RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-00257
BRANCH OF SERVICE:  Army		SEPARATION DATE:  20060403

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Signal Intelligence Analyst) medically separated for a lower left extremity disability.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  Chronic pain left foot was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded radial subluxation extensor mechanism left index metacarpal phalangeal joint as medically acceptable for PEB adjudication.  The Informal PEB adjudicated “loss of range of motion and chronic left foot pain post inversion injury of the foot and ankle” as unfitting, rated 10% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining left index metacarpal phalangeal joint condition was determined to be not unfitting.  The PEB also adjudicated left calf as not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI contended for his left foot, left heel, left ankle, lower back, right hip and right knee.  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 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 20060202	VA* - (~3 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Foot Pain Post Inversion Injury of Foot and Ankle	5271	10%	Ruptured Left Posterior Tibial Tendon, Status Post Repair and Fusion with Retained Surgical Hardware	5283	20%	20060613	
Other MEB/PEB Conditions x 2 (Not In Scope)	Other x 0	
RATING:  10%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20060620 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:

Left Ankle Condition.  According to service treatment records and the MEB narrative summary (NARSUM,) the CI injured his left ankle approximately 2 years prior to referral for MEB.  He sustained an inversion injury while playing basketball.  A left foot X-ray revealed accessory ossicles (bones) and/or old-fracture fragments in the region of the medial malleolus and talus and pes planus (flatfoot).  A podiatry encounter documented MRI findings of posterior tibial tendinopathy (chronic tendon degeneration without inflammation), osteochondral (bone and cartilage)/tibial lesions, bone spurs, and degenerative joint disease (DJD).  At the podiatry follow-up the CI complained of 7 months of medial left ankle pain.  He had failed conservative management which included orthotics, shoe modification, and Celebrex, a nonsteroidal anti-inflammatory drug (NSAID).  Podiatry performed a Kidner procedure (excision of accessory navicular [extra bone/cartilage within posterior tibial tendon] and repositioning of the posterior tibial tendon).  Postoperatively, the CI was non-weight bearing in a cast for 4 weeks, followed by a controlled ankle movement (CAM) walker boot for 1 to 2 months.  Following the posterior tibial tendon debridement and advancement, he continued to have pain and podiatry performed a medial cuneiform-navicular arthrodesis (surgical fixation/fusion of a joint).  An orthopedic surgery encounter recounted the X-ray findings which showed an unfused medial cuneiform-navicular joint with a single screw and a broken medial plate.  The assessment listed chronic foot pain with a failed attempted fusion of the medial cuneiform-navicular joint.  Orthopedic surgery performed a medial calcaneal slide osteotomy (cutting heel bone and shifting it medially), revision medial cuneiform-navicular arthrodesis, and a distal tibial bone graft.  Left foot and heel X-rays showed a 5mm medial displacement of the calcaneus, a screw fixing the calcaneal osteotomy, and a new fixation device bridging the medial cuneiform and navicular.  The orthopedic surgery left ankle exam documented a normal gait with the CI being unable to walk on toes or heels.  The left lower extremity exam revealed healed incisions and significant calf atrophy.  There was no local tenderness and left ankle range-of-motion (ROM) was dorsiflexion of 15 (20 normal) and plantar flexion of 40 (45) degrees.  Left ankle/foot X-rays showed orthopedic hardware, a healed calcaneal osteotomy (heel surgery), fusion of the medial cuneiform-navicular joint (foot joint), and no evidence of bone infection.  The NARSUM by orthopedic surgery, 4 months before separation, recounted the history and interventions.  Following the last surgery, the CI was in a short-leg cast for 2 months, and continued using a CAM walker.  The CI wore a CAM walker most of the time, but was able to wear a regular shoe and boot.  He complained of 3-4/10 pain most of the day, 7-8/10 pain with walking, and occasional pain at night.  Pain was exacerbated with weight-bearing and relieved with medications (Motrin or Tylenol), and being seated with his foot elevated.  The left lower extremity exam revealed multiple healed incisions.  There was no local tenderness and sensation was normal.  Left ankle ROM, measured with a goniometer, was full.  There was minimal relative restriction of inversion and eversion of the left foot and ankle relative to the right.  All motor groups of the left foot and ankle functioned, but there was significant calf atrophy.  The maximum calf circumference on the left measured 35 cm compared to 40.5 cm on the right.  The diagnosis listed chronic left foot pain following fusion of the cuneiform-navicular joint.  A left foot CT scan revealed findings consistent with surgical and post-operative changes.  A left foot X-ray showed stable calcaneal osteotomy screw fixation, stable cuneiform-navicular fusion, no evidence of hardware slippage or failure, and diffuse osteopenia (decreased bone mineral density).  Physical therapy (PT) measured repetitive (X3) ROM for the MEB.  Left ankle active ROM, measured with a goniometer, was dorsiflexion of 10/10/13 (20 normal) and plantar flexion of 30/33/33 (45 normal) degrees.

The VA Compensation and Pension (C&P) Foot exam recounted the history and interventions.  The CI complained of constant pain and frequent swelling in the left foot.  Symptoms were exacerbated by standing and walking and relieved by rest, ice, exercises, and Motrin.  He did not use orthotic inserts, was able to ambulate independently, and was able to do his usual job as an intelligence analyst.  The physical exam documented a normal gait, normal heel and toe gaits, and no evidence of unequal shoe wear.  The left ankle exam revealed mild diffuse swelling and tenderness.  Left ankle ROM was dorsiflexion of 10 (20 normal) and plantar flexion of 20 (45 normal) degrees.  The left foot exam revealed well healed surgical incisions, mild pes planus, and mild diffuse swelling and tenderness.  Temperature, color, and vasculature were normal and there was no heat, erythema (redness), breakdowns, or significant callus formation.  The fractures were clinically well healed and there was no angulation, shortening, or false motion.  There was no high arch, hindfoot, midfoot, forefoot, hammertoe, valgus, or varus deformity.  The Achilles tendons were well aligned and nontender.  The examiner opined “There is evidence of moderate weakened movement and excess fatigability.  There would be no additional loss of motion or functional impairment during flareups, since patient is currently in pain.”  The left ankle X-ray showed orthopedic hardware and no evidence of fracture, dislocation, or significant joint space narrowing.  The left foot X-ray showed orthopedic hardware and a healed calcaneus osteotomy.  The diagnosis listed ruptured left posterior tibial tendon status post repair and fusion.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 10% coded 5271 (Ankle, limited motion), cited chronic left foot pain, status post inversion injury of the foot and ankle.  The VA, cited the C&P exam 2 months after separation, rated the left ankle condition at 20% coded 5283 (Metatarsal bones,  malunion/nonunion).  The CI underwent a medial calcaneal slide osteotomy and imaging showed a healed calcaneus osteotomy and intact orthopedic hardware.  While there was a healed calcaneus osteotomy, there was no deformity for consideration under 5273 (Os calcis [calcaneus], malunion).  The CI underwent a medial cuneiform-navicular arthrodesis and imaging showed a stable cuneiform-navicular (cuneonavicular) joint fusion and intact orthopedic hardware.  While there was a fused cuneonavicular joint, there was no deformity for consideration under 5272 (Subastragalar or tarsal joint, ankylosis of).  While the CI had pes planus, it was characterized as mild, and he had stopped using orthotic inserts.  Board members agreed the condition did not exceed the mild (0%) rating under 5276 (Flatfoot, acquired).  While the C&P examiner opined there was evidence of moderate weakened movement, he documented a normal gait, and normal heel and toe gaits.  There was no significant weakness for consideration under 5277 (Weak foot).  There was no evidence of sensory pathology for consideration under 5279 (Metatarsalgia).  There was no deformity for consideration under 5270 (Ankle, ankylosis), 5273 (Astragalus [talus], malunion of), 5275 (Lower extremity bone shortening of), 5278 (Claw foot), 5280 (Hallux valgus), 5281 (Hallux rigidus), 5282 (Hammer toe), or 5283 (Metatarsal bones, malunion/nonunion).  There was no excision of the astragalus for consideration under 5274 (Astragalectomy).  Board members agreed that the ankle limitations in motion (5271) more closely approximated the moderate (10%) than the marked (20%) rating.  Board members agreed that there was sufficient evidence of pain with use prior, as well objective exam and imaging findings, to support a 10% rating considering VASRD §4.40 (Functional loss) and §4.59 (Painful motion).  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.

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.  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 20140101, 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 XXXXXXXXXXXXXXXXXXXXXXXX, AR20160002109 (PD201400257)

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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA