RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-01998
BRANCH OF SERVICE:  Army	BOARD DATE:  20140801
SEPARATION DATE:  20050527

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Army Reserve SPC/E-4 (91H/Optical Laboratory Specialist) medically separated for chronic left ankle pain and right posterior tibial tendonitis.  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 L3 profile and referred for a Medical Evaluation Board (MEB).  The MEB determined that the left posterior tibial dysfunction and right posterior tibial dysfunction conditions were medically unacceptable.  The CI requested correction of the terminology and the new diagnosis of bilateral adult flat-foot deformity, acquired, secondary to posterior tibial tendon dysfunction was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two other conditions.  The Informal PEB adjudicated “chronic bilateral ankle pain” as unfitting, rated the combined condition at 10%, and cited criteria of the US Army Physical Disability Agency (USAPDA) pain policy.  The remaining conditions were determined to be not unfitting.  The CI appealed to the Formal PEB (FPEB) which separated the ankles into two unfitting conditions and rated chronic left ankle pain and right posterior tibial tendonitis at 10% each for a combined rating of 20%, again IAW USAPDA pain policy.  The CI made no further appeals and was medically separated.

CI CONTENTION:  “Severity of symptoms and effects on daily function.  Required to use ankle braces for support.  Physical therapy was required.  Pain medication required.”

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 ratings for the unfitting chronic left ankle pain and right posterior tibial tendonitis conditions are addressed below; 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 FPEB – Dated 20050406	VA – (2 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Ankle Pain 	5099-5003	10%	Posterior Tibial Tendon Dysfunction Bilaterally, Plantar Fasciitis Bilaterally*	5299-5276*	30%*	20050726	
Right Posterior Tibial Tendonitis	5024	10%					
Other x 2 (Not in Scope)	Other x 3 (Not in Scope)		
Combined: 20%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20060523 (most proximate to date of separation [DOS]).
*VARD dated 25 July 2008 rated Posterior Tibial Tendonitis, right ankle 10% using code 5271 effective 24 March 2008 and Posterior Tibial Tendonitis, left ankle 10% using code 5271 effective 24 March 2008 and retained a 30% rating using code 5299-5276 for bilateral pes planus and plantar fasciitis (previously evaluated as posterior tibial tendon dysfunction bilaterally, plantar fasciitis bilaterally) 
ANALYSIS SUMMARY:  The Board acknowledges the CI’s information regarding the significant impairment with which her service-connected condition continues to burden her; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.

Chronic Left Ankle Pain and Right Posterior Tibial Tendonitis Conditions.  The accession examination showed that the CI had asymptomatic, mild pes planus (flat feet) bilaterally.  The records indicate that the CI developed left foot pain while in the rehabilitation platoon on/about 11 October 2000.  Subsequently, she was found to have a stress fracture on 5 December 2000 per a line of duty investigation dated 28 March 2001.  An orthopedic evaluation determined that this was an accessory navicular bone (located on the inner side of the mid foot) rather than a stress fracture and on 7 May 2001, she underwent surgical excision of it.  Subsequently, she underwent a posterior tibial tendon reattachment to the navicular in November 2001.  Post-operatively she did well and was issued a “PT2 profile for running” per the narrative summary (NARSUM).  The service treatment record then falls silent until a 24 September 2004 line of duty report which noted the onset of bilateral posterior tibial tendinitis (inflammation of the tendon connecting some of the calf muscles to the inner aspect of the ankle) in March 2004.  The NARSUM subsequently noted that the CI complained of bilateral medial (inner) ankle pain in April 2004 while serving in Qatar exacerbated by lifting heavy boxes.  She was treated conservatively with duty limitations, medications and a CAM (controlled ankle movement) boot.  Post re-deployment she was treated with orthotics with near 100% improvement of the left side, but persistent pain on the right side required crutches.  X-rays were remarkable only for expected post-surgical changes on the left and an accessory navicular bone on the right.  Despite continued rehabilitation, she was unable to meet duty standards and entered into the MEB process.  The MEB NARSUM dated 9 December 2004, 6 months prior to separation, noted that the CI ambulated with crutches and had preserved arches of the feet when sitting and decreased upon standing.  She was “able to do a single-stance heel rise bilaterally, left greater than right,” albeit with significant pain and “had 5/5 dorsiflexion and plantar flexion strength” indicating adequate, but painful, posterior tibial tendon function.  She had a supple mid foot.  An X-ray showed “a suture anchor in the left navicular and accessory navicular of the foot.”  The NARSUM diagnosis was bilateral posterior tibial tendon dysfunction.  A permanent L3 profile was issued (following two temporary profiles) on 11 January 2005 that precluded the CI from physical fitness testing and allowed walking at her own pace with other exercise activities checked “no.”  At the MEB examination dated 4 January 2005, the CI reported bilateral posterior tibial tendon dysfunction, corns of the fifth toe on both feet, orthotics worn in both shoes, and a metal fastener in left navicular attaching tendon.  The MEB physical exam noted abnormal lower extremities without further details and the use of crutches.  The commander’s statement dated 26 January 2005 indicated the CI’s conditions prevented her from performing many of the functional activities required of a soldier and critical job duties in her MOS.  She was unable to run, walk, complete sit ups, fire an individual weapon, or wear protective mask and all chemical defense equipment.  The commander did not attribute her symptoms to one side over the other.  At an outpatient consultation on 15 March 2005, she described pain in the left ankle as “a sharp, shooting pain commencing distally over the medial malleolus (inner ankle) and radiating proximally over the medial leg.”  Examination of the left lower extremity revealed mild to moderate allodynia (pain from stimuli that normally do not produce pain) with light touch over the inner ankle with mildly decreased dorsiflexion strength of the left foot, which was “consistent with a neuralgia likely saphenous neuralgia.”  Treatment was with Neurontin (for nerve pain) and with a non-steroidal anti-inflammatory medication.  No comment was made on gait or the use of crutches.  A follow-up pain clinic visit on 3 May 2005 did document the use of crutches.

At the VA Compensation and Pension (C&P) examination performed on 26 July 2005, 2 months after separation, the CI reported flare-ups with weather changes or with shopping, which required her to sit, lie down, and take pain medication from time to time.  She still used orthotics, but no longer used crutches or a cane, but still had difficulty carrying more than 10 pounds due to ankle pain.  She walked with a limp, could walk on both of her feet rotated inward (supination), but was unable to walk with her feet rotated out (pronation) or rise on her toes bilaterally.  She could heel walk only with support from the examiner.  There was no edema (swelling) of the left or right ankles.  A soft corn was noted over the fifth toe of the left foot.  There were no callosities of the plantar surfaces of the feet.  Also, there was no tenderness to the plantar fascia of either the left or right foot as would be expected in plantar fasciitis.  She did not have pes planus (flat foot) or hallux valgus (bunion) of either foot.  The VA examiner’s assessment was the CI had “posterior tibial tendon dysfunction bilaterally of a moderate degree.  She was limited on repetitive use by pain and weakness, but pain had the major functional impact.  Bilateral plantar fasciitis, bilaterally by history.”  However, on another general C&P examination the same day the CI had a normal gait without limitations in mobility.  She was also evaluated in neurology that day as well for her headache condition.  The neurologist noted that she had a normal gait and to be able to walk on her heels and toes without difficulty.  The goniometric range-of-motion (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.

Ankle ROM
(Degrees)	MEB ~ 5 Mo. Pre-Sep 	VA C&P ~ 2 Mo. Post-Sep 	
	Left	Right	Left	Right	
Dorsiflexion (20 Normal)	10	10	0	0	
Plantar Flexion (45)	35	35	40	40	
	Ambulation with crutches; pain left foot-possible saphenous neuralgia	Tenderness medial foot, decreased sensation dorsal foot, limited in weakness on repetitive motion, no pain on ROM	Limited on repetitive motion by weakness, moderate tenderness medial ankle, no pain on ROM	
§4.71a Rating	10%	10%	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The FPEB rated the CI’s unfitting condition of chronic left ankle pain, secondary to left accessory navicular excision and subsequent posterior tibial tendon reattachment at 10% using code 5099-5003.  The right posterior tibial tendonitis with prolonged altered gait secondary to left foot injury and pes planus was rated moderate using code 5024 (tenosynovitis) at 10%.  Despite finding no tenderness to the plantar fascia of either foot on the C&P examination, the VARD dated 23 May 2006, modified the diagnosis to bilateral pes planus and plantar fasciitis, coupled both the left and right ankle conditions and assigned a rating of 30% for posterior tibial tendon dysfunction bilaterally, plantar fasciitis bilaterally using code the analogous code 5299-5276 (Flatfoot, acquired).  The Board observed that several examinations, including the VA examination, failed to elicit tenderness of the plantar fascia.  The flat foot condition (pes planus) was present at accession.  The Board also noted that two (of three) separate examinations 2 months after accession showed a normal gait neurological examination.  Both were more proximate to separation than the MEB examination although a month further than the final pain clinic visit on 3 May 2005.  However, one was accomplished by a neurologist for a separate condition.  The Board found no route to a rating higher than the 10% adjudicated by the FPEB for each ankle since there was no evidence of any marked limitation of motion around the time of separation.  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 FPEB adjudication for the chronic left ankle pain and right posterior tibial tendonitis conditions.

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 chronic left ankle pain and right posterior tibial tendonitis conditions was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the chronic left ankle pain and right posterior tibial tendonitis conditions and IAW VASRD §4.71a, the Board unanimously recommends no change in the FPEB adjudication.  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 20131025, 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 XXXXXXXXXXXXXXXXX, AR20150001814 (PD201301998)

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