RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-01822
BRANCH OF SERVICE:  Army		SEPARATION DATE:  20090616

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Petroleum Supply Specialist) medically separated for chronic left ankle pain.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  Chronic left ankle pain, osteoarthritis was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded stress headaches and occasional mid thoracic spine/spasm for PEB adjudication.  The Informal PEB adjudicated chronic left ankle pain as unfitting, rated 10%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  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 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:

IPEB – Dated 20090303	VA* - (~10 Mo. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Ankle Pain	5271	10%	Ankle Strain, Left	5271	10%	20100422	
Stress Headaches	Not Unfitting	No VA Entry	
Mid Thoracic Spine/Spasm	Not Unfitting	Thoracolumbar Strain	5237	10%	20100422	
Other x 0 (Not In Scope)	Other x 2	
RATING:  10%	RATING:  50%	
*Derived from VA Rating Decision (VARD) dated 20100507 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY: 

Left Ankle Condition.  The service treatment record (STR) documents that the CI sustained recurrent left ankle injuries.  She initially twisted her left ankle during basic training.  A clinic encounter listed 7/10 left ankle pain, that was worse when actively moved.  The ankle exam revealed tenderness, without swelling, erythema (redness), or deformity.  Ankles showed full range-of-motion (ROM) and the diagnosis listed ankle sprain.  A year later, the CI stepped in a pothole and twisted her left ankle during a company run.  A left foot X-ray was normal and a left ankle CT showed medial ankle intra-articular loose bodies, but no obvious acute displaced fracture.  A physical therapy encounter documented the CI had left anterior ankle pain since she sprained it in basic training.  She had been treated with rest, ice, compression, elevation (RICE), ROM exercises, arch supports, and stretches for over a year.  Pain was exacerbated by weight bearing, weather changes, and movement and relieved by rest, elevation, hot showers, and Motrin.  The CI had been using a controlled ankle motion (CAM) walker for a month, and crutches as needed.  The physical exam showed an antalgic (assuming a gait to lessen pain) gait and the ankle was globally tender with abnormal ankle motion.  A left ankle MRI showed no free fragment, loose body, or ligamentous or tendinous pathology.  There was a 2mm bony (cortical) defect in the distal tibia.  The MEB narrative summary (NARSUM), 6 months before separation, recounted the history and interventions.  The CI complained of chronic 7/10 left ankle pain with associated mild swelling.  Pain was exacerbated to 9/10 with walking greater than 1/2 mile or riding a stationary bike for 30 minutes.  The physical exam documented an antalgic gait with a marked left ankle limp.  The left ankle exam revealed anterior ankle joint tenderness without masses, ecchymosis (bruising), or edema.  There was anterior ankle pain with stressing for stability assessment.  There was no instability to anterior, posterior, medial, or lateral stresses.  It documented “Good dorsi and plantar flexion passively” and that the rest of the physical exam was normal.  The left ankle ROM values, measured by PT with a goniometer, are in the chart below.  A left ankle X-ray and MRI were normal.  A PT exam documented an antalgic gait with tenderness at the left ankle and heel.  The left ankle ROM values are in the chart.

The VA Compensation and Pension (C&P) exam, 10 months after separation, recounted the history and interventions.  The CI complained of pain, swelling, stiffness, weakness, and severe weekly flare-ups.  She denied effusion, deformity, giving way, instability, incoordination, dislocation, subluxation, or locking.  Pain was exacerbated by activity and cold or rainy weather.  Pain was relieved by limiting activity, an ankle brace, an orthotic, physical therapy, ice, and a topical analgesic (lidocaine ointment 5%).  The CI reported "I can't walk, don't want to stand because it hurts too much, I can't clean house, can't go to the store, just stay home."  The CI was able to stand for 15-30 minutes but was unable to walk more than few yards.  The physical exam revealed an antalgic gait without evidence of abnormal weight bearing.  The left ankle exam revealed tenderness without instability, angulation, ankylosis, or tendon abnormality.  Strength, sensation, and deep tendon reflexes were normal.  Left ankle active ROM was dorsiflexion of 15 (20 normal) and plantar flexion of 30 (45) degrees.  There was evidence of pain with active ROM, but no additional limitation after three repetitions.  Repetitive testing ROM values were unchanged from baseline and no pain, fatigue, weakness, or incoordination was noted.

The goniometric 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.

DOS 20090616
Left Ankle ROM
(Degrees)	MEB 
~6 Mo. Pre-Sep	Podiatry 
~9 Mo. Post-Sep	PT 
~9 Mo. Post-Sep	VA C&P 
~10 Mo. Post-Sep	
Dorsiflexion (20 Normal)	5,5,5	Full	-10	0-15	
Plantar Flexion (45)	35,35,35	Full	WNL	0-30	
Comment	Goniometer used	Painful ROM	--	--	
§4.71a Rating	20%	10%	20%	10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 10% coded 5271 (Ankle, limited motion).  The PEB cited imaging findings, antalgic gait, tenderness, 35% loss of ROM, and painful motion in one joint.  The VA, citing the C&P exam 10 months after separation, rated the left ankle condition 10% also coded 5271.  The VA cited an antalgic gait, moderate limited ROM, and painful motion in one joint.  The ROM values in the proximate exams (MEB, podiatry, PT, C&P) showed an overall trend of improvement.  Board members agreed that the ankle limitations in motion (5271) 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), or 5273 (Os calcis or astragalus, malunion).  There was no excision of the astragalus for consideration under 5274 (Astragalectomy).  Board members agreed that there was sufficient evidence of pain with use prior, as well 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 stress headaches and mid thoracic spine/spasm conditions 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.  

Contended Stress Headaches Condition.  The STR documents two instances of headaches where the CI sought medical care.  At the first instance, the CI complained of 3 days of a dull, aching, boring frontal headache with associated sinus pain, sore throat, and cough.  The headache was not preceded by an aura and she denied a history of migraine headaches.  She was diagnosed with an upper respiratory infection (URI).  At the second instance, the CI presented to the emergency department because of foot pain and an upper respiratory infection.  She complained of a headache with associated sinus pain, nasal discharge, nasal congestion, sore throat, cough, and watering and itching eyes.  She was diagnosed with allergic rhinitis.  The STR remains silent regards headache complaints until after separation.

Contended Mid Thoracic Spine/Spasm Condition.  The STR documents an episode of low back pain, early in basic training, where the CI sought medical care.  At a clinic encounter, the CI complained of generalized, tight, cramps, 7/10 low back pain without stiffness or radiation.  The physical exam revealed a normal gait and stance.  The thoracolumbar, lumbar, and lumbosacral spine appeared normal.  There was thoracolumbar tenderness and lumbosacral spine motion was normal.  Straight leg raise tests (assesses sciatic nerve root compression by a herniated disc) were negative.  At a PT encounter a month later, the CI reported a month long history of lower back and right leg pain.  The physical exam documented a gait with decreased hip/trunk dissociation.  Lumbar spine active ROM showed flexion was 75%, and extension was 50%, of full ROM.  The assessment listed lower back pain with a plan to follow-up with her primary care manager for possible radiological testing if the pain persisted.  The STR remains silent regards back complaints until after separation.

The MEB NARSUM makes only a tangential reference to stress headaches in the medications list, and makes no reference to back complaints.  The stress headaches and mid thoracic spine/spasm conditions 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 either 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 the stress headaches and mid thoracic spine/spasm conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  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 stress headaches and mid thoracic spine/spasm 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.

RECOMMENDATION:  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 20140423, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

06 JUL 2016

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 XXXXXXXXXX, AR20160003407 (PD201401822)

I have reviewed the enclosed Department of Defense Physical Disability Board of
Review (000 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