RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  xxxxxxxxxxxxxxxxx	CASE:  PD-2013-01640
BRANCH OF SERVICE:  Army	BOARD DATE:  20150408
SEPARATION DATE:  20050413

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Automated Logistical Specialist) medically separated for a left ankle and right foot conditions.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic left ankle pain” and “right foot pain with bunion” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “chronic pain, left ankle” and “bunion, right foot” as unfitting, rated 0% and ---% (existed prior to service [EPTS]) respectively, citing the US Army Physical Disability Agency (USAPDA) pain policy for rating the left ankle condition.  The CI made no appeals and was medically separated.

CI CONTENTION:  “As of Aug 26, 2008 Fibromyalgia, as result of multiple joint pain.  My left & right shoulder pain has gotten worse, Also left & right knees.  Right wrist-cyst.”

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 Veterans Affairs Schedule for Rating Disabilities (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:

IPEB – Dated 20050223	VA* - (~7 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Left Ankle	5099-5003	0%	Left Ankle Strain	5299-5284	20%	20051110
+20050610records	
Bunion, Right Foot	5280	---%	Hallux Valgus, Right Great Toe	5280	0%	20051110	
Other x 0 (Not In Scope)	Other x 12	
RATING:  0%	RATING:  60%	
*Derived from VA Rating Decision (VARD) dated 20060501 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:

Chronic Pain, Left Ankle Condition.  The narrative summary (NARSUM) and treatment records noted onset of left ankle pain in April 2003 after a long road march.  Initial treatment was with medication, physical therapy (PT) and activity restriction with a later diagnosis of pes planus (flat feet) and arch supports in September 2003 [Note:  The CI’s entry physical dated July 2002 had documented feet with normal arch and asymptomatic].  Bone scan was normal.  Left ankle pain worsened with increased activity and foot X-rays in July 2004 documented multiple abnormalities [including both sides of the left ankle (old cyst and/or thinned bone), abnormal joint space, early 1st metacarpophalangeal joints (MP) (great toe) narrowing R>L with early bunion deformities.  A September 2004 follow-up magnetic resonance imaging in September 2004 was normal.  Evaluation for rheumatoid arthritis was negative and a follow-up bone scan in November 2005 documented a bunionette of the little toe area (5th metatarsal).

At the MEB NARSUM exam, dated 1 November 2004, approximately 5 months prior to separation, the CI reported sharp left ankle pain 25% to 50% of the day with no recent swelling while not wearing military boots.  She used an ankle brace as needed.  Pain was worse with wearing boots, impact activities, walking, or lifting.  The NARSUM physical exam noted a slightly antalgic gait with pain limited range-of-motion (ROM) as charted below.  There was ankle tenderness with no instability, edema, weakness or neurovascular abnormalities.  Two additional PT notes following the NARSUM documented pain limited motion and are summarized below.

At the VA Compensation and Pension (C&P) exam dated 10 November 2005, performed approximately 7 month after separation, the CI reported pain in the Achilles tendon and ankle three to four times a week, increased with prolonged standing.  She used anti-inflammatory medication, wore a brace, and restricted her activities.  She denied having any flares.  On exam, the CI had a normal gait and the ankle exam stated “(The CI) has some point tenderness along her medial malleolus and Achilles tendon.  Patient has dorsiflexion from 0 to 40 degrees in both ankles and 0-10 degrees of plantar flexion.  No pain noticed.”

The goniometric and other ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Left Ankle ROM
(Degrees)	NARSUM
~5 Mo. Pre-Sep	PT
~5 Mo. Pre-Sep	PT
~3 Mo. Pre-Sep	VA C&P
~7 Mo Post-Sep	
Dorsiflexion (20 Normal)	15	“FAROM except neutral DF”	15	40	
Plantar Flexion (45)	40		40	10	
Comment	Pain; antalgic gait; tender	Antalgic gait; TTP; discomfort w/motion	Painful motion, TTP, no toe walk	No pain (Error? DF/PF swap)	
§4.71a Rating	10%	10-20%	10%	10%-20%	

The Board directed its attention to its rating recommendation based on the above evidence.  All service exams documented painful motion meeting the 10% rating requirement IAW VASRD §4.50 (painful motion).  The ROMs from the after separation VA exam were not consistent with multiple service record exams or the CI’s ankle pathology and were likely a transposition error of dorsiflexion and plantar flexion measurements.  The Board adjudged that the PT exam 3 months prior to separation had the highest probative value for rating at separation and supported a 10% rating for painful motion.  There was insufficient evidence of “marked” ankle limitation of motion to warrant a higher rating under code 5271 (ankle, limited motion).

The Board next considered a 20% (moderately severe) rating under code 5284 (foot injuries, other) with inclusion of all left ankle and foot pathology.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 10% for the left ankle condition.

Bunion (Hallux Valgus), Right Foot Condition.  The records noted normal feet on the CI’s entry exam (see above) and right foot pain had onset during treatment of the unfitting ankle condition discussed above.  The CI had complaints of chronic right toe pain with July 2004 X-ray evidence of “soft tissue swelling regional to each first metatarsophalangeal (1st MP joint) joint with narrowing of each joint greater on the right than on the left with early bunion deformities.”  Treatment notes documented painful motion of the great toe (1st MP joint) with prominence of the 1st MP joint with hammertoes of 2nd digit of the right foot.

At the MEB NARSUM exam, approximately 5 months prior to separation, the CI reported recurrent foot which was worse with wearing boots, impact activities, walking, or lifting.  The MEB physical exam noted a slightly antalgic gait with some apparent equal bilateral rear foot inversion clinically.  There was a dorsal medial prominence of the 1st MP joint of both feet and a hammer toe of the 2nd toe of the right foot.  There was painful ROM of the toes of both feet with tenderness to palpation over the right 1st MP joint.

At the VA C&P exam performed approximately 7 month after separation, the CI reported pain in the Achilles tendon and ankle three to four times a week, increased with prolonged standing.  She used anti-inflammatory medication, wore a brace, and restricted her activities.  She denied having any flares.  On exam, the CI had a normal gait and had normal arches.  There were “small bunions on both feet, but these are non-inflamed, nontender.  Patient does have some point tenderness along the insertion of the left plantar fascia.”  X-rays noted mild hallux valgus deformity of the right foot.  The examiner diagnosed bilateral bunions and stated “The (CI) is asymptomatic on exam today.”

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB found the condition unfitting, but as EPTS without permanent service aggravation and therefore non-compensable (---%).  However, the record of evidence documented normal foot exams without any foot symptoms at entry.  The record with imaging studies and timeline also clearly documented increasing right foot symptoms and development of clearer (more advanced) 1st MPJ bunion.

The Board adjudged that there was sufficient evidence that the CI’s bunion condition was permanently aggravated by service and therefore compensable.  The record documented slight symptoms from the right foot condition.  There was insufficient evidence of severe 1st MP joint symptoms, equivalent to amputation of the great toe, to warrant a 10% rating under code 5280 (hallux valgus) and a 0% rating coded 5280 is recommended IAW VASRD §4.31 (a no-percent rating).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 0% for the right foot 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.  As discussed above, PEB reliance on the USAPDA pain policy for rating the left ankle condition was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the left ankle condition, the Board by a majority vote recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the right foot condition, the Board unanimously recommends a disability rating of 0%, coded 5280 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

CONDITION	VASRD CODE	RATING	
Chronic Pain, Left Ankle	5099-5003	10%	
Bunion, Right Foot	5280	0%	
COMBINED (W/BLF)	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20120924, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	

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 xxxxxxxxxxxxxxx, AR20150011083 (PD201301640)

1.  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 to modify the individual’s disability rating to 10% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     

CF: 
(  ) DoD PDBR
(  ) DVA