Citation Nr: 1329804 Decision Date: 09/17/13 Archive Date: 09/25/13 DOCKET NO. 09-23 970 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for planter fasciitis. 2. Entitlement to an initial compensable rating for a right wrist disability. REPRESENTATION Appellant represented by: Joshua Stone, Agent WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD L. Barstow, Counsel INTRODUCTION The Veteran had active military service from June 1997 to June 2001 and from March 2005 to June 2006. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2008 rating decision of the VA Regional Office (RO) in Manchester, New Hampshire. In June 2013, the RO increased the disability rating for the plantar fasciitis from zero percent to 10 percent disabling, effective June 23, 2006. The Board notes that since the increase did not constitute a full grant of the benefit sought, this issue remains in appellate status. AB v. Brown, 6 Vet. App. 35, 39 (1993). In February 2009, the Veteran testified at a hearing before a Decision Review Officer. In June 2012, he testified at a hearing before the undersigned Veterans Law Judge. Transcripts of both hearings have been associated with the claims file. The case was most recently remanded in September 2012 to obtain additional treatment records and to afford the Veteran new VA examinations. Review of the record indicates substantial compliance. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board's remand also included the issues of service connection for gastroesophageal reflux disease (GERD) and a left knee disability. In a June 2013 rating decision, the RO granted service connection for those disabilities. As the Veteran has not expressed disagreement with the disability ratings and/or effective dates assigned, the Board concludes that those issues are no longer before it. FINDINGS OF FACT 1. The plantar fasciitis does not result in severe disability with objective evidence of marked deformity, pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities; it has not resulted in moderate disability in each foot. 2. The right wrist disability does not limit dorsiflexion to less than 15 degrees or limit palmar flexion in line with forearm; has not resulted in ankylosis; and the Veteran does not have traumatic or degenerative arthritis. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent for plantar fasciitis have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.71a Diagnostic Code (DCs) 5276, 5284 (2012). 2. The criteria for an initial compensable rating for a right wrist disability have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.321, 4.3, 4.7, 4.71a Diagnostic Code (DC) 5215 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 & 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). The notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Such notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Veteran was notified in letters dated in August 2006 and December 2012 regarding the type of evidence necessary to establish his claims. The Veteran was notified of what evidence and/or information was already in the RO's possession, what additional evidence and/or information was needed from the Veteran, what evidence VA was responsible for getting, and what information VA would assist in obtaining on the Veteran's behalf. In addition, the letters notified the Veteran of the criteria for assigning a disability rating and an effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Board notes that the Veteran's claims for higher initial ratings for his plantar fasciitis and right wrist disability arise from his disagreement with the initial ratings following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Regardless, the August 2006 and December 2012 letters informed the Veteran of the criteria for assigning a disability rating. See Dingess/Hartman, 19 Vet. App. 473. Regarding VA's duty to assist, VA obtained the Veteran's service treatment records (STRs), post-service medical records, and also secured examinations in furtherance of his claims. Pertinent VA examinations were obtained in May 2007, October 2007 and May 2013. 38 C.F.R. § 3.159(c)(4). The VA examinations obtained in this case are sufficient, as the examiners conducted complete examinations, recorded all findings considered relevant under the applicable law and regulations, and offered well supported opinions based on consideration of the full history of the disorders. The Board finds that VA's duty to assist the Veteran with respect to obtaining a VA examination concerning the issues adjudicated herein has been met. 38 C.F.R. § 3.159(c)(4). II. Analysis Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10. A distinction must be made between a veteran's dissatisfaction with original ratings and dissatisfaction with determinations on later filed claims for increased ratings. See Fenderson v. West, 12 Vet. App. 119, 125-26 (1999). Where there is a question as to which of two ratings should be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In determining the degree of limitation of motion, several regulatory provisions are taken into consideration: the provisions of 38 C.F.R. § 4.40 concerning lack of normal endurance, functional loss due to pain, and pain on use and during flare-ups; the provisions of 38 C.F.R. § 4.45 concerning weakened movement, excess fatigability, and incoordination; and the provisions of 38 C.F.R. § 4.10 concerning the effects of the disability on the veteran's ordinary activity. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The evaluation of the same disability under various diagnoses is to be avoided. 38 C.F.R. § 4.14. Here, as noted in the discussion below, the effects of pain on use, functional loss, and incoordination were taken into account in assessing the range of motion of the Veteran's service-connected joint disabilities. 1. Plantar Fasciitis The Veteran's plantar fasciitis is rated as 10 percent disabling by analogy under 38 C.F.R. § 4.71a, DC 5276, which evaluates impairment from acquired flatfoot. As the Veteran's disability has been shown to be bilateral, the Board will consider the ratings for bilateral disability. Pursuant to DC 5276, a 10 percent evaluation is warranted when there is moderate disability evidenced by weight-bearing line over or medial to the great toe, inward bowing of the tendo-Achilles, pain on manipulation and use of the feet. 38 C.F.R. § 4.71a, DC 5276 (2012). A 30 percent evaluation is warranted for severe bilateral disability when there is objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. Id. A 50 percent evaluation is warranted when there is a pronounced bilateral disability as evidenced by marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo-Achilles on manipulation, not improved by orthopedic shoes or appliances. Id. The Veteran's STRs prior to his discharge in June 2006 do not show symptoms such as objective evidence of marked deformity, pain on manipulation and use accentuated, indication of swelling on use or characteristic callosities. They show the use of orthotics. A VA treatment record in April 2007 shows that the Veteran had muscle function of 5/5 dorsiflexion, plantar flexion, inversion and eversion. There was no clonus and no palpable plantar fascial tenderness. He was tight in the ankle joint with dorsiflexion of 90 degrees with the knee fixed and 95 degrees bilateral lower extremities. He had a forefoot valgus type, bilateral feet and a flexible pes planovalgus foot type, bilateral feet. On stance, bilateral heels were rectus. He was able to raise on the ball of each foot with heel inversion and he only had slight anterior ankle joint tenderness on the left on single limb raise. He had normal range of motion of the subtalar joint on the left. He had limited ankle dorsiflexion bilaterally, left more limited than right. He had no talar tilt, no anterior drawer on the left compared to the right. The Veteran was provided custom orthotics in May 2007. The Veteran was afforded a VA examination in May 2007. He reported pain in the midfoot and at the base of both ankles; left side was worse than the right. He reported that he just had orthotics made and that he was not told that he had any physical problems. He did report that he could no longer run long distances because of this condition. Examination revealed full range of motion of the ankle. Dorsiflexion was to 20 degrees bilaterally and plantar flexion to 45 degrees bilaterally. He had normal Achilles tendon alignment and the arch on the left side appeared to be slightly lower than the arch on the right side. There was no palpable tenderness along the midfoot, forefoot or hindfoot. No swelling or erythema otherwise noted. The examiner opined that on examination of the feet, there was the absence of painful motion on the day of examination. The Veteran did not describe any flare-ups that would cause any further loss of range of motion. That condition had no effect on his occupation or activities of daily living. An October 2007 record shows that the Veteran continued to use custom orthotics. He stated he did not feel enough support in the medial longitudinal arches. A December 2008 record reveals that the Veteran reported that he had stopped wearing orthotics after having increased medial knee pain. He still had plantar fasciitis type symptoms at the end of the day. Examination showed mild forefoot valgus foot type, bilateral feet. He also had a rear foot varus foot type. On stance, left was approximately 2 degrees in valgus; right was near rectus. He had no edema, erythema or calor along the medial ankle gutter. The posterior tibial tendon looked fully intact with full strength to confrontation. There was no crepitus that was evident. He had mild tenderness along the medial ankle gutter. The Veteran was diagnosed with chronic plantar fasciitis, pronating foot type. At his February 2009 hearing, the Veteran testified that he had been recast for new orthotics. February 2009 Hearing Transcript (H.T.) at 15. He reported that with the feet, periods of inactivity caused pain. Id. at 16. He did not run that much anymore. Id. The Veteran testified that he estimated having significant pain a couple of times per week. Id. at 17. He testified at his June 2012 hearing that he had pain in both feet. June 2012 Hearing Transcript (T.) at 4. He reported having really intense pain in the arch area with any kind of inactivity. Id. He testified that he tried to be active. Id. The Veteran was afforded a VA examination in May 2013. He reported that he continued to be treated for bilateral plantar fasciitis and that he continued to have bilateral foot pain worse at the end of the standing/walking activity or at the end of the day. He reported having failed four different shoe orthotics because they caused an increase in left knee pain. That day on examination, there was no tenderness of the plantar fascia at eight am. The Veteran reported that was his usual pattern; no am pain, bilateral foot pain occurred later in the end day every day. The examiner opined that plantar fasciitis at that date would be considered mild. The examiner indicated that the Veteran did not have metatarsalgia, hammer toes, hallux valgus, hallux rigidus, claw foot, malunion or nonunion of tarsal or metatarsal bones, weak foot or other foot injuries. The Veteran used no assistive devices. His condition impacted his ability to work; he had worse foot pain with walking later in the day. Based on a review of the evidence, the Board concludes that an initial rating in excess of 10 percent is not warranted at any time since the award of service connection. The next higher rating of 30 percent is warranted for severe disability with objective evidence of marked deformity, pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities. The May 2013 examiner opined that the Veteran's disability was mild. In this case, the pertinent treatment records and VA examinations fail to show objective evidence of marked deformity. The Board acknowledges the December 2008 treatment record showing pronating foot type. However, marked deformity in other records and at the VA examinations has not been shown. Although the Veteran has reported pain on use, it has not been shown to be accentuated. Indeed, the currently assigned 10 percent rating specifically contemplates pain on manipulation and use of the feet. The Veteran has not reported swelling on use, nor have the records documented swelling. Additionally, characteristic callosities have never been shown, nor has the Veteran reported having callosities resulting from this disability. The symptomatology shown on appeal as discussed above has not approximated severe disability. At his hearings, the Veteran testified regarding pain, but did not indicate other symptoms such as those contemplated for in the 30 percent rating. Therefore, the evidence fails to show that an initial rating in excess of 10 percent under DC 5276 is warranted. In reaching this conclusion, the Board has considered whether the Veteran's painful motion contributes to the actual limitation of motion such that an increased rating is warranted. Here, even when taking into account the pain on use experienced by the Veteran, the Board finds that an increased rating for limitation of motion is not warranted. See 38 C.F.R. § 4.40 (a little used part of the musculoskeletal system due to pain may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity, or the like). The evidence reflects pain. The VA examinations reports reflect that the Veteran's pain on use and the functional loss it resulted in were taken into account. None of the examinations or treatment records shows that the Veteran had muscle atrophy or other evidence of disuse. The Veteran was shown to have muscle function of 5/5 in April 2007. Accordingly, the criteria for an initial rating in excess of 10 percent for limitation of motion for the Veteran's service-connected plantar fasciitis have not been met. 38 C.F.R. § 4.71a, DC 5276. The Board has also considered whether a rating in excess of 10 percent is warranted under any of the other diagnostic codes use to rate foot disabilities. The May 2013 examiner specifically indicated that the Veteran did not have weak foot, claw foot, anterior metatarsalgia, hallux valgus, hallux rigidus, hammer toes and malunion or nonunion of tarsal or metatarsal bones. Therefore, ratings under 38 C.F.R. § 4.71a, DCs 5277, 5278, 5279, 5280, 5281, 5282, 5283 are not warranted. The Board has also considered whether a rating in excess of 10 percent is warranted by assigning separate ratings for each foot under DC 5284, which evaluates impairment from other foot injuries. A 10 percent rating is warranted for moderate disability. 38 C.F.R. § 4.71a, DC 5284 (2012). A 20 percent rating is warranted for moderately severe disability. Id. To have a combined rating in excess of 10 percent, the Veteran needs to have a separate 10 percent rating for each foot under DC 5284. See 38 C.F.R. § 4.25 (2012). In this case, each of the Veteran's feet has not been shown to equate to moderate disability. As "moderate" is not defined in the rating criteria, the Board finds it particularly instructive as to what warrants 10 percent ratings for unilateral foot disabilities under the rating criteria. The currently assigned 10 percent rating under DC 5276 is warranted for bilateral or unilateral disability. The Veteran has pain on use, but the evidence has not shown weight-bearing line over or medial to great toe or inward bowing of the tendo achillis in each foot. While the Veteran's combined symptomatology for both feet warrants the assigned rating for bilateral disability, the symptoms shown for each foot are not tantamount to the symptoms contemplated for by moderate unilateral disability under DC 5276. A 10 percent rating for unilateral claw foot requires symptoms such as great toe dorsiflexed, some limitation of dorsiflexion at ankle and definite tenderness under metatarsal heads. 38 C.F.R. § 4.71a, DC 5278. None of the Veteran's treatment records or VA examinations have shown such symptoms. The May 2007 VA examination specifically indicated normal ankle range of motion. The symptomatology shown during this appeal has not equated to what would warrant a 10 percent disability for unilateral claw foot. In this case, when considering the symptoms discussed above as shown on examinations, documented in treatment records, as well as reported by the Veteran, the Board concludes that such symptoms do not equate to moderate disability of each foot such that separate ratings to be combined under DC 5284 is warranted. Rather, the evidence shows that the currently assigned 10 percent rating for bilateral foot disability under DC 5276 adequately compensates the Veteran for the actual symptomatology shown since the award of service connection. For these reasons, the Board finds that the criteria for an initial rating in excess of 10 percent for plantar fasciitis is not warranted. 2. Right Wrist Disability The Veteran's right wrist disability is rated as zero percent or noncompensably disabling under 38 C.F.R. § 4.71a, DC 5215, which evaluates impairment from limitation of motion of the wrist. Pursuant to DC 5215, a 10 percent evaluation is warranted for both the minor and major arm when dorsiflexion is less than 15 degrees or palmar flexion is limited in line with forearm. 38 C.F.R. § 4.71a, DC 5215 (2012). The Veteran's STRs prior to his discharge in June 2006 do not show that the Veteran had dorsiflexion of less than 15 degrees or that palmar flexion was limited in line with forearm. A treatment record dated in April 2007 shows that the Veteran reported that his right wrist had been bothering him. He used a mouse at work and as the day went on, that became more painful. He was advised to use a gel pad under his wrist for using his mouse. The Veteran was afforded a VA examination in May 2007. He reported having pain. The Veteran reported that because he was continuing with his current job, he had difficulty using a mouse and typing. He also found riding a motorcycle difficult. The Veteran reportedly had X-rays done in Iraq and was told he just had wrist tendinitis. He had a wrist splint that he used at night. Examination revealed negative Phalen and negative Tinel. There was full range of motion. The Veteran had dorsiflexion to 70 degrees; palmar flexion to 80 degrees; ulnar deviation to 45 degrees; and radial deviation to 20 degrees. The examiner opined that on examination, there was the absence of painful motion. With repetitive use, it was feasible that the Veteran would lose an additional 10 degrees of range of motion. That condition had a mild effect on his occupation and no effect on his activities of daily living. At an October 2007 VA examination, the Veteran reported working as a program manager and using a computer a lot. He reported that he had right wrist pain on a daily basis with flare-ups every few weeks. He used a right wrist splint at night during the time of a flare-up. He also described difficulty riding a bicycle. Examination revealed no palpable tenderness. There was no swelling of the wrist. Tinel and Phalen sign were negative. Grip strength was within normal limits. Range of motion testing revealed dorsiflexion to 70 degrees; palmar flexion to 80 degrees; ulnar deviation to 45 degrees; and radial deviation to 20 degrees. The examiner noted that the ranges of motion were within normal limits. The examiner again opined that the condition had a mild effect on his occupation and no effect on his activities of daily living. At his February 2009 hearing, the Veteran testified that he wore a brace. H.T. at 17. He also iced his wrist about once a month. Id. at 18. He had pain every day. Id. The Veteran adapted his work station at work because of his right wrist condition, which had helped. Id. at 19. He had not lost any work time. Id. At his June 2012 hearing, the Veteran testified that he had pain with movement. T. at 6. His strength had decreased; he testified that he did not really do any real strength training exercises. Id. He reported that his dexterity was "probably okay." Id. The Veteran was right handed. Id. He wore a splint on occasion; when he had a real bad flare-up, he wore it for "like a week or so until things calm down." Id. at 7. He was not sure what his range of motion was, but reiterated that he had pain with motion. Id. At a VA examination in May 2013, X-rays were normal. Range of motion in all spheres was normal. No muscle atrophy was found on examination on right wrist or forearm. There was mild tenderness reported over distal radius. The Veteran reported having flare-ups of occasional wrist pain with prolonged computer mouse use (10 hour day) at work. Range of motion testing revealed palmar flexion to 80 degrees with objective evidence of painful motion at 70 degrees; and dorsiflexion to 70 degrees with no objective evidence of painful motion. The Veteran was able to perform repetitive use testing. After repetition, he had 80 degrees of palmar flexion and 70 degrees of dorsiflexion; he did not have additional limitation in range of motion following repetition. The Veteran did have functional loss of pain on movement. He had pain on palpation. Muscle strength testing was normal at 5/5 for flexion and extension. There was no ankylosis. Diagnostic tests did not show degenerative or traumatic arthritis. The Veteran's wrist condition impacted his ability to work; it was at times painful using the mouse on the computer and required anti-inflammatory medication. The Veteran's pertinent treatment records throughout this appeal have not shown his right wrist range of motion. They have also not show that he has arthritis or ankylosis. Based on a review of the evidence, the Board concludes that an initial compensable rating is not warranted at any time since the award of service connection. The only rating available under DC 5215 of 10 percent requires that dorsiflexion is less than 15 degrees or that palmar flexion is limited in line with forearm. At worst, the Veteran's dorsiflexion was shown to be limited 70 during this appeal. His treatment records do not show that he had limitation less than 15 degrees. As for palmar flexion, normal range of motion is 80 degrees. See 38 C.F.R. § 4.71a, Plate I. At worst, the Veteran had objective evidence of painful motion at 70 degrees at the May 2013 VA examination. However, such limitation does not indicate that palmar flexion was limited in line with forearm. Accordingly, a compensable rating based on limitation of motion is not warranted. In reaching this conclusion, the Board has considered whether the Veteran's painful motion contributes to the actual limitation of motion such that an increased rating is warranted. Here, even when taking into account the pain on use experienced by the Veteran, the Board finds that an increased rating for limitation of motion is not warranted. See 38 C.F.R. § 4.40. The evidence reflects pain. The VA examinations reports all reflect that the Veteran's pain on use and the functional loss it resulted in were taken into account. None of the examinations or treatment records shows that the Veteran had muscle atrophy or other evidence of disuse. The May 2013 examination showed that the Veteran had full strength of 5/5 and he had normal grip strength in October 2007. Accordingly, the criteria for an initial compensable rating for limitation of motion for the Veteran's service-connected right wrist disability have not been met. 38 C.F.R. § 4.71a, DC 5215. The Board has also considered whether the Veteran may be entitled to a compensable rating under other applicable diagnostic codes. The only other diagnostic code used to rate the wrist is DC 5214, which evaluates ankylosis. The May 2013 VA examiner specifically found that the Veteran does not have ankylosis. As the VA examinations and treatment records do not show ankylosis, the Board finds that DC 5214 is not for application. 38 C.F.R. § 4.71a, DC 5214 (2012). The Board notes that DC 5003 provides for a 10 percent rating for each major joint or group of motion joints affected by limitation of motion when the limitation of motion of the specific joint or joints is noncompensable under the appropriate diagnostic codes. 38 C.F.R. § 4.71a, DC 5003 (2012). However, DC 5003 only applies to degenerative arthritis established by X-ray findings. Id. In this case, degenerative arthritis established by X-rays has not been shown. The May 2013 examination report reflects that X-rays were normal; degenerative or traumatic arthritis was not shown. Therefore, the Board finds that a compensable rating under DC 5003 is not warranted. For these reasons, the Board finds that the criteria for an initial compensable rating for a right wrist disability is not warranted. 3. Extraschedular Consideration Furthermore, the rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and their residual conditions in civil occupations. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the disability. 38 C.F.R. § 4.1. The Board notes that in exceptional cases where evaluations provided by the rating schedule are found to be inadequate, an extraschedular evaluation may be assigned which is commensurate with the veteran's average earning capacity impairment due to the service-connected disorder. 38 C.F.R. § 3.321(b). However, the Board believes that the regular schedular standards applied in the current case adequately describe and provide for the Veteran's bilateral feet and right wrist symptoms and disability level. Marked interference with employment beyond that contemplated by the schedular criteria has not been shown. The record does not reflect a disability picture that is so exceptional or unusual that the normal provisions of the rating schedule would not adequately compensate the Veteran for his service-connected disabilities. The evidence does not show that the Veteran's bilateral feet and right wrist disabilities have resulted in interference with employment or activities of daily life which would warrant increased ratings for each disability. Moreover, as the Veteran has not contended, nor does the evidence show that his disabilities render him unemployable, the issue of entitlement to a total disability rating based on individual unemployability has not been raised by the record. Rice v. Shinseki, 22 Vet. App. 447 (2009); Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). ORDER Entitlement to an initial rating in excess of 10 percent for plantar fasciitis is denied. Entitlement to an initial compensable rating for a right wrist disability is denied. ____________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs