RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01622
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20060101

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Personnel Specialist, medically separated for “left peroneal tendinitis,” with a disability rating of 10%. 

CI CONTENTION:  The CI received a higher rating from the VA.  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 - 20051128	VARD - 20060926	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Peroneal Tendinitis	5299-5271	10%	Status Post Left Ankle Surgery, Traumatic Arthropathy	5271	20%	20060908	
Left EHL Tendinitis	Cat II					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:

Left Peroneal Tendinitis.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent left ankle arthroscopic surgery on 31 March 2005 for peroneus brevis debridement and superficial peroneal nerve neurolysis.  Pre- and post-operative notes indicated an extensor hallucis longus (EHL) tendinitis had resolved.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “tibialis tendinitis” and “other enthesopathy of ankle and tarsus” for PEB adjudication.

An orthopedic surgical follow-up evaluation on 20 July 2005 (5 months prior to separation), showed left ankle pain severity was 5/10.  Examination exhibited no tenderness.  Left ankle dorsiflexion was 5 degrees (20 normal) and plantar flexion was 10 degrees (45 normal).  Re-evaluation by orthopedics on 3 August 2005, reported no pain that day and foot complaints were denied.  Examination showed dorsiflexion of 10 degrees and plantar flexion of 15 degrees.  There were no findings of ligament instability documented.  The examiner opined that tightness of the Achilles tendon was contributing to some back pain, though it was not clarified how Achilles issues related to the ankle condition.  At the time of the foot and ankle clinic appointment on 24 August 2005 (4 months prior to separation), the CI reported pain in “Achilles tendon” that increased with navigating stairs.  He was not doing his prescribed exercises because they caused pain.  On examination he had decreased strength (4/5) in all planes of movement in the left ankle and tenderness at the Achilles area.  There was no mention of ligament instability.  

At the time of the MEB orthopedic NARSUM examination on 26 October 2005 (2 months prior to separation), the CI’s chief complaint was left ankle pain, but symptoms included giving way, tingling, clicking, grinding, and limping.  Aggravating factors were walking barefoot, running, stairs, rough ground, changes in direction, hard pivots, jumping, quick starts and hard stops.  Examination showed no tenderness, and “normal voluntary extremity movement.”  Left ankle dorsiflexion was 10 degrees and plantar flexion was 15 degrees.  There was no mention of ligament instability.  The examiner’s diagnoses were left peroneal tendinitis and left EHL tendinitis.  During a physical therapy examination on 1 November 2005 the CI reported “some improvement with strength and balance.”  On examination there was mild tenderness over the lateral malleolus.  Dorsiflexion was reportedly -7 degrees and plantar flexion was 45 degrees.  There was mild (4/5) weakness of ankle strength in all directions.  Gait was not reported.  During a clinical visit on 8 November 2005, the CI displayed a normal gait.

A VA primary care clinic evaluation on 3 February 2006 (1 month after separation), noted a history of left Achilles tendinitis.  Exercise was reported to consist of walking for 30 minutes or more.  Examination showed “full ROM [range of motion] with left foot.”  The CI declined a referral for orthopedic evaluation unless the condition worsened.  At a VA primary care clinic appointment on 7 July 2006, 6 months after separation, the examination revealed a well-healed surgical scar, no swelling, and “normal range of motion at the ankle joint.”  The examiner concluded: “Clinically, his ankle looks normal to me, but if he occasionally has pain, he can use tramadol.”

At the VA Compensation and Pension (C&P) examination on 8 September 2006, performed 8 months after separation, the CI reported pain after “prolonged standing, prolonged walking, walking barefoot, walking on uneven ground, running, or jumping.”  Prolonged walking caused him to limp.  He worked 40 hours per week as a warehouse manager and had no difficulty with activities of daily living.  He required no assistive devices.  Physical examination showed a normal gait, but a slight limp developed after walking 200 yards.  There was mild tenderness of the left lateral malleolus and over the lower end of the Achilles tendon.  There was no redness or swelling.  Dorsiflexion was 20 degrees and plantar flexion was 35 degrees.  Repetitive motion was not associated with any pain but did cause loss of 10 degrees of dorsiflexion and loss of 20 degrees of plantar flexion.  Although the examiner did not record evidence of specific ligament damage or laxity (and there was no other documentation of such), “instability” and “weakness” after repetition were cited as the cause of loss of motion after repetition.  Fatigue and lack of endurance were also reportedly associated with repetitive motion.  X-rays were normal except for the presence of a surgical metallic density. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 10% coded 5299-5271 (limited motion of the ankle).  The VA assigned a 20% rating also under the 5271 code for marked limitation of ankle motion.  In deliberating a rating recommendation, the Board noted the variability and inconsistency in ROM assessments by different examiners.  The service orthopedic ROM evaluations performed 5 and 2 months prior to separation were consistent with “marked” limitation of motion; however, the PT examination performed just a few days after the second orthopedic evaluation (2 months prior to separation) showed completely normal plantar flexion and -7 degrees of dorsiflexion.  That degree of limited dorsiflexion was inconsistent with the normal gait reported just 1 week later, and with the VA note 1 month after separation documenting full ROM and the ability to walk greater than 30 minutes.  The VA C&P examination 8 months after separation noted limitation of ROM that was no more than “moderate” (20 degrees of dorsiflexion and 35 degrees of plantar flexion).  While a limping gait after walking 200 yards and a reduction of ROM to a “marked” degree after repetition was noted at this exam, there was inexplicably no pain present after repetition.  Board members debated if the ability to walk over 30 minutes and the additional VA clinic findings 6 months after separation (occasional pain, normal ROM) were consistent with the later C&P examiner’s measurements after repetition.  The Board concluded that the “moderate” stipulation most accurately described the condition at the time of separation.  The Board also considered whether a higher rating was supported under other diagnostic code options, but because there was no ankylosis, nonunion or malunion, VASRD §4.71a offers no applicable ankle joint code which would yield a higher rating.  Other foot injuries (5284) likewise provided no route to a higher rating, and the 5262 code (tibia and fibula, impairment of) was a clinically inappropriate choice.  The Board noted the one additional diagnosis determined by the PEB to be a Category II condition (contributes to the primary unfitting condition but not separately ratable).  Although the fact that the condition was found by orthopedics to be resolved renders the issue moot, even if it was still present, the overall ankle impairment from this additional diagnosis was appropriately subsumed under the rating for the ankle.  More than one rating based on the same impairment is prohibited IAW §4.14 (avoidance of pyramiding).  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:  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 left EHL tendinitis condition, the Board unanimously agrees that it cannot recommend it for additional disability rating.  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 20140318, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 31 May 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN

							XXXXXXXXXXXXXXXXXXXX	     				  					Assistant General Counsel
							(Manpower & Reserve Affairs)