately severe,” and 30% for “severe” muscle injury.  The panel considered that when coding the disability due to plantar fasciitis analogous to 5310 IAW VASRD §4.73, the characterizations depend on the presence of one or more cardinal signs or symptoms of muscle injury specified as “loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement” for moderate disability as opposed to none for slight disability.  There was evidence of foot tenderness and pain with weight bearing to support a 10% rating.  The panel judged the right foot disability could not be characterized as moderately severe, which by analogy members judged would require greater objective evidence of foot abnormalities such as swelling, malalignment, deformity, or callosities.  A 10% rating is also alternatively supported with code 5284 for moderate foot injury, but by similar reasoning as noted for the 5310 criteria the panel concluded the evidence did not support characterizing the foot injury as moderately severe for a higher rating.  The panel considered other VASRD foot and ankle codes, but all were less applicable or not advantageous for rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the right foot condition.  

Right Shoulder Pain.  According to the STR and the MEB NARSUM, the CI underwent right shoulder surgery in September 2006 for rotator cuff tendinitis and possible anterior labral tear with repair of two labral tears and a subacromial bursectomy.  At the 5 March 2007 orthopedic visit, the CI reported 2/10 pain right shoulder pain.  Physical examination showed no swelling.  Shoulder ROM was 150 degrees of forward flexion (normal 180) and abduction 160 degrees (normal 180).  There was no painful arc with ROM and no significant tenderness.  Strength was graded 5/5.  Impingement and apprehension signs were negative.  The 16 May 2007 MEB NARSUM examination, 8 months prior to separation, noted complaints of right shoulder pain with activity, especially with arm above shoulder level or lying on his right side.  Physical examination cited the same findings as the orthopedic evaluation above, with the exact same language.  

At the 10 October 2007 VA Compensation and Pension (C&P) evaluation, 3 months before separation, the CI reported stiffness, weakness, lack of endurance, fatigability, giving way, numbness, locking and dislocation of the right shoulder.  He reported constant localized shoulder pain.  The pain was not relieved by anything and at the time of pain, he had to stop activity.  Physical examination showed forward flexion of 165 degrees and abduction of 145 degrees, with pain at end ROM.  There was no additional limitation of motion with repetition.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder condition 10%, coded 5099-5003 (analogous to arthritis, degenerative), citing normal strength and near-normal ROM.  The VA rated the right shoulder condition 10%, coded 5299-5203, (analogous to clavicle or scapula impairment), based on the C&P examination 3 months before separation, citing pain on testing, normal X-rays and ROM of flexion to 165 degrees.

The VASRD §4.71a threshold for rating for ROM impairment (code 5201, arm limitation of motion) is “at shoulder level” (approximately 90 degrees from the side), and the examinations in evidence demonstrated motion above this level.  Although there was insufficient limitation of motion to support a rating under the 5201 code, panel members agreed that a 10% rating was justified under 5003 (and related codes) for painful, limited motion.  There was no malunion or recurrent dislocation of the humerus to justify a rating under the 5202 code (humerus, other impairment of); and no nonunion with loose movement of the clavicle to warrant the next higher 20% rating under the 5203 code (clavicle or scapula, impairment of).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the right shoulder condition.  

Contended PEB Condition:  Obstructive Sleep Apnea (OSA).  The panel’s main charge is to assess the fairness of the PEB’s determination that OSA was not unfitting.  The CI reported witnessed sleep apneas and daytime sleepiness and underwent a sleep study.  He was diagnosed with obstructive sleep apnea 19 November 2007, 2 months before separation, and treatment with a continuous positive airway pressure device (CPAP) was recommended.  The OSA condition was not profiled, implicated in the commander’s statement nor judged to fail retention standards.  There was no performance-based evidence from the record that OSA significantly interfered with satisfactory duty performance at separation.  According to DoDI 1332.38, if there has been adequate performance to the point of referral into the physical evaluation process, a member may be considered fit for duty even though medical evidence indicates questionable physical ability to continue to perform duty.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for OSA and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the right foot condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the right shoulder condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended obstructive sleep apnea, the panel recommends no change from the PEB determination as not unfitting.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination. 

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170217, 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

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-00599.

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,

		

								XXXXXXXXXXXXXXXXXX
								Director
								Air Force Review Boards Agency

Attachment:
Record of Proceedings