RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX					                          CASE:  PD-2013-01508
BRANCH OF SERVICE:  AIR FORCE  	SEPARATION DATE:  20040830

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Security Forces Craftsman) medically separated for a right ankle condition.  The right ankle condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty (AFS) or satisfy physical fitness standards.  He was issued an L4 profile and referred for a Medical Evaluation Board (MEB).  “Chronic right ankle pain” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  The MEB also identified and forwarded bilateral shoulder impingement for PEB adjudication.  The Informal PEB adjudicated “chronic right ankle pain” as unfitting, rated 10% citing application of DOD and Veterans Affairs Schedule for Rating Disabilities (VASRD) guidelines.  The bilateral shoulder impingement was determined to be a Category II condition (conditions that can be unfitting but are not currently compensable or ratable).  The CI appealed to the Formal PEB (FPEB), which affirmed the PEB findings and recommendations.  

CI CONTENTION:  His conditions continue to worsen and negatively impact his daily activities.  His complete submission is at Exhibit A.

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’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/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation.  The Board 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, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:  

SAFPC – Dated 20040712	VA* - C&P Exam Not Available	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Ankle Pain	5271	10%	Right Ankle Impingement	5271	20%	Not Available	
Bilateral Shoulder Impingement	CAT II	Rotator Cuff Tendonitis, Right Shoulder	5024	0%	Not Available	
		Rotator Cuff Tendonitis, Left Shoulder	5024	0%	Not Available	
Other x 0 (Not In Scope)	Other x 14 	
RATING:  10%	COMBINED RATING:  50%	
*Derived from VA Rating Decision (VARD) dated 20040907 (most proximate to date of separation (DOS)).  
ANALYSIS SUMMARY:  

Right Ankle Condition.  The service treatment record (STR) documents that the CI sustained a right ankle injury while playing football in June 1999.  A podiatry exam revealed severe tenderness along the right tarsal tunnel (canal formed between ankle bone [medial malleolus] and ligaments across foot [flexor retinaculum]) region.  There were no Valleix's points (areas along nerves where pressure causes pain) or Tinel's sign (percussing nerve elicits tingling over distribution of the nerve) with percussion of this area.  The assessments listed tibialis tendonitis (acute tendon inflammation or irritation) and tarsal tunnel syndrome ([TTS] compression neuropathy where tibial nerve is compressed in the tarsal tunnel).  The orthopedic surgery MEB addendum recounted the history and interventions to date.  The right ankle arthroscopy had relieved the lateral pain, but the CI had persistent medial pain.  Subsequent corticosteroid (cortisone) injections did not relieve the pain.  The CI wore orthotics and complained of both pain and instability.  Pain was exacerbated by prolonged standing, jogging, and distance walking.  The physical exam revealed the CI walked with a mild limp and was able to toe raise and heel walk on the right.  The right ankle exam showed a well-healed surgical scar with tenderness over the medial joint line and above the medial malleolus.  Bilateral ankle anterior drawer (assesses anterior talofibular ligament) and ankle valgus/varus stress (assesses medial/lateral ligaments) tests were symmetric.  Range-of-motion (ROM) was dosiflexion of 5 (normal 0-20) and plantar flexion of 30 (0-45) degrees.  The surgeon reported the right ankle MRI showed no osteochondritis dissecans ([OCD] cracks in articular cartilage from blood deprivation to underlying subchondral bone) and the bone scan was negative.  The surgeon documented the CI had “… likely had maximal medical improvement ….”  

The narrative summary (NARSUM) recounted the history and interventions to date, and cited the orthopedic surgery MEB addendum.  The physical exam of the extremities documented “No clubbing [pathological bulbous enlargement of finger/toe ends], cyanosis [bluish discoloration due to insufficient oxygen], edema [swelling from excess tissue fluid], and joints are within normal limits.”  The diagnosis listed chronic right ankle pain.  The findings from the compensation and pension (C&P) exams were transcribed from the VA rating decision (VARD) as they were not in evidence.  The exams documented a synovectomy (surgical removal of part of the synovial membrane) in March of 2000.  The CI complained of intermittent sharp, pinching, pain with movement of the ankle.  He stated the ankle felt loose, tended to roll outward daily, and swelled about two to three times per week.  The ankle exam documented “… a diffuse tenderness present on the medial aspect and on the inferior malleolar area on the lateral aspect.”  There was no effusion (fluid collection) or redness.  The ankle was stable when stressed in an anterior/posterior, eversion, and inversion manner.  The ROM was recorded as dorsiflexion of 6 (0-20) and plantar flexion of 60 (0-45) degrees.  There was no pain evident with ROM, and there were no additional limitations to ROM after repetitive motion.  An X-ray showed the alignment was notable for pes cavus (claw foot). 

The Board directed its attention to its rating recommendation based on the above evidence.  The formal PEB rated the right ankle condition 10% (VA code 5271; ankle, limited motion of:  moderate).  The PEB cited chronic right ankle pain and instability.  The VA rating decision (VARD), citing the VA C&P exams 1-2 months before separation, rated the right ankle condition 20% (5271; ankle, limited motion of:  marked).  The VARD cited limitation of dorsiflexion, ligament injuries by MRI, pes cavus by X-ray, status post synovectomy, pain, swelling, diffuse tenderness, and no instability with stress testing.  Board members agreed that there was sufficient evidence of pain with use prior to separation, as well objective exam and imaging findings, to support a 10% rating considering functional loss and painful motion (§4.40, §4.59).  Board members agreed that the ankle limitations in motion (5271) in the proximate exams more closely approximated the moderate (10%) than the marked (20%) rating.  The marked (20%) rating is the highest evaluation the law allows for this disability.  There was no deformity for consideration under 5270 (ankle, ankylosis), 5272 (subastragalar or tarsal joint, ankylosis of), or 5273 (os calcis or astragalus, malunion of).  There was no excision of the astragalus for consideration under 5274 (astragalectomy).  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the right ankle condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that bilateral shoulder condition was not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

Contended Bilateral Shoulder Condition (Category II).  The STR contained scant information regarding shoulder complaints prior to separation.  While the STR contained an operative report for right shoulder arthroscopy, it occurred 19 months after separation.  The Board directed attention to its recommendation based on the above evidence.  Air Force Category II conditions can be unfitting, but are not compensable or ratable.  While the shoulder condition was implicated in the commander’s statement “ongoing ankle and shoulder problems,” and MEB, it was not profiled.  It was considered not unfitting, and therefore not ratable, by the PEB.  There was no performance based evidence from the record that the bilateral shoulder condition significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the bilateral shoulder condition and so no additional disability rating is recommended.

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 right ankle condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended bilateral shoulder condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  

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

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130918, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2013-01508.

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.

Attachment:
Record of Proceedings