RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02826
BRANCH OF SERVICE:  Army  	BOARD DATE:  20150721
SEPARATION DATE:  20011004

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2 (Intelligence Analyst) medically separated for a left ankle sprain.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “left tarsal tunnel syndrome with left ankle pain and 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 “left tarsal tunnel syndrome…”as unfitting, rated 10% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  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 20020010822	VA* - (~10 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Tarsal Tunnel Syndrome	5299-8725	10%	Tarsal Tunnel Syndrome, Left Ankle	8725	10%	20020423	
Other x 0 (Not In Scope)	Other x 0	
RATING:  10%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20020812 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Left Ankle Condition.  The service treatment record (STR) indicated the CI twisted her left ankle during a run while at the fitness-training unit in July 2000.  Three days into basic training, she had acute ankle pain and was hospitalized for three days and received a cortisone injection prior to discharge, which did not help.  On 1 November 2000, she experienced pain and numbness on the plantar aspect of the left foot and was treated with crutches.  A podiatry examiner in December 2000 indicated the CI had taken amitriptyline, medication for nerve pain and naproxen, a nonsteroidal anti-inflammatory drug (NSAID) and his examination revealed exquisite tenderness into the plantar aspect of the left foot as well as in the region of the tarsal tunnel with the mildest percussion or pressure on the posterior tibial nerve.  The examiner’s impression was acute tarsal tunnel syndrome with lateral plantar nerve involvement of the left ankle.  However, electrodiagnostic studies did not confirm tarsal tunnel syndrome.   An MRI of the left ankle was normal in January 2001.  In February 2001, the CI stated her ankle was improving, but gave way after running.  Orthopedic evaluation in May 2001 demonstrated an anterior drawer test (for laxity determination) and tenderness to palpation (TTP) over the inner aspect of the left ankle posteriorly with a positive Tinel’s sign (to detect irritated nerves) with percussion of the posterior tibial nerve.  X-rays showed mild soft tissue swelling about the lateral malleolus (outer ankle) without any acute bony abnormalities; and a bone scan of the ankle demonstrated no uptake, but was abnormal in regard to stress reactions and stress fracture of the right second metatarsal.  The orthopedic impression was left ankle/foot pain with symptoms consistent with tarsal tunnel.  On 26 July 2001, the CI reported her ankle gave out a day earlier during a run when she fell down.  Treatment was with a nonsteroidal anti-inflammatory medication (Indocin), crutches, sneakers, and physical therapy (PT) referral.  At PT four weeks later she noted pain with prolonged walking and stranding, had a normal gain, had swelling of the dorsal aspect of the left foot post a wasp sting, was able to negotiate terrain and stream crossing without pain, had a full range-of-motion (ROM) of the left ankle, had full strength in all planes except inversion, which was 4+/5, and had TTP of the posterior medial malleolus (inner ankle).   

A permanent L3 profile was issued on 14 May 2001 for a left foot/ankle injury with limitations of no running for conditioning, no push-ups, no standing for more than 20 minutes without a break, and no wearing a backpack; and as a result she could not graduate from IET (Initial Entry Training).  The commander’s statement indicated the CI had gone on sick-call numerous times and received various profiles for left ankle pain, which increased whenever she engaged in any sort of physical activity.  Due to her profile limitations she would have been unable to pass a Record Army Physical Fitness Test (RAPFT) to qualify for any US Army MOS.  On the DD Form 2807-1, Report of Medical History, dated 29 May 2001, the CI noted her current medication was naproxen, a nonsteroidal anti-inflammatory drug (NSAID) and “ankle pain-currently wearing brace.”  On the DD Form 2808, Report of Medical Examination, dated 4 June 2001, the examiner recorded full active/passive ROM and good strength of the ankles bilaterally.  There was minimal TTP of the malleolus medially and posteriorly and no swelling or inflammation.  The CI’s feet were asymptomatic with normal arches.  The CI walked and jogged without difficulty, but her right foot protected the left foot when she jumped.  The MEB narrative summary (NARSUM) dated 21 July 2001 provided an in-depth review of the CI’s history and treatments.  Although she had an ankle sprain approximately 4 years prior to enlistment (EPTS), she had no difficulty over the previous years related to the left ankle.  At the time of the NARSUM, the CI related constant pain in the left ankle, could not walk over approximately 3/4-mile without increased pain, was able to do only sit-down duties, was taking no training, and had not taken a physical fitness test due to profile status.  

At the VA Compensation and Pension (C&P) examination dated 25 April 2002, performed almost 6 months after separation, the CI reported spraining her ankle on 21 July 2000 during training.  She indicated having had sprains in the past, which healed promptly without significant attention, but the pain in July 2000 did not improve.  At the time of the VA examination she noted symptoms of pain, weakness, stiffness, swelling, inflammation, instability, and numbness, specifically in her three lateral toes and that her left foot was 1/2 shoe size larger than the right.  On examination there were no signs of abnormal weight-bearing of the feet; posture and gait were normal; and the CI did not have any functional limitation of standing and walking.  Her ankle joints appeared within normal limits bilaterally.  The ROM of the ankle on the left was 0-15 degrees dorsiflexion and plantar flexion 0-45 degrees with pain.  The lateral three toes on the left foot had decreased sensation to light touch as compared to the rest of the foot, while the left foot was slightly more flatfooted than the right with no angulation with or without weight bearing.  X-rays of the left ankle were normal.  

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 ~3 Mo. Pre-Sep
	PT ~2 Mo. Pre-Sep
	VA C&P ~6 Mo. Post-Sep
	
Dorsiflexion (20 Normal)	“Full active range of motion”	“FAROM”	0-15	
Plantar Flexion (45)	“Full active range of motion”	“FAROM”	0-45	
Comment	Based on  exam 7 Nov 2000--pain on plantar flexion and flexion of the ankle	TTP posterior medial malleolus; strength normal	ROM with pain.	
§4.71a Rating	-	10%	VA 10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating taking into consideration an EPTS factor of unknown significance without any subtraction using code 5299-8725 (posterior tibial nerve neuralgia) for left tarsal tunnel syndrome.  The VA likewise assigned a 10% rating using code 8725.  The Board sought a route to a higher rating but was unable to find one in the absence of ankle ankylosis, moderate limitation of motion, malunion, surgery, pronounced acquired flatfoot, or acquired pes cavus (claw foot).  However, there was no significant motor dysfunction to warrant a severe rating for incomplete paralysis of the posterior tibial nerve.  Although the CI did fall as noted in the STR, and had several episodes of moderate neuralgia marked by the use of medication for nerve pain along with crutches to merit the 10% rating, the CI’s condition was not severe enough to undergo pain management, to be incapacitated, or to undergo surgery while on active duty.  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 tarsal tunnel 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.  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 left tarsal tunnel syndrome condition and IAW VASRD §4.124a, 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 20140610, 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 XXXXXXXXXX, AR20160003761 (PD201402826)  

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