RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXX	CASE:  PD-2013-01458
BRANCH OF SERVICE:  Army	BOARD DATE:  20140429
SEPARATION DATE:  20041010

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (71L/Administration) medically separated for a chronic left foot and ankle pain condition.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was issued a permanent P3L3 profile and referred for a Medical Evaluation Board (MEB).  The left foot and ankle condition, characterized as “chronic left ankle and foot pain, status post multiple surgeries and subtalar arthrodesis, left ankle loss of motion, secondary to post-traumatic changes and surgery, left ankle and foot dysesthesia, secondary to cutaneous nerve injuries from multiple surgeries,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The PEB adjudicated all three conditions, described as: “chronic left foot pain and ankle pain/dysesthesia, status post multiple surgical procedures,” finding this condition unfit, rated 20% combined.  The CI made no appeals and was medically separated.

CI CONTENTION:  “I. Fracture left heel w/residual plantar fasciitis. 2. Right hip bursitis 3. De-generative joint disease 4. Gastrointestinal reflux disease 5. Right ankle sprain 6. Lumbosacral Strain 7. Plantar fasciitis right foot w/Hx of right Achilles tendon bursitis 8. Allergic rhinitis w/Hx of sinusitis 9. Depression/ Anxiety (Denied).”

SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting left foot and ankle conditions are addressed below and, no additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20040629	VA - (5 days Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Foot Pain and Ankle Pain	5271	20%	Fracture L/Heel w/Residual Plantar…Entrapment Release	5271-5284	30%	20031005	
No Additional MEB/PEB Entries	Other x 8	20041005	
Combined:  20%	Combined:  60%	
Derived from VA Rating Decision (VARD) dated 20041119 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Left Foot and Ankle Condition.  According to the service treatment records and MEB narrative summaries (NARSUM), the CI sustained an open comminuted (multiple fragments) depressed fracture of the left calcaneus (heel bone) in November 1998 after falling from a third floor barracks window.  Surgery was performed and with post-operative physical therapy she returned to duty.  In early 2000, she re-injured her left foot when she stepped into a hole in the ground while mowing the lawn.  Examination revealed well healed scars through the medial aspect of the foot and posterior foot.  Range-of-motion (ROM) was generally within normal limits.  Treatment was conservative.  X-ray of the left foot on 7 July 2000 showed a markedly deformed calcaneus (heel bone) with no definite acute fracture.  In March 2001, she sustained an injury to her left foot when she stuck her left foot out to avert a fall off a bike.  Pain persisted in spite of medication.  X-ray of the left foot on 26 April 2001 showed status post-traumatic changes with marked deformity of the calcaneus.  Imaging with computerized axial tomography and magnetic resonance imaging in August 2001 demonstrated calcaneal deformity consistent with a remote fracture with malunion of the calcaneus, subtalar ankle joint degenerative arthritis and lateral impingement (pinching of soft tissues).  Orthopedic surgery was performed on 3 October 2001 on her left foot and consisted of a subtalar fusion, peroneal tendon reconstruction, neurolysis (freeing a nerve from adhesions) and a tarsal tunnel calcaneal exostectomy (removal of a piece of the heel bone).  Further surgery on 9 November 2001 consisted of lengthening of the left Achilles tendon.  She was treated with physical therapy and pain medications with some mild improvement but there was still pain with walking.  At the time of an orthopedic follow-up appointment on 14 January 2003, the orthopedic surgeon recorded “Over the last year, she has continued to improve considerably, and at this point seems to walk reasonably well without too much pain.”  He noted that she developed significant pain with prolonged standing and walking and advised a sedentary job.  At that time running, walking with a pack or performing anything other than office work was not advised.  He opined that she might improve over the following 6 months to a year to the point where she might be able to perform more strenuous physical activity.  A permanent profile L3 was issued on 20 May 2003 advising restrictions including no deployment, no standing more than 2 hours a day, no walking more than 15 minutes without at least a 10 minute rest break and a work week limited to 5 days.  The 10 September 2003 NARSUM indicated persistent chronic left foot pain with limited activities, no excessive walking, no running, limited carrying and no PT test.  Atrophy of the left foot was noted with intact sensation.  ROM was stated to be “generally within normal limits.”  The physical profile of 17 February 2004 listed the same activity limitations as the prior profile of 20 May 2003.  The commander’s statement dated 12 April 2004 reported the CI was working in her MOS, but was limited to 40 hours per week by her profile, while her co-workers worked 50 hours per week.  Lifting was limited to 10 pounds per the profile and she could not work to the same level of intensity as her peers or deploy.  The CI had not missed work since returning from post-surgery convalescent leave.  At the time of the MEB NARSUM examination on 13 May 2004, the CI reported continued ankle pain that had improved with good footwear and supportive orthotics.  She had difficulty wearing boots or shoes with a tight heel which irritated the nerve.  She was unable to run, wear combat boots or carry a rucksack.  On examination, there were multiple surgical scars about the ankle that were well healed.  There was “some mild” tenderness about the ankle tendons and sensitivity to tapping over the nerves, but sensation was intact.  There was marked atrophy (decreased mass) of calf muscles attributed to the surgery and decreased use.  Her ankle motion was 0 degrees of dorsiflexion, 20 degrees of plantar flexion.  Her gait was mildly antalgic.  At the MEB history and physical examination on 22 June 2004, the CI reported pain with weight bearing.  The MEB exam (DD Form 2808) noted decreased ROM of the left ankle and she was “unable to plantar flex.”  At the VA Compensation and Pension (C&P) examination performed on 5 October 2004, 5 days prior to separation, the CI reported “…continued pain with standing and fast pace walking or running;” pain and swelling with standing and walking and worse with weather change.  She reported she was very sensitive to touch where the surgical scar was and under the ankle bones.  There was occasional pain over the left Achilles tendon surgical site.  Closed shoes aggravated the symptoms.  Some of the symptoms were improved with rest elevation and constant moist heat.  On examination, of the left lower extremity, there was atrophy (loss of muscle mass) of the left calf and foot along with mild (“1+”) swelling around the entire ankle.  Surgical scars were well healed but very tender to palpation and there was tenderness about the heel and Achilles tendon.  Ankle ROM was dorsiflexion to 2 degrees (normal 20 degrees) and plantar flexion of 10 degrees (normal 45 degrees) limited by pain.  Inversion and eversion were 0 degrees (due to subtalar joint fusion).  There was pain reported with motion and pain with walking.  The examiner indicated there was incoordination and fatigability with flexion and extension.  Three weeks later at a follow-up appointment with her treating orthopedic surgeon on 26 October 2004, the surgeon recorded that she was doing well when she walks.  However, there was pain at a surgical scar that had contracted along the nerves and there was pain from one of the screws.  He advised surgery to release the scar and decompress the nerves and remove the hardware which was performed on 9 December 2004, 2 months after separation.  Post-operative orthopedic follow-up on 21 December 2004 indicated there was improvement in pain.  The CI improved sufficiently that she applied for a job as a mail handler a year later.  At the employment medical examination in February 2006, she reported occasional left foot and ankle discomfort, that she was “able to walk up to a mile with no significant pain or discomfort,” used no walking assistive device or special shoes and reported “no numbness or tingling in her left foot or ankle.”  On examination her gait was normal (including heel and toe walk).  However, the examiner noted the residuals of the ankle injury and advised that the CI would not be able to tolerate the prolonged walking and standing (8 or more hours a day) required of a mail hander.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the condition 20% based on code 5271 (ankle, limited motion of; marked) and the VA rated the condition 30% based on code 5284 (foot Injuries, other; severe).  The Board noted the complexity of the case and considered a rating that encompassed the involvement of the foot and ankle including the limited ROM and tendon and nerve involvement.  Therefore, the code 5271-5284 used by the VA included not only the very limited ROM, but also addressed the overall severity of the foot and ankle injuries.  The VASRD diagnostic code 5284 (foot injuries, other) provides for ratings of 10% for moderate, 20% for moderately severe and 30% severe impairment.  Actual loss of use of the foot is rated 40%.  Separate ratings for the different aspects of the foot and ankle condition could not be determined since such ratings would be based on the same functional impairment and is prohibited by VASRD §4.14 (avoidance of pyramiding).  The Board discussed whether the left foot and ankle condition impairment more nearly approximated the moderately severe (20%) versus the severe (30%) impairment under the diagnostic code for other foot injuries (5284) used by the VA.  The Board noted the fact that the subtalar joint was fused and the tibiotalar joint was limited in movement resulting in an antalgic gait.  The CI was limited to comfortable foot wear and could not wear boots or tight shoes.  While she was limited in prolonged walking and standing, she was however able to continue to work (normal civilian occupation) fulltime (40 hours) in her MOS except for more strenuous activities.  The Board also noted the VA C&P examination at separation reflected some worsening of reported symptoms, however the orthopedic appointment 2 weeks later stated she was doing well when she walked.  Following the December 2004 surgery to remove screws and release a scar she improved in the ensuing months walking up to a mile without significant discomfort.  She was nevertheless not considered medically suited for employment requiring prolonged walking or standing.  The Board discussed the severity of the initial injury and the requirement for multiple surgeries but noted that the rating is based on residual impairment.  The Board majority concluded that the examination findings, physical limitations reflected in the profile, the commander’s statement that she was able to work a full day and the orthopedic surgery note indicating she was doing well when she walked more nearly approximated the 20% rating, moderately severe under 5284.  The examination over a year later was of limited probative weight but did reflect stability of the condition.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) and §4.7 (higher of two ratings), the Board majority concluded that there was insufficient cause to recommend a change in the PEB 20% adjudication for the left foot and ankle condition.

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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the left foot/ankle pain condition and IAW VASRD §4.71a, the Board by a vote of 2:1 recommends no change in the PEB adjudication.  The single voter for dissent submitted the appended minority opinion.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130917, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				
Minority Opinion.  The minority voter concluded the overall disability picture more nearly approximated the 30% rating under VASRD diagnostic code 5284, other foot injuries based on the complexity and severity of the injuries, extensive surgeries, and the residual functional impairments which included fusion of the subtalar joint, decreased tibiotalar motion, tendon involvement, nerve sensitivity and decreased muscle mass.  While the rating of 20% addresses the limitation of the ROM, it does not take into account the interrelationship of the foot and ankle, the end result of which is an antalgic gait and limited capacity to walk or stand for extended periods of time or to carry heavy objects.  Although the commander’s statement indicated her ability to work a full day, there were still limitations preventing normal in-Garrison work related activity including difficulty wearing shoes with a tight heel and prolonged standing.  While an orthopedic examination in February 2006, some 16 months after discharge, found her foot and ankle status improved, nevertheless “she did have significant muscle atrophy of her left calf” that “would be expected to be a source of problems and difficulties in the future especially with prolonged periods of time on her feet and with bending, stooping, squatting, and carrying” and “her left foot injury appears to place her at risk of injury and symptomatology. . .”.  The minority voter after considering the evidence and VASRD §4.3 (reasonable doubt), recommends a 30% rating for the ankle and foot pain condition coded 5284.

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXX, AR20140019186 (PD201301458)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						 
CF: 
(  ) DoD PDBR
(  ) DVA