RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2014-01083
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20090727

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E6, Education and Training Craftsman, medically separated for “bilateral ankle instability,” with a disability rating of 20%.

CI CONTENTION:  His foot condition continues to negatively impact his daily activities and hypertension was not considered.  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 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 - 20090427	VARD - 20091113	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Ankle Instability	5099-5003	20%	Degenerative Joint Disease, Right Ankle (Claimed as
Osteochondral Defect)	5010-5271	10%	20090911	
			Degenerative Joint Disease, Left Ankle (Claimed as
Osteochondral Defect)	5010-5271	10%		
Hypertension	7101	Cat II	Hypertension (Claimed as High Blood Pressure)	7101	10%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Bilateral Ankle Instability.  The service treatment record (STR) and narrative summary (NARSUM) documented initial care for non-traumatic bilateral ankle pain in 1999-2000 that was diagnosed as bilateral osteochondral defects (OCDs) of the ankle (talar bones).  The STR was silent for any entries through 2005.  Arthroscopies were performed on the left ankle in October 2005 and on the right in January 2006.  Radiographic imaging in September 2007 documented bilateral OCDs (right greater than left), with “probable” degenerative changes of the right distal tibia.  At a podiatry visit in December 2007, the CI reported bilateral ankle pain (right greater than left) with cracking and popping, and with walking and running.  The examiner documented bilateral ankle crepitus, locking, bilateral anterior instability (positive anterior drawer sign, right greater than left) and diagnosed traumatic arthritis bilateral ankle joints (right worse than the left).  At orthopedic visits in February and April 2008, normal ROM, gait and strength were noted with no edema and mild anterior and posteromedial tenderness.  Anterior and lateral ankle ligaments were “stable” and there was symmetric ankle and subtalar motion with no ligamentous laxity; an immobility device was prescribed for the right ankle.  At an orthopedic visit in August 2008, the examiner documented 2-4 mm of anterior laxity bilaterally with tenderness of the lateral ankle (at the anterior talofibular ligament) bilaterally.  

At an MEB examination dated 24 November 2008 (8 months pre-separation), the CI reported bilateral ankle weakness with activity, and reported use of orthotics with his combat boots.  He denied locking, popping, and clicking and any significant swelling or tenderness of the ankles.  The examiner documented the absence of tenderness, painful motion, instability, laxity and subluxation.  There was full ROM of both ankles.  There was no STR documentation of physician prescribed bed rest for incapacitating episodes.  

The NARSUM examination was performed on 2 January 2009 (6 months pre-separation).  The examiner documented normal plantar flexion and dorsiflexion of the bilateral ankles with no tenderness, no laxity, and no pain during ambulation.  At a visit to physical therapy for orthotic replacements in February 2009 (5 months pre-separation), the CI reported that walking was less painful with orthotics.  

At the VA Compensation and Pension (C&P) examination dated 11 September 2009 (2 months post-separation), the CI reported constant 4/10 pain with intermittent swelling and instability.  Daily flares (7/10 pain) occurred and would “last all day.”  The examiner documented dorsiflexion of 10 degrees (normal 20), and plantar flexion of 20 degrees (normal 45).  There was tenderness bilaterally with painful motion; normal strength and stability; and no additional limitations on repetition.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB adjudicated the bilateral ankle condition as a single unfitting condition, rated 20%, analogously coded 5099-5003 (degenerative arthritis).  The VA rated each ankle individually at 10% each, analogously coded 5010-5271 (degenerative arthritis, moderate limitation of ankle motion).  In this case, both ankles were considered to fail retention standards, both were implicated by the NARSUM and both were profiled.  Both ankles had similar diagnoses, were equally addressed throughout the STR, and had similar surgeries and therapies.  Members agreed that the evidence of the record reasonably supported that each ankle was separately unfitting; and, that coding and rating features be essentially identical.  

The Board next considered the evidence for a rating higher than 20%.  In the absence of ankylosis (defined as as abnormal stiffening and immobility of a joint due to fusion of the bones), there was no route to a higher rating for using codes 5270 or 5272 for either ankle.  There was no surgical fusion of the talus bone (5273) or documentation of a marked deformity from malunion (5273) or nonunion (5283) of either right or left talus for a higher individual rating; nor was there was evidence of incapacitating episodes that would support a higher rating.  Several STR entries documented normal or full ROM of the bilateral ankles that would result in a 0% rating for each ankle under code 5271 (limited motion).  Only the post-separation VA exam documented a 50% reduction in ROM that could be described as a moderate limitation of ankle motion, and supportive of a 10% rating for each ankle.  There were no measurements in evidence to support a higher rating for marked limitation of motion.  There was radiographic evidence of degenerative arthritis of both ankles for coding under 5003.  There was remote documentation of crepitation; and painful motion noted bilaterally, that was also present post-separation in support of a 10% rating for each ankle IAW VASRD §4.59.  However, assigning a 10% rating to each ankle would be equivalent to the combined PEB adjudication and offer no advantage to the CI.  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 bilateral ankle condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the hypertension condition was 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.  The hypertension was note profiled or implicated in the commander’s statement and was not judged to fail retention standards.  All were reviewed and considered by the Board.   There was no performance based evidence from the record that the hypertension 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 condition and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the bilateral ankle condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended hypertension condition, the Board unanimously recommends no change from the PEB determination 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 20140219, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-01083.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings