RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02690
BRANCH OF SERVICE:  NAVY	BOARD DATE:  20150626
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 (Culinary Specialist) medically separated for right ankle instability.  The ankle condition could not be adequately rehabilitated to meet the physical requirements of her Rating.  She was placed on LIMDU and referred for a MEB.  The “pain in joint involving ankle and foot” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The MEB also identified and forwarded one other condition (other joint derangement, not elsewhere classified, ankle and foot) for PEB adjudication.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “right ankle instability” as unfitting, rated 10% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining condition was determined to be Category II (contributing to the unfit condition).  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 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 20090305	VA* - (~19 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Ankle Instability	5099-5003	10%	Right Ankle Strain	5271	20%	20110113	
Right Ankle Pain	Cat II					
Other x 0 (Not In Scope)	Other x 2 (equals SC, NSC & deferred)	
RATING:  10%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20110418 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Right Ankle Instability Condition.  The narrative summary (NARSUM) notes The CI injured her right ankle in June 2002.  Notes in the service treatment record indicated that the CI experienced ankle injury referred to as a “dislocation” and also as a “sprain.”  A magnetic resonance imaging (MRI) scan of the ankle on 17 December 2002 notes a small joint effusion and was otherwise normal.  The ankle symptoms improved, but over the next 5 years the CI had waxing and waning problems with ankle pain and swelling that was improvd by use of an ankle brace.  Evaluations over the years, including a bone scan and ankle and tibia-fibula X-rays, were negative.  According to the NARSUM the CI was managing with her ankle condition until she fell down a ladder in 2006 and the ankle pain worsened and physical therapy was recommended.  The CI failed a Physical Readiness Test in October 2007 because she had to stop running due to ankle pain and was referred to podiatry.  The podiatry evaluation noted normal ankle motion without instability, but noted guarding against subtalar joint movement (ankle joint between the talus and the calcaneus) and diagnosed foot sprain (subtalar joint).  At a follow-up podiatry visit on 28 January 2008, an MRI of the foot and ankle reportedly showed an effusion with no abnormality of the bone or cartilage.  Ankle arthroscopy was performed on 13 February 2008 with debridement of some inflamed joint tissue and scar tissue, with no other abnormality of the ankle noted.  Following the arthroscopy the CI continued to have pain and following another aggravation she reported numbness and tingling in the area.  She was evaluated by neurology and electrodiagnostic studies (EMG/NCV) of the right lower extremity (RLE) were normal.  A follow-up neurology visit dated 18 August 2008 noted normal strength, sensation, and reflexes of the RLE, but an antalgic gait was noted.  The neurologist did not think a significant nerve related diagnosis was likely.  Orthopedic evaluation on 20 August 2008 noted the CI used a boot walker while at work.  On exam ankle range-of-motion (ROM) was dorsiflexion (DF) 10 degrees and plantarflexion (PF) 5 degrees.  The CI was given an ankle injection and referred to pain management.  A pain management consult on 5 September 2008 noted that the CI did not meet all criteria for a diagnosis of reflex sympathetic dystrophy (RSD - also known as complex regional pain syndrome), but recommended a trial of injections for the pain.  The CI was also prescribed medication for nerve related pain, topical anesthetic patches, and was recommended to move the foot and ankle more and abandon the walker boot.  An orthopedic evaluation on 20 November 2008 noted the CI had no benefit from the pain management injections and recommended an MEB.  A civilian neurological opinion dated 17 December 2008 was addressed to the MEB NARSUM examiner.  The neurologist indicated that he did not think there was any evidence of RSD and suspected the ankle pain was due to joint pathology.

At the MEB examination on 17 December 2008, the CI reported right ankle pain with weight bearing activities and a “feeling of instability.”  The MEB physical exam noted right ankle swelling with anterior and lateral tenderness of the ankle.  No LE motor or sensory deficits were noted.  Ankle ROM was DF 10 degrees and PF 15 degrees.  There was full ROM of the knee without instability.  The skin appeared normal and there was tenderness of the calf.  Ankle X-rays reportedly showed no soft tissue swelling or degenerative joint changes.

A VA outpatient podiatry evaluation for ankle surgery dated 17 November 2010, 17 months after separation noted TTP of the ankle and “guarded ROM,” but the examiner could dorsiflex the foot and the exam was otherwise normal.  Ankle X-rays from 2010 were noted to show “no gross abnormalities” and the assessment was chronic right ankle arthralgia secondary to trauma.

At the VA Compensation and Pension (C&P) General examination on 13 January 2011, performed 19 months after separation, the CI reported use of an ankle brace, daily pain medication, and medication for nerve related pain.  The exam noted an antalgic gait, with normal pulses, strength, sensation, and reflexes of the LEs, without skin abnormalities.  The VA examiner noted “there is no objective evidence of neuropathy on exam.”  At the C&P Joints exam the same day the CI reported the same symptoms and indicated she wore an ankle brace all the time.  On exam the CI’s gait was noted to be antalgic, with tenderness and swelling of the ankle and guarding of joint movements, without instability or deformity.  Ankle ROM was DF of 10 degrees and PF was 25 degrees with painful motion.

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.

Right Ankle ROM
(Degrees)	MEB ~6 Mo. Pre-Sep
(20081217) p.28	VA C&P Joints ~19 Mo. Post-Sep
(20110113 p.86	
Dorsiflexion (20 Normal)	10	10	
Plantar Flexion (45)	15	25	
Comment	No instability; +brace	No instability; +brace	
§4.71a Rating	20% (PEB 10%) 	10-20% (VA 20%)	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the ankle condition, characterized as “right ankle instability” 10%, coded 5099-5003 (analogous to degenerative arthritis) and adjudicated “right ankle pain” as a Category II condition.  The VA rated the ankle condition 20%, coded 5271 (limited ankle motion).  The Board agreed that the evidence in record supports that the ankle condition met a 10% rating coded as 5003 for painful, limited ankle ROM or coded as 5271 for “moderate” limited ankle ROM.  The Board reviewed to see if a higher evaluation was achieved with any applicable coding choice IAW §4.71a (musculoskeletal conditions).  The next higher evaluation of 5003 requires rating of two or more major joints or groups of minor joints, not in evidence in this case.  There was no evidence of ankyloses of the foot or ankle or malunion of the ankle with “marked” deformity to support a higher rating.  The Board next noted that the rating criteria of 5271 are subjective with 10% for “moderate” and 20% for “marked” limited ankle ROM.  The Board considered that at separation total right ankle ROM was less than 50% of normal ankle ROM and was combined with objective findings of recurrent ankle tenderness, swelling, and an antalgic gait on exams, with reported use of an ankle brace all the time  The Board noted that at the C&P examination the CI’s ankle ROM alone was improved and was more consistent with “moderate” limited ankle motion, but the exam was 19 months after separation and the CI was still noted to have a swollen, tender ankle, and reported using daily medications and an ankle brace.  Member consensus was that with consideration of VASRD §4.40 (Functional loss) the CI’s disability picture due to the ankle condition at separation more closely met the 20% rating for “marked” ankle limited motion, the highest rating available with this code.

The Board finally discussed whether coding the ankle condition IAW §4.124a (neurological conditions) was appropriate in this case.  The weight of medical opinion in record, before and after separation, did not support that the CI had RSD or a neuropathy of the RLE.  However, prior to separation the civilian pain specialist pursued treatment of the ankle for possible nerve contributions to the pain.  The Board’s opinion was that the medical evidence did not provide strong support for the §4.124a coding approach, but considered the option.  The Board noted that coding analogous to tarsal tunnel syndrome (8699-8625, posterior tibial nerve neuritis) - a compressive neuropathy of the foot that causes medial ankle and foot pain symptoms (similar to the CI’s anterior and lateral ankle pain) would result in no higher than a 10% rating IAW VASRD §4.123, which states that the maximum rating for a neuritis without sensory or motor deficits, or abnormal reflexes is the “moderate” level.  The Board makes note that the PEB also adjudicated “right ankle pain” as a Category II diagnosis; but, in this case right ankle instability and ankle pain refer to the same disability and two ratings are not sanctioned by VASRD §4.14 (Avoidance of pyramiding).  Thus, the Board concluded that the evidence supports a 20% rating for the disability due to the ankle condition and no higher.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the right ankle condition, coded 5271.

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 ankle condition, the Board unanimously recommends a disability rating of 20%, coded 5271 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	
Right Ankle Instability Condition	5271	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140528, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
		     DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)
       RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
      (b) PDBR ltr dtd 31 Aug 15 ICO XXXXXXXXXXXXXXX
      (c) PDBR ltr dtd 16 Jul 13 ICO XXXXXXXXXXXXXXX
	 (d) PDBR ltr dtd 31 Aug 15 ICO XXXXXXXXXXXXXXX
	 (e) PDBR ltr dtd 28 Aug 15 ICO XXXXXXXXXXXXXXX
	 (f) PDBR ltr dtd 31 Aug 15 ICO XXXXXXXXXXXXXXX

1.  Pursuant to reference (a) I approve the recommendations of the Physical Disability Board of Review set forth in references (b) through (f).

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXX, former USN: Entitlement to disability severance pay effective date of discharge with a 10 percent disability rating (increased from 0 percent).

     b. XXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 20 percent) effective date of discharge (9 Jun 2002). ****

     c. XXXXXXXXXXXXXXX, former USN: Entitlement to disability severance pay effective date of discharge with a 20 percent disability rating (increased from 10 percent).

     d. XXXXXXXXXXXXXXX, former USN: Entitlement to disability severance pay effective date of discharge with a 20 percent disability rating (increased from 10 percent).

     e. XXXXXXXXXXXXXXX, former USN:  Entitlement to disability severance pay effective date of discharge with a 10 percent disability rating (increased from 0 percent).

****This case was previously adjudicated on 27 Aug 2013.  That decision erroneously listed the PDRL date as 2009 vice 2002.  Correction is now required to ensure service member receives appropriate compensation.

3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.