RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02014
BRANCH OF SERVICE:  NAVY	BOARD DATE:  20141219
SEPARATION DATE:  20080630

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Records Custodian) medically separated for a right ankle condition.  The right ankle condition could not be adequately rehabilitated to meet the physical requirements of his Rating or satisfy physical fitness standards.  He was placed on limited duty and referred for a Medical Evaluation Board (MEB).  The right ankle condition, characterized by the MEB as “villonodular synovitis involving ankle and foot,” “other joint derangement, not elsewhere classified, ankle and foot” and “other enthesopathy of ankle and tarsus,” were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “chronic post traumatic ankle synovitis, right ankle” as unfitting, rated 10%, with likely application of the VA Schedule for Rating Disabilities (VASRD).  Chronic sinus tarsi syndrome, right ankle and foot and pes planus with subtalar joint instability bilateral feet were determined to be Category II conditions (which contributed to the Category I condition, but not rated).  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI stated, “increase in pain and overall medical condition.”

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/Naval 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 IPEB – Dated 20080118	VA* - (6 Mos. Pre-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Post Traumatic Ankle Synovitis, Right Ankle	5299-5003	10%	Right Ankle Strain s/p Arthroscopy	5271-5024	10%	20071219	
Chronic Sinus Tarsi Syndrome, Right Ankle and Foot	CAT II	No VA Entry	
Pes Planus with Subtalar Joint Instability, Bilateral Feet	CAT II	No VA Entry	
Other x 0 (Not in Scope)	Other x 7	
Rating:  10%	Combined:  60%	
*Derived from VA Rating Decision (VARD) dated 20080730 (most proximate to date of separation (DOS))

ANALYSIS SUMMARY:  The PEB combined the right ankle, right foot and bilateral pes planus (flat feet) conditions under a single disability rating (Category I right ankle and Category II bilateral feet) conditions.  The right ankle and foot conditions are discussed together as the ankle and foot conditions significantly overlapped clinically.  The left ankle and foot conditions are considered together, but separately from the right side.

Right Ankle Condition (Right Ankle Synovitis; Right Foot Chronic Sinus Tarsi Syndrome; and Bilateral Feet Pes Planus with Subtalar Joint Instability).  The record and narrative summary (NARSUM) noted that the CI entered Service with moderate asymptomatic pes planus (flat feet-documented on Military Entrance Processing Station physical dated May 2004).  He had a right ankle inversion sprain during training in March 2006 with recurrent ankle pain and swelling.  Imaging (X-ray and magnetic resonance imaging) found no evidence of fracture or extra bone formation (os trigonum).  The CI underwent steroid injection followed by arthroscopic surgery in May 2007.  The diagnosis was synovitis and surgery included a synovectomy (removal of the inflamed joint lining) with no cartilage damage found.  Right ankle limited motion and pain persisted despite physical therapy and inserts (orthotics).  The NARSUM stated “The (CI) now continues to have pain secondary to the pes planus, and chronic ankle pain/ subtalar joint pain in both feet with standing, walking, running, marching, and field activities.  … complaints of bilateral foot pain and right ankle pain.”  The MEB physical exam performed 8 months prior to separation noted right ankle with full active range-of-motion (ROM) without pain.  Scars were well healed and there were no neurologic or vascular deficits.  The examiner indicated the CI was obese with no limp.  Feet exam indicated a normal exam and normal arch.

At the VA Compensation and Pension exam performed 6 months prior to separation, the CI reported right ankle weakness, pain, giving way, “locking non-movement sometimes and joint moves around bone.”  He did not have “heat, redness, fatigability and dislocation.”  Exam indicated a normal gait with right ankle tenderness.  There were no signs of edema, guarding or instability.  Ankle ROM was 20 degrees dorsiflexion (normal) and 45 degrees plantar flexion (normal) with pain on repetition, but no decreased in ROM.  There was no VA exam or claim for the feet.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right ankle at 10% analogous to 5003 (arthritis) including all MEB conditions of the right lower extremity (included right foot/right flatfoot).  The VA rated the right ankle at 10% coded 5271-5024 (ankle limited motion and tenosynovitis) without exam or rating of the foot.  The Board considered that neither exam proximate to separation indicated symptoms or pathology of the right foot that that would have been separable from the ankle condition (IAW §4.14 - avoidance of pyramiding).  Higher rating under code 5271 (marked limited motion-20%) was not supported by the evidence.  The Board discussed potential alternate coding and rating under code 5276 (pes planus – flat foot) or code 5284 (foot injuries; other) to include the ankle synovitis and all ankle and foot disability; however, there was insufficient support for higher than a 10% (moderate) disability at the time of separation.  No coding change would provide for any benefit 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 right ankle and foot condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the left foot and ankle conditions were not separately unfitting and ratable.  The evidence makes clear that the right ankle and foot was associated with more disability than the left one in this case.  The disparity was such that the question is raised of whether the left ankle and/or foot were reasonably justified as unfitting.  There was scant evidence of left ankle/foot symptoms prior to the CI’s entry into the disability system; however, the right ankle condition may have overshadowed the left and may have placed additional stress on the left side.  The MEB exam of the left ankle and foot indicated no limitation of motion or pain, while the NARSUM indicated left pes planus, subtalar instability, and pain-limited ankle motion.

The VA pre-separation exam indicated normal ROM of the left ankle without pain and with a normal gait.  Any rating of the left ankle/foot would be no higher than “mild” (0%) analogously to 5099-5276 IAW VASRD §4.71a.  After due deliberation in consideration of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB determination (as Category II; not rated) for the left ankle/foot contended 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 right ankle condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended left ankle and bilateral feet (pes planus) conditions, the Board unanimously recommends no change from the PEB determinations as Category II (not separately rated).  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 20140502, 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 10 Jun 15

      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:

- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN