RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02593
BRANCH OF SERVICE:  Army	BOARD DATE:  20150327
SEPARATION DATE:  20030730

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-1 (Basic Trainee) medically separated for bilateral ankle conditions.  These conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was issued a permanent L3 and referred for a Medical Evaluation Board (MEB).  Sinus tarsi syndrome bilaterally condition was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB..  The Informal PEB adjudicated sinus tarsi syndrome bilaterally as unfitting, rated 0% with likely application of the US Army Physical Disability Agency (USAPDA).  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/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:

IPEB – Dated 20030716	VA* - (~2 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Sinus Tarsi Syndrome Bilaterally	5009-5003	0%	Sinus Tarsi Syndrome Right Ankle	5299-5272	10%	20030916	
			Sinus Tarsi Syndrome Left Ankle	5299-5272	10%	20030916	
Other x 0 (Not In Scope)	Other x 0	
RATING:  0%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20040121 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:  The PEB combined sinus tarsi syndrome as a single unfitting and rated condition, coded analogously to 5003 IAW the USAPDA pain policy.  The Board must apply separate codes and ratings in its recommendations, if compensable ratings for each condition are achieved IAW VASRD §4.71a.  If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each “unbundled” condition was unfitting.  Not uncommonly this approach by the PEB reflects its judgment that the constellation of conditions was unfitting; and, that there was no need for separate fitness adjudications, not a judgment that each condition was independently unfitting.  Thus the Board must exercise the prerogative of separate fitness recommendations in this circumstance, with the caveat that its recommendations may not produce a lower combined rating than that of the PEB.

Sinus Tarsi Syndrome Bilaterally.  The CI was seen initially on 8 May 2003 for ankle pain; and treatment was with a profile and a nonsteroidal anti-inflammatory medication.  The CI’s condition was diagnosed as the sinus tarsi syndrome bilaterally and the left foot and was treated with an injection.  The injection did not help and another was given 7 days later.  X-rays were reported to be negative for fractures.  Ankle braces were added to the treatment regimen because of Achilles’ tendonitis bilaterally.  Bed rest and Tylenol # 3 (a narcotic-codeine and acetaminophen) were prescribed.  A bone scan dated 9 July 2003 for of the tibia and fibula bilaterally indicated moderate stress changes of the tibial shafts without focal stress fractures and moderate stress changes in the ankles and mid feet bilaterally.  Severely intense stress change was noted in the distal portion of the talus (the bone where the ankle adjoins the foot) bilaterally and also in the navicular bone of the right foot.

A permanent P3 profile was issued on 6 June 2003 for sinus tarsi bilaterally with limitations of military functional activities and physical fitness testing.  At the MEB Medical History (DD 2807-1) dated on 11 June 2003, approximately 3 weeks prior to separation, the CI reported “both ankle joints very painful,” “unable to walk correctly or stand for long,” and “cannot run.”  “Achilles tendinitis” as the defects and diagnoses and noted “see Podiatry Board for details.”  No commander’s statement was available for review.

At the MEB narrative summary examination dated 30 June 2003, a month prior to separation, the CI reported bilateral foot pain, which began in the first week of basic training in the left foot and 5 days later in the right foot in the absence of trauma.  Treatment consisted of braces, crutches, profiles, medication (Indocin-a nonsteroidal anti-inflammatory medication) and multiple injections into the sinus tarsi area, all without relief of pain.  The CI considered the severity of the pain at 8/10.  As a result she was unable to stand for long periods of time, sustain prolonged walking, squatting, marching, or running.  Examination revealed pain to palpation to the sinus tarsi area (posterior lateral foot between the ankle and heel); pain with the subtalar joint range-of-motion (ROM) for inversion and eversion; and pain at the end of ankle dorsiflexion.  The CI was diagnosed with sinus tarsi syndrome bilaterally.

At the VA Compensation and Pension examination dated 16 June 2003, 6 weeks after separation, the CI reported bilateral ankle pain with extension into the right lateral foot and swelling in both ankles and feet.  The pain ranged from 7/10 to 9/10 in severity.  Both ankles had a full ROM with flexion of 45 degrees (normal 45 degrees) and dorsal extension of 15 degrees (normal 20 degrees).  There was exquisite tenderness present in multiple areas, especially each medial and lateral ankle as well as over the sinus tarsi areas.  The anterior tibial areas (front of the lower legs near the ankles) were mildly sensitive to pressure.  The examiner expected improvement and recommended the CI be re-evaluated in 4 to 6 months.  In an addendum the examiner noted the tenderness in the feet and ankles was not related to ankle motion, which was not limited by pain, fatigue, weakness or lack of endurance.

At a VA podiatry visit dated 12 January 2004, 6 months after separation, the CI indicated the pain was localized to the anterior ankle and not the sinus tarsi.  She also had discomfort at the lateral and posterior ankle and had tenderness at the sinus tarsi.  Additionally, she had a mild drawer sign (indicating laxity) of the right ankle compared to the left.  The CI was re-evaluated by the VA on 14 July 2004, 2 weeks short of a year after separation.  The CI, who was 3 weeks post-partum, noted significant ankle swelling during the pregnancy.  Her right foot had pain more adjacent to the Achilles tendon and over the lateral ankle as well as portions of the 4th and 5th metatarsals (bones of the mid foot).  She took both Vicodin (a narcotic-hydrocodone and acetaminophen) and Tolectin (tolmetin-a nonsteroidal anti-inflammatory medication) and used neoprene wraps around both ankles for stability.  She had a right-sided limp and full ROM of the right ankle, but did not dorsiflex the ankle when she walked.  The CI had discomfort over the inferior aspect (lower portion) of the right lateral ankle and the 4th and 5th right metatarsals and mild discomfort below the right inner ankle over the sinus tarsi.  On the left ankle, she had mild discomfort over the lateral ankle and minimal discomfort on the inner ankle with no pain on palpation of the Achilles tendon.  The ROM of both feet was plantar flexion 0-50 degrees, dorsiflexion 0-15 degrees, inversion 0-35 degrees, and eversion 0-20 degrees with discomfort at the endpoint of the entire ROM, which was not limited by repetition.  A right draw sign showed mild laxity compared with the left.  She was able to walk on her heels and toes with a slight limp on the right.  In November 2004 the CI had good ROMs and tenderness on palpation of the lateral compartment of both ankles with the impression of bilateral chronic ankle pain.  The CI was fitted for crutches on 3 February 2005.  On 31 March 2005 the CI reported hydrocodone lost effectiveness and Oxycodone worked to relieve the pain.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a rating of 0% using code 5099-5003 (degenerative arthritis) for the bilateral sinus tarsi syndrome that was rated for pain, moderate, intermittent.  The VA assigned a 10% rating using code 5299-5272 (subastragalar or tarsal joint, ankylosis) for sinus tarsi syndrome of the right ankle and 10% using code 5299-5272 for sinus tarsi syndrome of the left ankle.

The Board first considered whether the left ankle sinus tarsi syndrome pain was reasonably justified as separately unfitting.  Members agreed that the evidence supports that the functional limitations of the left ankle sinus tarsi syndrome could be reasonably justified as separately unfitting and a separate rating is recommended.  Use of code 5099-5003 affords an opportunity for a 10% rating; however, there is no route to a higher rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left ankle tarsi syndrome condition.

The Board then considered whether the right ankle sinus tarsi syndrome was reasonably justified as separately unfitting.  Members agreed that the evidence supports that the functional limitations of the right ankle sinus tarsi syndrome could be reasonably justified as separately unfitting and a separate rating is recommended.  Use of code 5099-5003 affords an opportunity for a 10% rating; however, there is no route to a higher rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right ankle tarsi syndrome condition.

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 PEB appeared to rely on the USAPDA pain policy for rating the bilateral tarsi syndrome was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the left tarsi syndrome condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the right tarsi syndrome condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:

CONDITION	VASRD CODE	RATING	
Sinus Tarsi Syndrome Left Ankle	5099-5003	10%	
Sinus Tarsi Syndrome Right Ankle	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140522, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB									

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, AR20150014884 (PD201402593)

1.  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 to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     

CF: 
(  ) DoD PDBR
(  ) DVA