RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00516
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050215

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6 (Intelligence Analyst) medically separated by the Informal Physical Evaluation Board for “left ankle pain, instability and restricted motion” with a disability rating of 10%.   

CI CONTENTION The VA considered all of his conditions; the PEB did not consider all of his conditions.  His complete submission is at Exhibit A. The applicant’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  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 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:  

SERVICE PEB - 20041227	VARD - 20051028	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Ankle Pain, Instability and Restricted Motion	5271	10%	Sprain, Left Ankle, with Laxity of Lateral Ligament and Instability	5271	0%	20050923	
Lateral Epicondylitis	Not Unfitting	Epicondylitis, Left Elbow	5299-5206	NSC	20050923	
		Epicondylitis, Right Elbow	5299-5206	NSC	20050923	
Carpal Tunnel Syndrome	Not Unfitting	Carpal Tunnel Syndrome, Right Wrist	8599-8515	10%	20050923	
		Carpal Tunnel Syndrome, Left Wrist	8599-8515	10%	20050923	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Left Ankle Condition.  According to service treatment records (STR) and the MEB narrative summary (NARSUM), the CI injured his left ankle approximately 6 years prior to referral for MEB.  A left ankle X-ray on revealed a small avulsion (forcible separation/detachment of a bodily structure/part) off the medial malleolus (ankle rounded bony prominence) and an intercalary bone (small nodular bone imbedded in a tendon) between the tibia and the talus.  A left ankle X-ray with stress views showed no evidence of ligamentous laxity and three old chip fractures (two small rounded loose joint bodies between medial malleolus and talus and one lateral to fibula and talus).  At a clinic encounter, the CI complained of recurrent left ankle inversion injuries; the physical exam documented a normal gait.  The left ankle exam revealed tenderness over the posterior talofibular ligament.  There was no bony tenderness or instability and the ankle anterior drawer (assesses anterior talofibular ligament [ATFL]) was negative.  The assessment listed left ankle sprain.  

A left ankle X-ray with stress views on 30 November 2004, showed no findings diagnostic of instability and a possible old injury with fibrous union at the medial malleolus.  A clinic left ankle exam on the same day, revealed mild tenderness of the posterior tibia.  The ATFL, calcaneofibular ligament (CFL), and Achilles tendon were not tender.  The ankle anterior drawer test was negative.  The range-of-motion (ROM) was dorsiflexion of 20 (normal) and plantar flexion of 45 (normal) degrees.  

The MEB DD Form 2808, Report of Medical Examination, documented that the left ankle anterior drawer was minimally positive and the ankle talar tilt (assesses CFL) was negative.  The active ROM was dorsiflexion of 30 (normal 20) and plantar flexion of 25 (normal 45) degrees.  At the NARSUM exam, 2 months before separation, the CI complained of chronic left ankle pain, instability, and recurrent sprains.  He reported that instability forced him to wear a brace much of the time.  The CI completed a course of physical therapy (PT) but he still had residual instability.  Orthopedic surgery offered surgery but he declined.  The examiner referred to the DD Form 2808 for significant findings.  The focused left ankle exam revealed no deformity or tenderness.  The diagnosis listed chronic ankle instability.  

At the VA Compensation and Pension (C&P) examination performed on 23 September 2005, 7 months after separation, the CI reported a history of a left ankle avulsion fracture and recurring sprains.  He complained of chronic aching and laxity.  The CI reported flare-ups 1-2 times per month with associated increased pain and swelling.  Symptoms were exacerbated by prolonged standing, walking on uneven ground, climbing ladders, and stairs and relieved by rest and medications (Motrin and Tylenol).  He wore a supportive brace for prolonged ambulation, yard work, and house chores.  The physical exam documented a normal gait, favoring the left side at onset of ambulation.  The CI was able to stand on toes and heels and no ambulatory aids were used.  The left ankle exam revealed increased lateral ligament laxity.  There was no tenderness or grinding.  There was neutral ankle and midline foot alignment.  Active ROM was dorsiflexion of 0-20 (normal) and plantar flexion of 0-45 (normal) degrees.  There was no pain noted during ROM and no additional limitation following repetitive ROM.  Strength, sensation, and deep tendon reflexes (DTRs) were normal and pathologic reflexes were absent.  The left ankle X-ray showed possible prior avulsion injuries of the medial malleolus without other significant abnormalities.  The impression listed left ankle strain/fracture injury with residual lateral ligament laxity.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 10% (coded 5271) citing history of repeated sprains, lateral instability by imaging, no degenerative joint disease, pain, instability, laxity, weakness, restricted motion, and rated as moderate limitation of motion.  The VA, citing the C&P exam 7 months after separation, rated the left ankle condition 0%, coded 5271 (ankle, limited motion).  The VA cited avulsion fracture secondary to ankle sprain, no evidence of degenerative joint disease, lateral ligament laxity, normal gait, no assistive devices, neutral ankle alignment, midline foot alignment, no tenderness, no grinding, normal ROM, no pain with ROM, and no additional limitation following repetitive ROM.  The medical exam for the MEB and NARSUM, documented hypermobile dorsiflexion and reduced plantar flexion.  Board members agreed that the ankle ROM measurements in these exams more closely approximated the moderate (10%) than the marked (20%) rating.  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).  Board members agreed that there was sufficient evidence of pain with use, as well as 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.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the lateral epicondylitis and carpal tunnel syndrome 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.

Lateral Epicondylitis.  The STR documented a clinic encounter where the CI complained of right arm pain with flexion and extension that went from the elbow to the ulnar aspect of the hand.  He reported associated pain and tingling to the third, fourth, and fifth digits.  The differential diagnosis listed lateral epicondylitis versus carpal tunnel syndrome (CTS) versus ulnar syndrome (ulnar neuropathy).  The NARSUM recorded a past medical history of lateral epicondylitis, but did not record any related symptoms or active medications.  The NARSUM diagnosis listed lateral epicondylitis which met retention criteria.

Carpal Tunnel Syndrome (CTS).  A clinic encounter documented numbness and tingling in the ulnar nerve distribution of the left hand.  Though the symptoms suggested ulnar nerve involvement, the assessment listed CTS (affects the median nerve).  The CI was referred to occupational therapy (OT).  The OT exam documented a negative Tinel's sign (percussing nerve elicits tingling over distribution of the nerve) for the ulnar nerve at the Guyon’s canal and cubital tunnel.  There was left wrist pain with resisted flexion and tenderness at the medial epicondyle.  The exam recorded that passive elbow flexion for 15 seconds resulted in pain and pronation.  The assessment listed symptoms of cubital tunnel syndrome.  The NARSUM recorded a past medical history of CTS that was currently managed without braces or medications.  The NARSUM diagnosis listed CTS which met retention criteria.

The lateral epicondylitis and carpal tunnel syndrome were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed and considered by the Board.  There was no performance based evidence from the record that these conditions 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 contended lateral epicondylitis and carpal tunnel syndrome conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  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 contended lateral epicondylitis and carpal tunnel syndrome conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  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 20131224, 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 XXXXXXXXXXXXXXXXXX, AR20160002518 (PD201400516)

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