RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02936
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20060702

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Computer System Analyst, medically separated for “asthma” with a disability rating of 10%.  “Left chronic foot and ankle pain in a setting of pes planus which is severe and symptomatic” was determined to have existed prior to service (EPTS), was not permanently service aggravated, and not rated.

CI CONTENTION:  “…I had left ankle surgery as a result of plantar fasciitis.  This has furthered my ailments with lower back and hip pain. I also continue diabetic treatment as a result of PCOS, which has so far caused infertility.”  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 - 20060419	VARD - 20071029	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Asthma	6602	10%	Seasonal Asthma	6602	30%	20070807	
Left Chronic Foot and Ankle Pain… 	EPTS	Bilateral Pes Planus with Left Plantar Fasciitis and Left Posterior Tibial Tendonitis	5279	10%	20070807	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Asthma.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s asthma condition began in approximately 2002 after recurrent episodes of bronchitis.  She noticed significant worsening of coughing, wheezing, and chest tightness especially with weather changes.  Pulmonary function tests (PFTs) on 16 November 2005 revealed FVC 116% predicted, FEV1 97% predicted and FEV1/FVC 72%.  She also had a positive methacholine challenge test consistent with severe bronchial hyper-responsiveness.  On 18 November 2005, a pulmonologist assessed that the CI’s symptoms, which occurred nocturnally more than once a week, were consistent with moderate persistent asthma.  

At a pulmonary clinic visit on 21 February 2006, she reported her symptoms were mainly brought on by exercise, but also occurred with temperature changes and exposure to smoke and strong perfumes; she denied severe attacks, emergency room treatment or hospitalizations.  The provider noted that the CI had been prescribed an albuterol inhaler 2 years earlier, which improved her wheezing and cough, and that she had not missed work due to her asthma.  She sometimes experienced a “slow” attack after exercising; and wheezing only occurred with exercise and was worse in the morning, during cold weather or with upper respiratory infections.  On examination, her lungs were clear to auscultation and no wheezing was heard nor was there a prolonged expiratory time.  The examiner assessed well-controlled (with albuterol) “mild persistent asthma” which did not interfere with work, and rendered the CI fit for full duty.  

The 21 February 2006 MEB NARSUM pulmonary examination, 5 months prior to separation, noted complaints of coughing and wheezing with no nocturnal episodes.  She was able to do the Army physical fitness test (APFT) on a bike (due to left foot injury) and could wear chemical protective gear for training.  No physical examination was performed and the provider noted she required albuterol as needed for symptoms.

At the 7 August 2007 VA Compensation and Pension (C&P) examination, 13 months after separation, the CI reported shortness of breath with exercise and that she needed to use an inhalational bronchodilator.  Physical examination showed symmetric breath sounds without rhonchi or rales, and the expiratory phase was within normal limits.  Before bronchodilator use, FVC was 101% predicted, FEV1 86% predicted, and FEV1/FVC 73%.  After bronchodilator use, FVC was 103% predicted, FEV1 96% predicted, and FEV1/FVC 79%. A chest X-ray was normal.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the asthma condition 10%, coded 6602 (asthma, bronchial), citing intermittent medication use.  The VA rated the seasonal asthma condition 30%, coded 6602, based on the C&P examination, citing FEV-1 of 56 to 70 percent of predicted value; or FEV1/FVC of 56 to 70 percent; or daily inhalational or oral bronchodilator therapy; or inhalational anti-inflammatory medication.  Members agreed that a 10% rating, which requires intermittent inhalational or oral bronchodilator therapy, was justified by the intermittent use of albuterol as reflected in the pulmonary and NARSUM evaluations.  A 10% rating was also justified by PFTs documented at the pulmonary and C&P examinations, with no PFT results supporting the next higher 30% rating.  Likewise, a 30% rating was not justified in the absence of daily inhalational or oral bronchodilator therapy, or inhalational anti-inflammatory medication.  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 asthma condition.  

Contended PEB Conditions:  Left Chronic Foot and Ankle Pain.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  While not implicated in the commander’s statement, the conditions were profiled, with preclusion from the 2-mile run, but not from alternate events. The MEB indicated the conditions did not meet retention standards, and the PEB noted “Dysfunction of the foot and ankle complex may result in altered gait pattern leading to compensatory changes in the knee and hip joints.” It then determined the condition (pes planus) existed prior to entry on active duty and was not permanently service aggravated and not rated.  

A podiatry clinic note on 30 August 2005, indicated the CI had experienced bilateral foot and ankle pain for 2 years.  Examination revealed bilateral ankle tenderness medially at the tarsal canal and a positive Tinel’s sign (indicative of nerve root irritation) on the left.  There was also bilateral posteromedial tibia tenderness with pitting edema and swelling of both feet.  The left foot had swelling and tenderness over the tibialis posterior tendon with pes planus and ankle edema, and a plantar fasciitis test elicited pain and tenderness along the fascia centrally.  There was also tenderness of the navicular tuberosity and abnormally increased subtalar joint motion with no weakness.  The podiatrist referred to bone scan results on 3 August 2005 which showed a right mid tibia Grade I stress fracture and diffuse uptake within the posterior tibiae bilaterally consistent with shin splints.  There were also diffuse stress changes in both knees and ankles, and focal stress changes of the left first metatarsal bone and cuneiform.  

At a primary care visit on 26 October 2005, the CI reported reinjuring her foot while marching the previous day.  She was noted to have tarsal tunnel syndrome and shin splints based on the prior bone scan, and the examiner recommended rest and prescribed a nonsteroidal anti-inflammatory drug and narcotic.  At a physical therapy visit on 16 November 2005, the CI complained of left leg pain above the heel.  Range of motion (ROM) measurements showed average dorsiflexion (presumably on the left since the table was not clearly labeled) of 6 degrees (normal 20) and plantar flexion of 46 degrees (normal 45); and average dorsiflexion of 7 degrees and plantar flexion of 35 degrees on the right, with pain greater on the left than the right.

The 18 November 2005 MEB NARSUM podiatry examination noted the CI’s chronic foot and ankle pain began in the spring or summer of 2001, after resuming her physical training post-partum.  She had a dull ache in the left heel while running, and when returning to running after 4 weeks off, she had immediate recurrence of symptoms.  After approximately 4 cycles of no running followed by running, she had a trial of steroid injections which worsened symptoms and resulted in a permanent profile in March 2003.  At the time of the examination, the CI had aching pain in the left arch and ankle with a feeling of instability precipitated by standing, walking, running, and marching; the pain was relieved by rest, heat, compression, inserts, pain medications, and liniment soaks.  She also had bilateral shin pain precipitated by any pressure on the shins, ruck marching, prolonged standing or walking and wearing combat boots; the pain was relieved by rest and heat.  Physical examination showed bilateral tenderness and tissue thickening of the anteromedial tibias, flexible flat feet, and marked tenderness at the left tarsal tunnel.  Physical therapy ROM studies revealed a marked decrease in active dorsiflexion bilaterally with a greater limitation on the left than the right.  Eversion and inversion were not greatly decreased from normal or from the contralateral side, and none of the passive ROM measurements showed significant laxity.  Imaging studies were within normal limits with the exception of the bone scan mentioned above.  The CI passed the APFT (alternate bike test) with a mild increase in pain lasting for a few days afterwards.  For individual physical training, she was able to use an elliptical trainer, power walk on a treadmill, and do weight training, lower body conditioning, and step aerobics.  The examiner also noted “Her profile stated she is unable to move two miles with a fighting load, though she actually can and does do this but with some pain.”  

The commander’s statement, dated 16 January 2006, indicated the CI was able to perform all the duties required of a systems management instructor and that she would be able to perform general soldier duties involving “some lifting, walking, carrying a weapon and wearing a helmet and flak vest under tiring and stressful conditions.”  

In an email thread dated 27 March 2006 and 7 April 2006, the treating podiatrist provided a biomechanics reference indicating the lower extremity joints from the ankle distally had an influence on one another and could alter gait and lead to compensatory changes to include “shin splints, stress fractures of the tibia and distally plantar fasciitis.”  

At the 7 August 2007 C&P examination, 13 months after separation, the CI reported a history of chronic plantar fasciitis with bilateral pes planus.  Physical examination revealed a normal gait and bilateral medial tibial border tenderness with a negative heel tap.  Neither lower extremity showed signs of edema, effusion, weakness, tenderness, redness, heat, subluxation, or guarding.  However, on the left, there was tenderness along the course of the posterior tibial tendon and pain with inversion against resistance.  Bilateral ankle ROM measurements were normal at 20 degrees dorsiflexion and 45 degrees plantar flexion.

Although there was no clear-cut performance-based evidence from the record that the conditions significantly interfered with satisfactory duty performance at the time of separation, the CI had a permanent L3 profile which restricted him from the AFPT 2-mile run as well unlimited running and walking.  The panel discussed whether avoidance of pyramiding IAW VASRD §4.14 would be invoked when not unbundling the foot and ankle conditions.  However, the podiatrist noted foot and ankle mechanisms were interrelated with the potential to alter the functional mechanics of the other.  Thus, members agreed the foot/ankle complex does not require unbundling, and therefore determined the left chronic foot and ankle pain was service aggravated and unfitting.   After due deliberation, the panel agreed that the preponderance of the evidence with regard to the functional impairment of left chronic foot and ankle pain favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 5284-5262 (foot injuries, other-tibia and fibula, impairment of) and meets the VASRD §4.71a criteria for a 10% rating.  

BOARD FINDINGS:  In the matter of the asthma condition and IAW VASRD §4.97, the panel recommends no change in the PEB adjudication.  In the matter of the contended left chronic foot and ankle pain condition, the panel agrees that it was unfitting and recommends a disability rating of 10%, coded 5284-5262 IAW VASRD §4.71a.  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 as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Asthma	6602	10%	
Left Chronic Foot and Ankle Pain	5284-5262	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170423, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180008800, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction. 

	A copy of this decision has also been provided to the Department of Veterans Affairs. 

Sincerely,					      
Enclosure