RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2014-02804
BRANCH OF SERVICE:  Army	BOARD DATE:  20150421
SEPARATION DATE:  20070203

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Wheel Vehicle Mechanic) medically separated for left ankle.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic left ankle instability” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “chronic pain/instability left ankle” as unfitting, rated 10%, citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  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 20061206	VA* - (~4 Yrs. & 5 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain/Instability Left Ankle.	5099-5003	10%	Left Ankle Instability	5271	0%	20110324	
Other x 0 	Other x 6 	
RATING:  10%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20110725 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:  As noted above, the left ankle unfitting condition is in scope; however, the right ankle also had findings not in scope, but of relevance to understanding the development and course of the left ankle condition.
Left Ankle.  The CI complained of right ankle pain for one day on 3 September 2005 as a result of walk that ranged in severity from 3/10 to 7/10 with activity.  Treatment for the ankle sprain/stress reaction consisted of Ibuprofen, a nonsteroidal anti-inflammatory medication, soft shoes, and crutches.  Follow-up in the podiatry clinic for pain in both heels and ankles revealed a right stress fracture of the calcaneus and changes in the left heel on X-rays as noted by the podiatrist.  However, X-rays of the heels were reported as an unremarkable study on 6 September 2005.  X-rays of the ankles dated 9 September 2005 revealed soft tissue swelling about the left ankle with a small osseous density inferior to the distal fibula likely representing an avulsion fracture.  The report also noted soft tissue swelling about the right ankle with a small osseous density inferior to the distal fibula, which may have represented an “acute injury” with soft tissue swelling.  Clinical correlation with history and site of pain was recommended.  The CI was placed on Med Hold for 30 days.  The stress fractures were healing on 23 September 2005.  Arch supports were prescribed on 3 October 2005 for plantar fasciitis manifested by pain above the heels of each foot, the left worse than the right while running and jumping.  The CI was returned to duty on 4 October 2005.  A bone scan dated 20 June 2006 was performed for shin pain, but there was no evidence of shin splints or stress fractures in either tibia.  The CI complained of pain in the feet and a Harris view X-ray (to assess talocalcaneal coalition [an abnormal connection between two or more bones causing a rigid flat foot]) of the left heel was negative for fracture, dislocation, lytic or blastic (malignant) lesions.  No obvious coalition was appreciated, although a fibrous coalition could not be excluded.  A magnetic resonance imaging (MRI) dated 10 July 2006 was requested for chronic pain with swelling and paresthesias of the medial ankle.  The impression was a density involving the posterior tibialis tendon near the sustentaculum tali (upper horizontal portion of the calcaneus bone of the foot).  The finding consisted of an ovoid mass that could be secondary to a partial tear of the tendon and resultant fibrous degeneration from a partial tear of the tendon.  Weight bearing X-rays of the left ankle taken for ankle instability revealed a small calcaneal spur at the insertion of the Achilles tendon.

A permanent L3 profile was issued on 18 October 2006 for left ankle instability with limitations of military functional activities and physical fitness testing as well as no running, jumping, or prolonged standing.  He was to use a laced ankle brace as needed and no personal load was to exceed 30 pounds and avoid walking on uneven ground.  On the Report of Medical History for the MEB dated 2 November 2006, the CI noted he had ankle/foot pain and had two sets of orthotics made and wore a laced ankle braced and was treated with nonsteroidal anti-inflammatory medications that were of no help.  At the MEB physical examination dated 7 November 2006, the examiner noted tenderness to palpation of the lateral aspect of the left ankle.  The active range-of-motion (ROM) was limited with decreased plantar flexion and dorsiflexion.  There were no limitations with the passive ROM.  Pain was elicited by the heel walk, eversion, and inversion.  Mild asymptomatic pes planus was also noted.

The MEB narrative summary dated 16 November 2006 indicated the CI originally injured his ankle during basic training in 2005 and was held over for approximately a month.  Treatment consisted of NSAIDS (nonsteroidal anti-inflammatory medications), a profile, custom inserts and an ankle brace.  At an evaluation in October 2006 the CI indicated he was unable to run, had difficulty walking on uneven ground, could not carry a combat load, and could not stand greater than 10-20 minutes without pain-limiting symptoms.  After his MRI and X-rays were evaluated, surgical repair was offered, which was declined.  On examination, the CI was intact to light touch, pulses were good, capillary refill time was less than three seconds, and the feet were warm bilaterally.  There was slight edema of the left ankle and the skin was clear.  There was a positive clinical talar tilt and anterior drawer (to determine instability) stress examinations with pain mainly over the anterior talofibular ligament.  Instability was observed with weight bearing examination, single leg stance.  The ROM was approximately 10 degrees dorsiflexion (Normal 20 degrees) and 30 degrees plantar flexion (Normal 45 degrees).  An MRI revealed no osteochondritis dissecans (small segment of bone separates from its surround; the surrounding bone and cartilage begin to crack and loosen) lesion, no anterior talar fibular ligament tear or any other lateral ligament tear.  A positive posterior tibial asymptomatic mass was observed and a lateral X-ray revealed a possible small avulsion fracture at the tip of the lateral malleolus.  The final diagnosis was left, chronic ankle instability.  The commander’s statement dated 29 November 2006 indicated the CI was unable to tolerate wearing field gear or personal protective equipment, perform heavy lifting and combat tasks.  His limitations prevented assignment in a combat environment due to intolerance of protective equipment.

An orthopedic evaluation on 2 April 2007, 2 months after separation, indicated the CI was discharged because he had degenerative changes within the left posterior tibial tendon.  On examination he was swollen all along the medial aspect of his left ankle, was tender along that area, was unable to hold inversion against manual resistance, could not stand on the side for very long, and did not form a good arch.  X-rays of the left ankle were normal.  An MRI dated 4 April 2007 revealed mild paratendinous inflammatory changes consistent with tenosynovitis.  The CI underwent decompression of the left posterior tibial tendon on 25 April 2007; and there were no degenerative changes within the tendon itself.  Post-operative PT was successful in rehabilitating the CI’s left ankle.  By 4 weeks post-operatively the swelling resolved and the CI had no pain when pressure was applied.  On 5 June 2007 the CI was pain free; his posterior tibial tendinitis had resolved; and he was discharged from orthopedic care.  A week later, however, the CI presented with left ankle pain and swelling.  X-rays revealed diffuse soft tissue swelling and possible erosive changes involving the anterior aspect of the articular surface of the distal tibia.

At the VA Compensation and Pension examination dated 24 March 2011, performed 4 years and 2 months after separation, the examiner noted the CI presented with bilateral plantar fasciitis that began in 2005 when he was having problems with pain in the heels and burning in his feet and was given orthotics.  The CI noted pain (while standing and walking) for over 15 minutes or any time walking without his orthotics.  Loss of arch was noted during the examination and appeared to be secondary to ligament laxity of the ankle.  The CI stated that while in basic training he noticed his left ankle hurt and swell and the foot burned like some was “poking something in the bottom.”  He was diagnosed with a “stress fracture” and was put in a boot cast for 45 days and was on profile for 90 days.  He was offered surgery, which he declined.  The VA examiner noted the inconsistencies of the X-rays and clinical examinations resulting in incongruities of the left and right feet and ankles.  The CI described symptoms of primarily plantar fasciitis with swelling of the ankle on the left and throbbing “across the foot” on the right, although symptoms were consistent with plantar fasciitis.  The left ankle was visibly larger than the right, but no edema.  The left ROM was dorsiflexion 0-17 degrees and left plantar flexion 0-70 degrees.  Bilateral ankle films dated 24 March 2011 revealed mild scattered bilateral degenerative changes.  The final VA diagnosis instability of the left ankle, which resulted in decreased mobility and a history of a stress fracture of the right ankle.

The 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.

Left Ankle ROM
(Degrees)	MEB ~2 Mo. Pre-Sep
	VA C&P ~4 Yrs.2 Mo. Post-Sep
	
Dorsiflexion (20 Normal)	10	0-17	
Plantar Flexion (45)	30	0-70	
Comment	Instability with weight bearing	Left ankle visibly larger than the right	
§4.71a Rating	10%	VA 0%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using the analogous code 5099-5003 (degenerative arthritis) for chronic pain/instability of the left ankle, which was rated as slight/frequent.  The VA assigned a 0% rating based on an examination more than 4 years after separation for left ankle instability using code 5271 (ankle limited motion) for left ankle instability and a 10% rating using code 5276 for bilateral plantar fasciitis, which was not in the scope of review.  The Board notes the earliest VA evaluation was 50 months after the DOS.  DoDI 6040.44 provides for consideration of after separation VA findings, particularly within 12 months of separation, although the Board’s recommendation is premised on the degree of disability at separation.  Therefore the service record evidence was assigned more probative value with respect to the Board’s recommendation.  Only VA evidence which can be reasonably interpreted to reflect disability at separation is probative to the Board’s recommendation.  The Board sought a route for a higher rating.  VASRD code (Ankle, limited motion) offers a 20% option for marked limitation; however, the limitation of motion was closer to moderate at 10%.  Code 5024 (tenosynovitis) was considered as an alternative, but it is rated using code 5099-5003, which already affords a 10% rating.  The Board was unable to find a route to a higher rating.  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.

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.  As discussed above, PEB reliance on the USAPDA pain policy for rating chronic pain/instability left ankle was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the left ankle 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.

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 20140606, 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, AR20150018719 (PD201402804)

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 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