RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02652
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20020917

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Job Title, medically separated for “ankle instability” rated 0% and 0% for each ankle, with a combined disability rating of 0%.

CI CONTENTION:  The CI requested review of all their application.  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 - 20020611	VARD - 20030129	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Ankle Instability	5311	0%	Tendonitis of Peroneal Tendons of Right Foot 	5099-5024	0%	20021210	
	5311	0%	Tendonitis of Peroneal Tendons of Left Foot	5099-5024	0%	20021210	
Ligamentous Laxity	Cat II	No VA Placement	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Ankle Instability (Bilateral).  The service treatment records and Medical Evaluation Board (MEB) narrative summaries (NARSUM) indicated the CI was initially referred to the podiatry clinic in July 2000 with the chief complaint of pain on the back of her right heel that began when she fell down a [ship] ladder on the way to liberty in January 1999.  She had treatment including physical therapy, electrical stimulation, and stretching, and used a CAM [controlled ankle movement] walker and an ankle brace.  Further conservative treatment and a rheumatologic evaluation were carried out.  On examination the CI had extreme ligamentous laxity of the ankles and hyperextension of the knees with hypermobility of the patellae (kneecaps), thumbs, and wrists and was diagnosed as having benign hypermobile joint syndrome without any signs of classic Ehlers-Danlos syndrome (involving the skin, bones, blood vessels, and many other organs).  The CI was placed on limited duty for 8 months with restrictions of no running, no jumping, no physical readiness training, no shipboard duty, and no prolonged standing or walking.  The diagnosis of Achilles tendonitis, which was resolving and ligamentous laxity of both ankles bilaterally (EPTE, service aggravated) was made.  Continued orthotics use, strengthening and stretching exercises, and Trental (pentoxifylline, to increase blood flow) for sickle cell trait, were prescribed.  The Trental was discontinued due to headaches.  Pain in both ankles radiated to the calves and knees.  Vioxx (rofecoxib, a nonsteroidal anti-inflammatory drug (NSAID), Ultram (tramadol, an opioid-like medication) and Pamelor (nortriptyline, an antidepressant medication and for nerve pain), were prescribed.  Possible surgical options involving tendon transfers were considered in March 2001 to stabilize the ankles and prevent instability and inversion sprains.  Surgery of the right foot and ankle was performed for ankle instability and ligamentous laxity in June 2001 with improvement postoperatively.  The CI underwent left ankle surgery consisting of a peroneal tendon transfer and lateral stabilization in October 2001.  At a follow-up visit in January 2002, 3 months after surgery, the CI had transitioned from crutches to sneakers and had some soreness and discomfort.  The range of motion of her ankles was good and stable and she was able to perform a heel raise without pain.  Limited duty was approved on 24 October 2001 citing ligamentous laxity bilaterally and ankle instability bilaterally.  The undated non-medical assessment indicated the CI was not working out of her specialty because of a medical condition, was able to stand watch, had good potential for continued service, was motivated for continued active duty and was recommended for another period of temporary limited duty.  At the MEB examination dated 7 March 2002, the CI reported on DD Form 2807-1, Report of Medical History she used orthotics, had foot surgery, had impaired use of her feet after surgery, had foot pain and numbness and tingling in both feet.  The MEB physical examiner noted on DD Form 2808, Report of Medical Examination, “tenderness/pain on flexion/extension and internal/external rotation” of the feet.  

The NARSUM dated 5 April 2002 indicated the CI was 6 months post-op for left peroneal tendon transfer ankle stabilization procedure and 9 months for the right peroneal tendon transfer ankle stabilization procedure.  She was doing well in weight-bearing in sneakers, but related her left foot did have occasional aches, but no burning or sharp pain.  On examination her incisions were well-healed and her ankles were significantly improved in terms of stability.  Only normal inversion was noted, not the excessive motion that she had prior to surgery.  She also felt occasional muscle spasms through the lateral calf, which were consistent with weakening of the tendon that had been split and transferred.  

At the VA Compensation and Pension (C&P) examination of multiple joints dated 19 December 2002, performed 3 months after separation, the CI reported she still was having pain in her ankles “with rolling under both ankles” and “had actually no relief from the surgery.”  She used NSAIDs for pain relief.  She also noted that she developed multiple other joint pains after the injuries to the ankles.  Physical examination was completely normal and she had full ROM of all joints [including the ankles bilaterally].  She had good strength in all joints and there was no instability or subluxation of the joints.  Her muscle tendon junctions were normal without tenderness or weakness.  There were scars over the lateral malleolar areas bilaterally and tenderness in the peroneal tendon insertions of both ankles.  The diagnosis was chronic tendonitis of the peroneal tendons of both feet.  No other leg abnormalities were noted.  She had full squatting capability and good heel and toe raising capability.  There were no neurologic deficits in the lower extremities.  The examiner opined the CI had a normal examination, but felt there was a large emotional overlay to her condition and a psychological evaluation was most appropriate.  An X-ray of the left ankle showed post-surgical changes, but no fracture, dislocation or acute traumatic abnormality, while an X-ray of the right ankle showed post-surgical changes with two clips noted over the mid talus as well as a clip and an osteotomy defect over the fibula.  

The Board directed its attention to its rating recommendation based on the above evidence. The PEB assigned a 0% rating for the Category I (unfitting condition) ankle instability using code 5311 (Group XI IAW VASRD §4.73 (muscle injuries) (presumably for one ankle, the ipsilateral ankle) and a 0% rating using code 5311 (presumably the other ankle, the contralateral ankle) for the Category I ankle instability.  The PEB determined that ligamentous laxity was a Category II (conditions that contribute to the unfitting conditions) and was related to the Category I diagnosis of ankle instability.  The VA assigned a 0% rating using code 5099-5024 (tenosynovitis) for tendonitis of peroneal tendons of the right foot claimed as right foot/ankle tendonitis.  The VA assigned a 0% rating using code 5099-5024 for tendonitis of peroneal tendons of the left foot claimed as chronic left foot/ankle tendonitis.  Additionally, the VA assigned a 0% rating using code 7804 (scar(s), unstable or painful) for scars of the left and right ankles, which were not in the scope of review.  The Board sought a route to a higher rating and noted that the PEB assigned separate ratings for each ankle condition.  A 10% rating using code 5311 requires the a condition to be of moderate severity; however, examinations proximate to separation demonstrated normal healing of the right ankle and healing in process of the left ankle, which militate against a moderate rating for either ankle, but at the VA examination, although the examination of each ankle was normal, nevertheless the diagnosis of chronic tendonitis of the peroneal tendonitis of both feet was made.  Furthermore, the CI was able to do heel raises without pain that precludes the use of analogous code 5099-5003 (degenerative arthritis) in the absence of objective evidence of pain and noncompensable ROMs for each ankle, although at the MEB physical examination tenderness/pain was reported on ankle motion, but subsequent examinations (NARSUM and VA C&P) did not find painful motion.  Additionally, in the absence of ankylosis of the ankle (5270) or subastragalar (below the talus) or tarsal joint ankylosis (5272), limited motion of the ankle (5271), malunion of the os calcis or astragalus (calcaneous or talus) or astragalectomy (removal of the talus bone) (5272) of either ankle, the Board was unable to find a route to a higher rating.  However, the Board did determine that ligamentous laxity, the Navy Category II condition, did contribute to the Category I ankle instability condition of each ankle and is not separately unfitting and not compensable.  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 instability condition.

BOARD FINDINGS: In the matter of the bilateral ankle instability condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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 20140512, 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 24 Jun 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 USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC 

						XXXXXXXXXXXXXXXXXXXX
	     				  	Assistant General Counsel
						(Manpower & Reserve Affairs)