RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00534
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20071001

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Light Wheeled Vehicle Mechanic, medically separated for “bilateral heel pains from Achilles tendonitis,” with a disability rating of 0%.

CI CONTENTION:  The CI contended for sleep apnea, esophageal reflux (GERD), Hypertension, and major depression in addition to his unfitting bilateral feet.  The CI’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 Physical Evaluation Board (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 - 20070813	VARD - 20080310	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Heel Pain	5024	0%	Bilateral Chronic Achilles Tendonitis	5024	10%	20080107	
Sleep Apnea	Not Unfitting	Sleep Apnea	6847	50%	20080107	
GERD	Not Unfitting 	GERD	7399-7346	10%	20080107	
Hypertension	Not Unfitting	Hypertension	7101	0%	20080107	
Major Depression	Not Unfitting	Major Depression	9434	NSC	20080107	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Bilateral Achilles Tendonitis.  The service treatment record (STR) and narrative summary (NARSUM) documented the onset of bilateral Achilles tendonitis in February 2005.  The CI denied trauma.  Surgery was performed on the right ankle in March 2006 with no improvement in the pain.  The STR documented a normal gait at four separate visits in September, October, November and December 2006.  Tenderness to palpation of the individual or bilateral Achilles tendon insertion points was documented at eight separate visits between September 2006 and February 2007.  Mild right ankle edema was noted at three visits.  Right ankle dorsiflexion was documented as 15 degrees (normal 20) in September and October 2006.  At a podiatry visit in February 2007, 10 months before separation, the CI reported bilateral Achilles tendon pain, right (rated 5-6/10) greater than left (rated 4-5/10).  The examiner documented tenderness at the bilateral insertions of the Achilles tendons, without edema, crepitus, or tenderness during ankle and foot range-of-motion.  Strength was 5/5 bilaterally.  There was no STR evidence for gait disturbance, joint instability, or more significant range-of-motion impairments prior to separation.  

At the Medical Evaluation Board (MEB) examination (recorded on DD Forms 2807 and 2808) dated February 2007, 7 months prior to separation, the CI reported swollen ankles and heels that caused “impaired use of both feet.”  The examiner documented tenderness over the bilateral Achilles tendons and full range-of-motion of the ankles.  There was also bilateral tenderness of the retrocalcaneal areas of the feet, right greater than left.  

At the MEB NARSUM examination on 21 March 2007 (6 months prior to separation), the CI reported the inability to run, jump, march, or carry heavy equipment or tool boxes without severe pain.  The examiner documented tenderness to palpation of the plantar heel and at the insertion of the Achilles tendon bilaterally, right greater than left.  There was bilateral ankle dorsiflexion of 8 degrees (normal 20) with pain bilaterally.  The CI was able to perform bilateral and single toe raises although unable to elevate the right heel as high as the left.  Muscle strength during left ankle plantar flexion was 4/5 compared to 5/5 muscle strength for the rest of the ankles bilaterally.  There was no edema or crepitus in either ankle or foot.  

At the VA Compensation and Pension (C&P) examination in January 2008, performed 3 months after separation, the CI reported constant 2-3/10 pain on the left and 5/10 pain on the right, with flares occurring after prolonged walking, standing and weather changes.  The flares could last 1-2 hours and were alleviated with rest, ice and pain medication.  The examiner documented a normal gait, “mild pain” of the bilateral Achilles tendon during squatting.  There was tenderness on palpation of the right and left Achilles tendons.  Right and left ankle dorsiflexion was to 15 degrees and eversion was to 15 degrees, both with pain; and plantar flexion and inversion were both normal and without pain.  There was no change in range-of-motion (ROM) or additional limitations after repetition.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under the 5024 code (tenosynovitis), citing no mechanical loss of motion.  The VA assigned a 10% rating using the 5024 code based on the VA C&P examination 3 months after separation, citing painful or limited motion of a major joint or group of minor joints.  Although VARSD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  The Board must follow suit if the PEB combined adjudication is not compliant with the latter stipulation, provided that each ‘unbundled’ joint can be reasonably justified as separately unfitting in order to remain eligible for rating.  If the members judge that separately ratable joints are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended.  The Board thus first considered if each ankle, after de-coupling from the combined PEB adjudication, remained itself unfitting as above.  

Both ankles were considered to fail retention standards; both were implicated by the NARSUM; and, both were profiled.  Since the disability attendant to a single ankle could not be isolated by the clinical evidence, or extricated from the fitness implications of the bilateral limitations; members agreed that each ankle condition was justified as separately unfitting.  

The Board next considered the evidence for rating the right and left ankle conditions.  Given the absence of ankylosis or malunion, the only route to a higher rating would be 20% under 5271 for “marked” limitation of motion.  The Board deliberated the justification for “marked,” “moderate,” and “mild.”  As both the NARSUM and VA ankle ROM measurements could not reasonably be considered as having a “marked” limitation of motion, the disability of the right and left ankles could not be rated 20%.  The ROM evidence documented in the NARSUM findings could be reasonably characterized as “moderate,” in support of a 10% rating coded 5271 for moderate limitation of motion or 5024 (tenosynovitis).  The VA measurements for dorsiflexion (which was near full) would be more reasonably characterized as “mild,” with evidence of painful motion, in support of a 10% rating coded 5024 (tenosynovitis).  Members agreed that the decreased and painful motion support a rating of 10% for both the right and left Achilles tendonitis.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% each for the right and left Achilles tendonitis, coded 5024.  

Contended PEB Conditions.  

Sleep Apnea.  The STR documented that the CI was diagnosed with sleep apnea in July 2006 (15 months before separation) and prescribed a breathing assistance device.  At a visit with the pulmonologist in October 2006, he was “much improved.”  At the follow-up visit with pulmonology in March 2007, the CI reported improvement with breathing device.  The examiner documented that the CI was not a candidate for surgery and would require the breathing machine for life.  The commander’s statement listed the sleep apnea condition but did not differentiate functional limitations attributable to the condition.  The sleep apnea condition was profiled, and noted to fail retention standards by the MEB; however it was determined to be not unfitting by the PEB, citing the availability of reliable power in most areas of assignment with his occupational specialty.  Routinely obstructive sleep apnea (OSA) is not considered unfitting solely on the basis of field and operational impediments to the use of CPAP [continuous positive airway pressure].  There is no evidence in this case that OSA was associated with any functional impairment that was not corrected by CPAP.  Accordingly, members concurred that the PEB’s fitness determination was reasonable; and, 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 sleep apnea condition and so no additional disability rating is recommended.  

Major Depression, Hearing Loss, Hypertension, and Gastroesophageal Reflux Disease.  The Board’s main charge is to assess the fairness of the PEB’s determination that the major depression, gastroesophageal reflux disease, hearing loss, hypertension, and were not unfitting.  The major depression, hearing loss, hypertension, and gastroesophageal reflux disease 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 any of 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 these contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the right and left Achilles tendonitis, the Board unanimously recommends a disability rating of 10% for the right ankle and 10% for the left ankle, both coded 5024 IAW VASRD §4.71a.  In the matter of the contended sleep apnea, major depression, gastroesophageal reflux disease, hearing loss, and hypertension condition, 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 recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Achilles Tendonitis	5024	10%	
Left Achilles Tendonitis	5024	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140122, 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, AR20160005856 (PD201400534)

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, accept the Board’s recommendation to modify the individual’s disability rating to 20% 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:

CF: 
(  ) DoD PDBR
(  ) DVA