RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2013-01692
BRANCH OF SERVICE:  NAVY	BOARD DATE:  20150306
SEPARATION DATE:  20040725

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Interior Communications) medically separated for left Achilles tendonitis and left knee pain.  The conditions could not be adequately rehabilitated to meet the physical requirements of his Rating or satisfy physical fitness standards.  He was placed on limited duty (LIMDU) and referred for a Medical Evaluation Board (MEB).  The “early degenerative chg lt knee” and “left patellofemoral pain syndrome” were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The MEB also identified and forwarded four other conditions (in the chart below) for PEB adjudication.  The Informal PEB adjudicated “left Achilles tendonitis, peroneus brevis tendonitis” and “early degenerative changes as well as patellofemoral pain syndrome left knee status post knee scope in 1995” as unfitting, rated 10% and 10% respectively, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be Category III (not separately unfitting and do not contribute to the unfitting condition).  The CI made no appeals and was medically separated.

CI CONTENTION:  “The rating for discharge of 20%, 10% L achilles tendonitis and L knee degenerative have progressively worsened.  The following right wrist DeQuervains, migraines, asthma, sinunitis [sic] were not recognized by the PEB.  However, the VA rated respectively to 10%, 30%, 10% and 10%.”  “Migraines were rated at 30% and have gotten worse since initial rating.  The ankle L has also gotten progressively supported by documentation.  Right great toe has undergone numerous procedures after discharge.  This also has gotten a rating by the VA.  My physical ability has gotten worse beyond the PEB results, that ignored the signs in my medical records.”

The CI also attached a one page statement to his application which was reviewed by the Board and considered in its recommendations.

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:

IPEB – Dated 20040408	VA* - based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Achilles Tendonitis, Peroneus Brevis Tendonitis	5024-5003	10%	Left Achilles Tendonitis	5271	NSC	STR	
Early Degenerative Changes as well as Patellofemoral Pain Syndrome Left  Knee Status Post Knee Scope in 1995	5299-5003	10%	Left Knee Meniscus Tear, Status Post Repair	5257	0%	STR	
Right Great Toe Chronic Ingrown Toenail, Status
Post Excision And Nail Bed Ablation  	Cat III	Ingrown Right Great Toenail, Recurrent	7899-7806	0%	STR	
Recalcitrant Right Hand Pain and Numbness
Consistent with Early Carpal Tunnel Syndrome and First CMC Degenerative Joint Disease Status Post Right Hand Dequervain's Release in 2000.	Cat III	Residuals, Right Wrist Dequervain's Tenosynovitis,
Status Post Release Surgery	5215	0%	STR	
Other x 0 (Not In Scope)	Other x 4	
RATING:  20%	RATING:  0%	
*Derived from VA Rating Decision (VARD) dated 20050124 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Left Ankle Condition.  The January 2004 narrative summary (NARSUM) notes the CI injured his left ankle 2 years earlier playing basketball and reported it had never improved.  Left foot X-rays on 15 May 2003 were normal.  The CI was evaluated by podiatry for bilateral foot pain on 8 August 2003.  He was diagnosed with bilateral plantar fasciitis and orthotics were ordered.  Magnetic resonance imaging (MRI) performed on 11 December 2003 showed tendinitis of the Achilles tendon and a tendon that passes behind the lateral malleolus (peroneus brevis), without other abnormalities.  Physical therapy (PT) evaluation on 16 December 2003 noted an antalgic gait and tenderness to palpation of the Achilles tendon.  Foot therapy was interrupted by right toe surgery, discussed further below.  At the next PT visit on 3 February 2004, the reported symptoms and findings remained the same, but at a follow-up on 10 March 2004 the CI reported improvement in his foot pain following two physical therapy treatments.  A note in the STR dated 3 December 2003 indicated that the last physical readiness test (PRT) was in 2000 due to “knees and Achilles.” and another dated 30 December 2003 noted “LIMDU [limited duty] ankle no running no --- [illegible word]” and “wrist no push-ups.”  According to the NARSUM the CI had been “unable to complete a PRT in a long period of time” due to “chronic and ongoing pain”.

At the MEB examination on 20 January 2004, 6 months prior to separation, the CI reported left ankle swelling and pain.  The MEB physical exam noted posterior ankle swelling and tenderness to palpation (TTP) of the Achilles tendon and the calf muscle, with normal pulses and sensation.  The CI had difficulty standing on his toes, but there was no evidence of an Achilles tendon tear (negative Thompson’s).  The MEB examiner noted that the CI was in a CAM (controlled ankle motion) walker for the ankle at the exam and was still in therapy.

The CI did not attend a scheduled VA Compensation and Pension (C&P) examination on 22 November 2004.  The earliest VA C&P examination in record which addressed the left foot condition was 6 April 2006, 20 months after separation.  At the exam the CI reported that he was not being treated for the left foot and used over the counter medications as needed.  He reported current symptoms of tightness in the morning, discomfort all the time that was “not excruciating” but was worse than “annoying”, without instability.  The ankle did not incapacitate him and he did not use any assistive devices for ambulation.  The exam noted a second left ankle MRI performed on 22 March 2005 was unchanged from 2003.  The CI reported that he had a podiatry evaluation in 2005 and there was no plan for further treatment based on the MRI results.  The exam noted a normal gait and TTP over the Achilles tendon without swelling or bony tenderness.  Ankle range-of-motion (ROM) was dorsiflexion of 15 degrees (normal 20 degrees) and plantar flexion of 15 degrees (normal 45 degrees) with painful motion noted with repetition, but no additional loss of ROM.  Lower extremity strength, sensation, and reflexes were normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 10%, coded 5024-5003 (degenerative arthritis with tenosynovitis).  The CI did not attend the scheduled initial VA C&P examination and the left ankle condition was not service-connected by the original VARD.  The later VARD dated 6 June 2006 rated it 10%, coded 5299-5271 (analogous to limited ankle motion), effective the day after separation.  The rating criteria for codes 5024 or 5003 provide only a 10% rating for a single joint with limited ROM.  The rating criteria of 5271 are subjective with 10% for “moderate” and 20% for “marked” limited motion.  The Board noted that the CI was in a CAM walker at the MEB examination and still going to PT, but shortly after the MEB exam, the CI reported significant decreased ankle pain after a couple of PT treatments and at the remote C&P the CI had a normal gait.  Board consensus was that the evidence in record supports the disability due to the left ankle condition was best described as moderate and not marked.  The Board concluded that a 10% rating was achieved with either code for painful, limited ankle ROM, and there was no malunion, ankylosis or deformity of the joint, or impairment of the tibia or fibula in this case to provide a higher evaluation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left ankle condition.

Left Knee Condition.  The NARSUM notes that the CI had knee pain with locking and giving way and had arthroscopic surgery in 1995, which noted changes consistent with an old injury of the medial meniscus and no other abnormalities.  Notes in the STR indicated the CI continued to report knee pain after the surgery and in 1998 knee symptoms worsened following an acute injury and a repeat arthroscopy was planned.  There is no documentation in the record that a second surgery was performed and at the remote after separation VA C&P examination in 2006, the CI reported only one knee surgery in 1995.  According to the NARSUM the CI had recurrent effusions and had been unable to perform any PRT activity in a long time.  At treatment visits for left knee pain in September 2003 the CI reported a single episode of locking and both exams noted mild swelling and TTP.  As described above, notes in record from December 2003 indicated the CI was unable to meet physical fitness standards due to “knees and Achilles” and a LIMDU reference cited the ankle and the wrist.  According to the NARSUM the CI continued to have “recurrent effusion…as well as inability to perform any type of PRT activity.”

At the MEB examination on 20 January 2004, 6 months prior to separation, the CI reported left knee pain.  The exam noted a mild effusion with medial joint line tenderness without instability. ROM was extension-flexion of 0 degrees to 135 degrees (normal 0 degrees – 140 degrees) with pain at end ROM and the LLE was neurologically intact.

As noted above the CI did not attend the initial scheduled C&P examination and the earliest C&P examination in record which addressed the left knee condition was 6 April 2006, 20 months after separation.  At the exam the CI reported that he was not being treated for the left knee and used over the counter medications as needed.  He reported one episode of his knee “giving out” 4 months earlier.  He was moving furniture down stairs and his knee “subluxed” and he “had to wait several moments before he could continue.”  The examiner noted that otherwise, the CI denied instability or locking and reported the knee did not incapacitate him, or cause him to use a use a cane or a crutch.  The exam noted a normal gait and TTP of the medial joint line and patellar tendon without swelling, instability, or evidence of meniscal (semilunar cartilage) symptoms.  Knee ROM was 0 degrees to 130 degrees, without crepitus or painful motion.  Lower extremity strength, sensation, and reflexes were normal.  Knee X-rays showed no abnormality.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10%, coded 5299–5003 (analogous to degenerative arthritis).  The CI did not attend the scheduled initial VA C&P examination and the left knee condition was service-connected by the original VARD and rated 0%, coded 5257 (other knee impairment).  The later VARD on 6 June 2006 increased the rating to 10%, effective the day after separation.  The Board agreed that the left knee could be rated 10% with 5003 criteria for painful limited motion; with a ROM code IAW §4.59 (painful motion); or, analogous to code 5259 (semilunar cartilage removal, symptomatic).  Members deliberated whether the evidence in record supported a higher evaluation of 20% coded as 5258 (semilunar cartilage injury) “with frequent episodes of `locking’, pain, and effusion into the joint.”  The Board noted that there was only one treatment note for the knee in the STR 10 months prior to separation, at which the CI reported a single episode of locking, and the MEB exam noted a mild knee effusion, but the exam was non-specific.  At the C&P exam 20 months after separation the CI reported a single episode of locking 4 months earlier and exam was unremarkable except for TTP and mild decreased ROM.  The Board found this was insufficient support to recommend more than a 10% rating for active symptoms due to meniscal injury and there was no evidence of ankylosis, instability, or impairment of the tibia/fibula or femur to provide higher or additional disability rating of the knee condition.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left knee condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended right hand and right toe conditions were 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.

Right Hand Pain/Carpal Tunnel Syndrome Condition.  The NARSUM noted that the CI had surgery for tendinitis of the thumb in 2000 but reported only minimal improvement.  Notes in the STR indicated that following the surgery on 13 June 2000 the CI reported increased symptoms when he returned to work and a MEB placed him on a second period of LIMDU, followed by a fit for duty determination on 21 February 2001.  Following return to full duty there were no treatment visits in record until a note in the STR dated 3 December 2003 indicated that the CI could not do his job due to difficulty with gripping things such as wrenches and the exam noted swelling over the thumb joint, with minimally decreased wrist ROM.  A clinic visit on 30 December 2003 for wrist problems noted “+swelling and “+pain is increasing” and the examiner notated “LIMDU ankle no running no [illegible word]” and “wrist no pushups.”  According to the NARSUM recent electrodiagnostic (EMG) studies showed “very early carpal tunnel syndrome.”  At the MEB examination 6 months prior to separation the CI reported periods of difficulty holding things due to thumb and hand pain.  The MEB examination, noted the CI was right hand dominant and had mildly decreased grip strength on the right compared with to left (Graded 4+/5).  The exam noted “minimally positive” clinical testing for carpal tunnel syndrome and noted no vascular or neurological abnormalities.  The NARSUM examiner noted that the CI was limited “at the performance of his job as far as lifting or walking.”  The non–medical assessment (NMA) indicated that due to the CI’s conditions including the “legs and right wrist” it was unlikely he could continue in the military.

The Board noted that the NMA mentioned the wrist and notes in the STR indicated LIMDU limitations due to the wrist of “no push-ups.”  However, the Board majority considered that there was no performance based evidence from the record that the right hand pain significantly interfered with satisfactory duty performance.  There are no reported duty related difficulties or treatment visits for the right hand condition in record following the CI’s return to full duty in 2001 until just prior to the MEB examination.  The noted EMG findings of “very early” carpal tunnel syndrome may have been contributing to the CI’s reported increased right hand pain, but there was no evidence of any treatment recommendation.  The Board consensus was that there was insufficient evidence of permanent disability in record due to the chronic thumb condition or the newly identified early CTS to overcome the PEB’s not unfit determination for the hand condition.  After due deliberation in consideration of the preponderance of the evidence, the Board majority concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the right hand condition and so no additional disability rating is recommended.

Right Great Toe Condition.  The NARSUM noted the CI had multiple procedures to his right great toe.  Notes in the STR indicated the toenail was infected with a fungus (onychomycosis) which led to recurrent ingrown toenail with repeated resection of the nail, which would grow back.  The CI had the toenail completely removed in 2001 and a podiatry referral in 2003 indicated that the toe was again painful and was last surgically treated 2 years earlier.  The podiatry evaluation on 8 August 2003 noted the nail had been surgically removed as many as 10 times.  The CI had chemical ablation of the nail on 16 January 2004.  The MEB examination on 20 January 2004, 6 months prior to separation, noted the right great toe was wrapped because of the recent procedure.  As described above, notes in the STR in December 2003 indicated the CI was unable to meet physical fitness standards due to the knee and ankle condition and referenced limitations due to the ankle and the wrist.  The NMA indicated that due to the CI’s conditions including the “legs and right wrist” it was unlikely he could continue to remain in the military.

The Board considered that the NMA mentioned the “legs,” but noted the CI had problems of the knees and ankle and therefore the comment did not necessarily refer to the toe condition and LIMDU notations did not list the toe condition.  The evidence in record supports that the right toe condition was quiescent following the complete nail removal in 2001 until July 2003 and it was reasonably anticipated that the CI would again obtain relief with the most recent nail ablation.  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 contended right toe 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 left ankle condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended right wrist condition, the Board by a majority recommends no change from the PEB determination as not unfitting.  In the matter of the contended right toe condition, the Board unanimously recommends no change from the PEB determination as not unfitting.

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 20130920, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS
Subj:	PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATION 
Ref:	(a) DoDI 6040.44
(b) CORB ltr dtd 25 Jun 15

In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual's records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy' s Physical Evaluation Board:

-	XXXXXXXXXXXXXXXXXXXX, former USN
-	XXXXXXXXXXXXXXXXXXXX, former USN
-	XXXXXXXXXXXXXXXXXXXX , former USN
-	XXXXXXXXXXXXXXXXXXXX, former USN
-	XXXXXXXXXXXXXXXXXXXX, former USMC
-	XXXXXXXXXXXXXXXXXXXX, former USN
-	XXXXXXXXXXXXXXXXXXXX, former USN
-	XXXXXXXXXXXXXXXXXXXX, former USN
-	XXXXXXXXXXXXXXXXXXXX, former USMC
-	XXXXXXXXXXXXXXXXXXXX, former USN
-	XXXXXXXXXXXXXXXXXXXX, former USMC
-	XXXXXXXXXXXXXXXXXXXX, former USMC
-	XXXXXXXXXXXXXXXXXXXX, former USN