RECORD OF PROCEEDINGS 
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXX		BRANCH OF SERVICE: AIR FORCE
CASE NUMBER:  PD0900281		BOARD DATE: 20090512
SEPARATION DATE: 20070312
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SUMMARY OF CASE:  This covered individual (CI) was Technical Sergeant, Communications Specialist medically separated from the Air Force in 2007 after more than ten years of active service.  The medical basis for the separation was chronic left ankle pain due to chronic tendonitis.  The CI was referred to the Physical Evaluation Board (PEB), found unfit for continued military service, and separated at 10% disability using the Veterans Affairs Schedule for Ratings Disabilities (VASRD) and applicable Air Force and Department of Defense regulations.
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CI CONTENTION:  The CI states: “When I was discharged from the Air Force, the only medical condition that was considered was my left ankle.  I also have issues with my right ankle, knees, my ring finger and my back.”
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RATING COMPARISON:

Service PEB	VA (4 Months after Separation)	
Unfitting Conditions	Code	Rating	Date	Condition	Code	Rating	Exam	Effective	
Chronic Left Ankle Pain Due to Chronic Tendonitis (Peroneus Brevis) and Post-Surgical Changes	5311	10%	20070129	Left Ankle Strain And Tenosynovitis Status Post Surgery w/Residual Scar	5271	10%	20070724	20070313	
Additional Conditions	PEB	DES							
Chronic Left Ankle Pain due to Chronic Tendonitis and Post Surgical Changes, Possible Scar Tissue or Nerve Changes		Yes	NARSUM	Left Sural Neuralgia (Claimed as Left Foot Pain and Loss of Mobility)	8599-8523	10%	20070724	20070313	
		No		Cervical Degenerative Joint Disease	5242	10%	20070724	20070313	
		No		Left Knee ACL and Iliotibial Band Strain	5260	10%	20070724	20070313	
		No		Right Knee Strain	5260	10%	20070724	20070313	
Right Ankle Brostrum 2004; Right Ankle Surgery 1998		Yes	NARSUM 	Right Ankle Strain and Tenosynovitis Status Post Surgery w/Residual Scars	5271	10%	20070724	20070313	
Right Finger Tendon Repair 1996		Yes	NARSUM	Right 4th Finger Tendon Rupture Status Post Surgery w/Residual Scar	5299-5230	0%	20070724	20070313	
		No		Tension Headaches	8199-8100	0%	20070724	20070313	
		No		Right Lateral Femoral Cutaneous  Paresthesia/ Dysesthesia (Claimed as Right Thigh Pain)	8599-8529	0%	20070724	20070313	
		No		Lower Back Pain	NSC				
TOTAL Combined:  10%	TOTAL Combined (Includes Non-PEB Conditions):
Bilateral factor of 4.1% for diagnostic codes 5271,8523,5260,5260    
50%  from 20070313
 	
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ANALYSIS SUMMARY:

Left Ankle/Left Foot

The CI had multiple injuries to both ankles while on active duty and multiple outpatient visits starting in 1996, one year after entered active duty.  He had a Brostrom procedure on his right ankle in 2004 and apparently did well afterward.  He had the same procedure on left ankle in July 2005 and initially did well after surgery.  However, in October 2005 he felt a pop and noted pain after a calf raising exercise.  A Magnetic resonance imaging (MRI) done in March 2006 demonstrated: 1. Anterior talofibular ligament thickening with obscuration from adjacent metallic artifact and post-operative changes.  2. New peroneus brevis longitudinal split tear, which can be a sequelae of ankle instability.  3. Tenosynovitis involving the peroneus longus and brevis and, to a lesser extent, involving the flexor digitorum and posterior tibialis tendons.  The CI underwent surgical repair of the peroneus brevis tendon in June 2006.  Although the tendon repair was apparently successful, he continued to have pain and was unable to return to full duties.  He was then evaluated by a civilian podiatrist in October 2006 who noted continued pain with activity, particularly with propulsion gait as well as some neurogenic symptoms with burning and shooting pains.  The pain was burning and achy pain along the lateral forefoot with continued pain in the anterolateral ankle joint.  While injections had not brought any relief in the past, the CI received injections in October 2006 in an attempt to isolate the pain.  A follow-up visit the next month documented little to no relief with these injections.

The CI had anterolateral left ankle pain all along and additionally had lateral foot pain after the tendon repair surgery.  The civilian podiatrist determined the pain in his ankle and foot was secondary to peroneal tendinopathy, sural nerve entrapment neuritis, as well as anterior ankle joint impingement which may be due to either scar tissue build up in the anterolateral aspect of the ankle joint or even a low-lying Basset's ligament. 

The PEB rated this condition using a muscle code, possibly secondary to the tendon involvement.  The VA rated it using the code for ankle, limited range-of-motion (ROM) and rated the nerve condition separately as well.  The peroneus brevis tendon had been repaired and was not the cause of the decreased ROM of the ankle.  The decreased ROM was due to painful motion of the ankle joint and 5271 is a more appropriate code.  However, both are consistent with a 10% rating.

There is no VASRD code for ankle joint laxity, only limited ROM, ankylosis, or malunion.  The VA examiner stated instability was present in the diagnosis but did not demonstrate this on exam. The narrative summary (NARSUM) did not evaluate joint instability. Neither ankylosis nor malunion were present.

Ankle
Movement	Normal ROM
	ROM Mil
20061031	ROM VA
20070724	
Right Dorsiflexion	0 – 20	None	20	
Right Plantar flexion	0 - 45	None	30	
Notes:		None	Inversion 5/5 and eversion 3/5	
Left Dorsiflexion	0 – 20	Past 90 degrees	20	
Left       Plantar flexion	0 - 45	Slight decrease	30	
Notes:		Able to invert and evert but ROM painful	Inversion 5/5 and eversion 3/5	

Left sural nerve neuralgia:  This condition was not documented prior to the second surgery (tendon repair) and the CI was not referred to Military Evaluation Board (MEB) until after he had foot pain in addition to his ankle pain after second surgery.  It is difficult to separate continuing left ankle pain from left foot pain as the sole cause for unfitness.  The CI had both after the second surgery and either alone could have been a sufficient reason for referral to the PEB.  More likely than not, the neuralgia by itself would have required the same physical limitations the CI had with both conditions present.  Therefore more likely than not, it was unfitting at the time of separation and it should also be rated. 

VA rated this 10% for moderate neuralgia.  The CI had pain and inability to flex his 4th and 5th digit of the left foot.  No sensory examinations of the foot or ankle were performed.  This condition could be considered mild or moderate; the maximum permissible rating is for moderate IAW §4.124 Neuralgia, cranial or peripheral.

Other Conditions:  Right Ankle Strain and Tenosynovitis Status Post Surgery w/Residual Scars and Right 4th Finger Tendon Rupture Status Post Surgery w/Residual Scar.  

No physical limitations are attributable to the finger condition.  Physical limitations could be attributable to the right ankle as well as the left.  However, the CI was not referred to the MEB until after his second surgery where his left ankle pain increased and he additionally had left foot pain and the left sural neuralgia. The right ankle pain was not severe enough or limiting enough to be unfitting.

Other Conditions not in Disability Evaluation System (DES) Package:  Cervical Degenerative Joint Disease; Left Knee ACL and Iliotibial Band Strain; Right Knee Strain; Tension Headaches; and Right Lateral Femoral Cutaneous Paresthesia/Dysesthesia 
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BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. After careful consideration of all available evidence, the Board unanimously determined that the CI’s condition is most appropriately rated at a combined 20% with 10% for Chronic Left Ankle Pain due to Chronic Tendonitis (Peroneus Brevis) and Post-Surgical Changes and 10% for Left Sural Neuralgia. 

The CI’s left ankle plantar flexion is limited to thirty out of forty-five degrees. This is considered a moderate limitation and a 10% rating is warranted.

The Left Sural Nerve Neuralgia was not documented prior to second surgery (tendon repair) and the CI was not referred to the PEB until after he had left foot pain in addition to his left ankle pain.  It is difficult to separate continuing left ankle pain from left foot pain as the sole cause for unfitness; the CI had both after second surgery and either alone could have been reason to refer to PEB.  More likely than not, the neuralgia by itself would have been unfitting and therefore should also be rated. If it was the only condition present, the CI could have had the same limitations he did have with both conditions present.

The Board also considered Right Ankle Strain and Tenosynovitis Status Post Surgery with Residual Scars and Right 4th Finger Tendon Rupture and unanimously determined that none of these conditions were unfitting at the time of separation. None of the physical limitations are attributable to these conditions and none of them interfered with satisfactory performance of required duties. The right ankle condition was much less of a problem than the left. The CI had right ankle surgery in 1998 and seemed to do well.  He did have trouble when the left ankle was painful and he put more weight onto his right ankle. However, it appears he did not have significant difficulties performing his required duties until he had increased problems with his left ankle. Therefore, the right ankle was not unfitting.  

The other diagnoses rated by the VA (Cervical Degenerative Joint Disease; Left Knee ACL and Iliotibial Band Strain; Right Knee Strain; Tension Headaches; and Right Lateral Femoral Cutaneous Paresthesia/Dysesthesia) were not mentioned in the Disability Evaluation System package and are therefore outside the scope of the Board.  The CI retains the right to request his service Board of Correction for Military Records (BCMR) to consider adding these conditions as unfitting.
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RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation.

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Left Ankle Pain due to Chronic Tendonitis (Peroneus Brevis) and Post-Surgical Changes	5271	10%	
Left Sural Neuralgia 	8599-8523	10% 	
COMBINED	20% 	
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The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 27 MAR 2009, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans' Affairs Treatment Record.

                              

SAF/MRB
1535 Command Drive, Suite E-302
Andrews AFB, MD  20762-7002

	Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2009-00281.

	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 Administration 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.  The office responsible for making the correction will inform you when your records have been changed.

							Sincerely

 

Attachments:
1.  Directive
2.  Record of Proceedings

cc:
SAF/MRBR

PDBR PD-2009-00281

MEMORANDUM FOR THE CHIEF OF STAFF

	Having received and considered the recommendation of the Physical Disability Board of Review and under the authority of Section 1554, Title 10, United States Code (122 Stat. 466) it is directed that:

	The pertinent military records of the Department of the Air Force relating XXXXX be corrected to show that the diagnoses in his finding of unfitness were Chronic Left Ankle Pain due to Chronic Tendonitis (peroneus Brevis) and Post-Surgical Changes, VASRD code 5271, rated at 10%; and, Left Sural Neuralgia, VASRD code 8599-8523, rated at 10% with a combined rating of 20%.