RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01064
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080723

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Infantryman, medically separated for “limitation of motion, ankle hypermobility and pain of left ankle,” and “chronic low back pain without motor neurologic deficit,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  “Please consider all conditions.”  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 based upon a 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 - 20080327	VARD - 20080926	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Limitation of Motion, Ankle Hypermobility and Pain of Left Ankle…	5271	10%	Left Ankle Shrapnel Injury	7805	0%	20080815	
			Left Ligament Tendon and Peroneal Tendon Tear Status Post Surgery	5271	10%		
Chronic Low Back Pain without Motor Neurologic Deficit	5299-5237	10%	Low Back Strain	5237	10%		
Depression	Not Unfitting	Posttraumatic Stress Disorder	9411	30%	20080818	
Posttraumatic Stress Disorder						
Primary Insomnia						
Essential Hypertension		Hypertension	7101	0%	20080812	
Hyperlipidemia		No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Limitation of Motion, Ankle Hypermobility and Pain of Left Ankle from Chronic Ankle Sprain of Anterior Fibular Ligament and Calcaneofibular Ligament Following Reinjury after Modified Brostrom.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left ankle condition began in September 2003 when he fell after rolling his ankle during a run.  X-ray studies on 2 February 2005 showed marked ligamentous laxity of the left ankle and follow-up studies on 2 March 2005 showed alignment of the joint spaces were unremarkable, but the fine bone detail was obscured by a cast.  A Brostrom procedure consisting of lateral left ankle ligament repair/augmentation and peroneal tenosynovectomy/debridement surgery were performed in March 2005.  Pathology revealed a left peroneal tendon sheath, unremarkable skeletal muscle, and adipose tissue.  Electrodiagnostic studies (EMG/NCV) performed on 25 August 2005 were negative for left lower extremity neuropathies or radiculopathy of nerve roots L5 through S1.  Postoperative joint instability was reported in August 2005, which the CI noted the he “rolled” the operated ankle three times since the surgery.  Magnetic resonance imaging (MRI) on 8 September 2005 showed a small effusion with thickening of the peroneal tendons and no other abnormalities were noted.  In November 2005 the CI still had joint pain in the ankle and was prescribed Sulidac (clinoril, a nonsteroidal anti-inflammatory drug (NSAID)) and gabapentin (for nerve pain) for complex regional pain syndrome-like (CRPS) symptoms  The CI claimed he rolled his ankle on a regular basis in-country in February 2006 while deployed.  X-rays ordered for a laterally unstable left ankle dated 27 March 2007 showed widening of the ankle joint with subluxation of the tibiotalar joint.  The examiner concluded there were tiny ossific densities inferior to the lateral malleolus, which could have represented small avulsion fractures or ununited ossification centers.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic left ankle pain and instability status-post surgical repair,” for PEB adjudication.  

The 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.

Left Ankle ROM
(Degrees)	
PT ~10 Mos. Pre-Sep
	
PT/MEB ~5 Mos. Pre-Sep
	
VA C&P ~1 Mos. Post-Sep
	
Dorsiflexion (20 Normal)	8/10/10	0	0-14	
Plantar Flexion (45)	28/30/30	55	0-35	
Painful motion	Present	Present	Present	
Abnormal gait	Not addressed	Absent	Absent	
Other impairments* 	Not addressed	Capsular tightness	None	
Comments	Pain on motion/ limited ROM	Pain on motion/ limited ROM	Pain on motion/ limited ROM	
§4.71a Rating	20%	20%	10%	

During the MEB examination dated 10 March 2008, 5 months prior to separation, the CI reported constant left ankle pain rated as 6/10.  The ankle would swell occasionally and the pain limited his ability to perform rigorous activities.  Physical examination showed normal gait and sensation.  There was slight swelling over the left talofibular ligament area and tenderness to palpation over the swollen area and the calcaneofibular ligament area.  The CI appeared to have hypermobility of the left ankle and the ROM after repetition was severely limited (0 degrees) in dorsiflexion.  

X-rays of the left ankle dated 14 August 2008 demonstrated a 3 mm osseous density adjacent to the lateral malleolus suggesting an old ununited avulsion fracture fragment and there was a slight deformity of the medial malleolus and a cortical bone island in the distal tibia, which measured 0.5 cm.  At the 15 August 2008 VA Compensation and Pension (C&P) examination, performed a month after separation, the CI reported constant, daily left ankle pain rated 6/10, which increased to 8/10 when aggravated by walking or standing.  The CI wore a brace with increased activity and his pain was relieved by medication (gabapentin and Percocet (oxycodone, a narcotic and acetaminophen, a pain reliever).  Physical examination showed a normal gait, no deformities, laxity, or tenderness to palpation.  The ROM after repetition was limited with associated pain as recorded in the chart.  
The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 10%, coded 5271 (limited motion of the ankle), citing limited painful motion.  The VA rated the left ankle condition 10%, coded 5271 (limited motion of the ankle), citing limitation of motion.  The Board considered whether the limitation of motion was moderate or marked when considered under 5271, limitation of ankle motion.  The Board agreed that the ROM examinations proximate to separation detailed above were consistent with a moderate limitation of motion with associated pain for the 10% rating under this code, albeit the sole examination where dorsiflexion was 0 degrees, but plantar flexion was increased and the CI walked normally.  The Board considered alternative VASRD ankle and analogous codes, but all were less applicable and not advantageous to rating.  Additionally, the Board considered code 5262 (Tibia and fibula impairment) first for nonunion based on X-ray findings; however, loose motion, requiring a brace almost fit, but there was no clinical evidence of loose motion.  Additionally, malunion was considered with either slight ankle disability, which affords no additional benefit to the CI, or moderate ankle disability, which was not supported by the STR evidence and the facts that the CI worked as a landscaper post-separation and was pending an exercise treadmill test that requires walking and/or running on either a flat or inclined moving surface.  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.

Chronic Low Back Pain without Motor Neurologic Deficit.  According to STR and the MEB NARSUM, the CI’s chronic low back pain condition began in 2004.  The CI denied any specific injury or trauma.  X-ray studies 17 September 2007 showed a normal lumbosacral spine and a computerized axial tomography (CT) scan on 25 January 2008 showed no gross abnormalities.  Conservative treatment including multiple chiropractic treatment sessions did not result in improvement sufficient to allow unrestricted duty and there was no surgical indication.  The MEB forwarded “chronic low back pain,” for PEB adjudication.The ROM examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Thoracolumbar ROM
(Degrees)	
CHIRO ~7 Mos. Pre-Sep
	
PT/MEB ~5 Mos. Pre-Sep
	
VA ~1 Mo. Post-Sep
	
Flexion (90 Normal)	FULL ROM	85	0-85	
Extension (30)	FULL ROM	20	0-25	
R Lat Flex (30)	FULL ROM	30	0-25	
L Lat Flex (30)	FULL ROM	25	0-25	
R Rotation (30)	FULL ROM	30(45)	0-25	
L Rotation (30)	FULL ROM	30(45)	0-25	
Combined (240)	FULL ROM	220	210	
Painful motion	Not addressed	Not addressed	Present	
Tenderness	Present	Present	Absent	
*Spasm or guarding	Present	Absent	Absent	
**Altered Gait 
  due to *	Not Addressed	Absent	Absent	
**Altered contour due to *	Not addressed	Not addressed	Absent	
***Incapacitating episodes IVDS	Not Addressed	Not addressed	Not addressed	
Misc Functional Loss	 Not Addressed	Not addressed	Not addressed	
Comments	Tenderness to palpation/ full ROM 	Tenderness to palpation/ mildly limited ROM	Painful slightly limited ROM	
§4.71a Rating	10%	10%	10%	
During the MEB examination dated 10 March 2008, 5 months prior to separation, the CI reported constant low back pain primarily in the left lower back and lower lumbar spine rated 4-8/10.  The pain prevented him from lifting heavy objects or wearing body armor, two key functions required by his military specialty.  Physical examination showed normal gait, sensation, and reflexes with no muscle spasms.  There was tenderness to palpation from L2-S1, and the left and right paralumbar muscle areas.  Straight leg raise (SLR) testing (to determine nerve root irritation) was negative for radiating symptoms.  Thoracolumbar ROM after repetition was mildly limited as recorded in the chart.  
    
At the 15 August 2008 VA Compensation and Pension (C&P) evaluation, performed a month after separation, the CI reported constant low back pain without radiation or numbness, described as sharp and rated 7/10, which increased to 8/10 when bending over.  The pain was aggravated by sleeping but not by lifting.  Physical examination showed normal spinal curvature, gait, reflexes, sensation, and no muscle spasm.  Straight leg raise testing (to determine nerve root irritation) was 0-80 degrees bilaterally with mild pain.  Thoracolumbar ROM after repetition was mildly limited by pain as recorded in the chart.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic low back pain condition 10%, coded 5299-5237 (lumbar spine strain), citing tenderness and mildly limited forward flexion.  The VA also rated the chronic low back pain condition 10% coded 5237 (lumbar spine strain), based on the VA C&P examination a month after separation, citing limitation of forward flexion or combined ROM.  Although there was insufficient limitation of motion to support a minimum rating, the Board agreed a 10% rating was justified for the presence of tenderness and painful motion.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis nor were there any episodes of incapacitation to support a higher rating.  The Board then considered whether an additional Service rating could be recommended under a peripheral nerve code.  Although the pain component of the neuropathy is appropriately subsumed in the spine rating IAW VASRD §4.71, which states that “rating is performed with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease,” there was no sensory component with any significant functional implications and no motor weakness was in evidence.  Therefore, a radiculopathy could not be recommended for additional disability rating.  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 chronic low back pain condition.   

Contended PEB Conditions:  Depression, Posttraumatic Stress Disorder, Primary Insomnia, Essential Hypertension, and Hyperlipidemia.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.  

Depression.  The CI complained of depression and anhedonia for 2 months as well as low energy in May 2006.  Treatment consisted of Paxil and referral to CST (community support team).  

Posttraumatic Stress Disorder (PTSD).  The CI had tinnitus in February 2006 after exposure to an IED attack.   In November 2007 the CI was diagnosed with an anxiety disorder (R/O PTSD) with a General Assessment of Functioning (GAF) score of 58-60 (moderate symptoms) of based on feeling tired, having a decreased appetite and concentrating ability along with high irritability, depression, initial insomnia, middle-night awakening, nightmares, and loss of interest.  Doxepin (an antidepressant) was prescribed sleep.  In August 2008, a month after separation, the CI was evaluated for PTSD at which time the CI related his combat experiences including losses of buddies and unit members as well as receiving a shrapnel injury to the left leg.  He reported intrusive thoughts with avoidance of such thoughts, nightmares, limited affect, sleep disturbance, anger problems, poor concentration, hypervigilance, and an exaggerated startle.  On examination he was articulate, verbal and generally cooperative.  His thought process was logical, coherent, and relevant.  His affect was blunted; he was calm and well oriented to time, place, person and situation.  Reasoning and judgment were fair.  He reported constant low-grade sadness, but not intense depression, and denied any psychotic symptoms, mania, or suicidal ideation.  He had some homicidal thoughts, which were passing in nature, and he knew better than to act on them.  He worked 10-12 hours per day in his own business, but had fewer friends and was not socially outgoing.  The diagnosis of PTSD was made and his GAF was 65 (some mild symptoms).  In January 2009 the CI indicated of several medications taken for sleep impairment, only Lunesta (eszopiclone, a sedative) was helpful.  Mental status examination revealed the CI to be calm and cooperative with an “OK” mood and affect that was congruent and constricted.  He had no delusions, hallucinations, or suicidal or homicidal ideation.  Insight, judgment, and cognition were intact.  Treatment consisted of Paxil (paroxetine, an antidepressant), prazosin (an alpha blocker for high blood pressure, anxiety and PTSD), and Lunesta.  He did not want to try therapy due to a bad prior experience.   

Primary Insomnia. The CI complained of non-refreshing sleep with excessive daytime somnolence.  A sleep study in November 2007 revealed no evidence of significant sleep apnea-hypopnea syndrome.  The CI used doxepin and Lunesta for primary insomnia.  In October 2008 the CI was diagnosed with mild obstructive sleep apnea.  CPAP (continuous positive airway pressure) treatment was instituted with a setting of 11 cm of water.  The CPAP helped the middle insomnia and the CI was able to get from 2 to 6 hours of sleep.

Essential Hypertension.  Blood pressure (BP) measurements in early Sept 2007 ranged from a low of 131/84 to a high of 150/94, while on 17 September 2007 the BP was 133/75.  Telmisartan (an angiotensin receptor blocker) was initially prescribed and was replaced by telmisartan/hydrochlorothiazide (a diuretic).  By December 2007 BP was 130/82.  Propanolol (a beta blocker) was added to the treatment protocol in December 2007 and BP at follow-up was 140/82.  Post-separation in December 2008 BP was 136/90 and treatment was switched to atenolol (a beta blocker) and benazepril (an ACE inhibitor).  By February 2009 the CI’s BP was 120/80.  

Hyperlipidemia.  The CI’s lipids (cholesterol 230, triglycerides 201, and LDL 152) were elevated in January 2005 and remained elevated in September 2007.  Treatment consisted of simvastatin (a lipid lowering medication).  However, hyperlipidemia is not a physical disability.

There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended 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 or majority recommends no change in the PEB adjudication.  In the matter of the chronic low back pain condition and IAW VASRD §4.71a, the Board unanimously or majority recommends no change in the PEB adjudication.  In the matter of the contended depression, PTSD, primary insomnia, essential hypertension, and hyperlipidemia conditions, the Board unanimously or majority 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 20140221, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

18AUG2016

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 XXXXXXXXXXXXXXXXXXXX, AR20160010629 (PD201401064)

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