RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03312
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20030801

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4, Satellite Communications Operator, medically separated for right ankle pain, rated at 0%.

CI CONTENTION:  “Please consider all conditions.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  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 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 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 20030610	VA* - (~1 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Ankle Pain	5010	0%	Right Ankle Injury w/Posttraumatic Arthritis Calcification and Hell Spur	5271	10%	20030714	
Sleep Apnea requiring CPAP	Not Unfitting	Obstructive Sleep Apnea	6847	50%	20030714	
Gastroesophageal Reflux Disease	Not Unfitting
	Hiatal Hernia w/Gastroesophageal Reflux Disease	7336	0%	20030714	
Rectal Bleeding secondary to Internal Hemorrhoids	Not Unfitting	Internal Hemorrhoids and Excision of Benign Rectal Polyp	7346	0%	20030714	
Mild Heading Loss	Not Unfitting	Bilateral Hearing Loss	NSC	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 3	
RATING:  0%	RATING:  60%	
*Derived from VA Rating Decision (VARD) dated 20030909 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Right Ankle Pain Condition.  The service treatment record (STR) was limited in primary source material and the earliest reference to an ankle sprain was dated 7 November 2001.  Pain persisted and the CI underwent physical therapy.  By May 2002, pain had decreased and he was able to run 2 miles on a treadmill without pain, but he still noted limited flexibility.  An X-ray series dated 13 September 2002 revealed degenerative changes of the ankle joint on the right with a relatively large osseous (bony) fragment seen adjacent to the medial malleolus (inner ankle), which was suspected to be related to remote trauma.  An acute fracture was not identified.  A follow-up X-ray series of the left leg revealed ossification of the interosseous ligament within the lower leg, while an X-ray series of the right ankle demonstrated mild to moderate degenerative changes of the right ankle with probable old trauma to the medial malleolus (inner part of the ankle).  An orthopedic surgeon in October 2002 noted the CI had right ankle pain for a year and the CI had a few twisting injuries playing sports, the worst being in basic training.  The pain localized anteriorly and increased with activity (maximum 2-4 miles).  Tylenol gave no relief, although he had some relief with a nonsteroidal anti-inflammatory drug (NSAID).  The range-of-motion (ROM) of the right ankle was dorsiflexion 0 degrees and plantar flexion 25 degrees with pain and a painless subtalar ROM.  Motor function and sensation to light touch were intact.  There was tenderness of the anterolateral ankle and a drawer test (for instability) was negative.  A note dated 25 October 2002 indicated the CI had been prescribed Celebrex (celecoxib, a NSAID) by the orthopedic surgeon. 

A very detailed commander’s statement dated 14 April 2003 indicated the CI experienced a rough fall while running downhill during a bivouac training operation in October 2001.  Orthopedic evaluation indicated the CI was not a candidate for surgery.  As a tactical satellite operator/maintainer the CI had to be able to withstand extensive physical hardship, and his condition precluded this.  A permanent L3 profile was issued in May 2003 for chronic right ankle pain (arthritis) with limitations of no rucking, no running, and no jumping. 

Orthopedic consultation for the MEB and examination on 7 May 2003 revealed no tenderness to palpation of the right lower extremity, but positive tenderness to palpation anterolaterally at the ankle.  Dorsiflexion was 0 degrees and plantar flexion was 25 degrees with pain and a painless subtalar ROM.  Motor strength was normal as was sensation and there was no instability.  X-rays revealed decreased joint space, positive osteophyte (bony outgrowth) formation at the medial malleolus and throughout the syndesmosis (an immoveable joint in which bones are joined by connective tissue [e.g. tibia and fibula).  Recommendations included continued NSAIDs, viscosupplementation (hyaluronic acid injection), and profiling.  The MEB narrative summary (NARSUM) dated 16 May 2003 noted the CI’s ankle failed to improve with physical therapy, medication, and profiles.  The MEB physical examination, originally dated 26 November 2002 and updated on 16 May 2003, noted on a DD Form 2808 that the right ankle was enlarged and tender to palpation at the medial malleolus and exhibited decreased dorsiflexion, while the CI reported on a DD Form 2807-1 right ankle arthritis and excessive ossification/calcification in the right ankle.  

At the VA Compensation and Pension (C&P) examination dated 14 July 2003, performed a month before separation, the CI reported he sustained an injury to his right ankle in November 2001, had a soft cast applied to the ankle, and returned to full duty 6 weeks after the injury.  The condition did not interfere with his posture or gait at the time of the examination, but he was subject to limitations in walking and running because of pain.  Examination revealed the right ankle to be normal in outline and symmetric in form with the left.  ROM measurements were dorsiflexion 0-10 degrees (Normal 20 degrees) and plantar flexion 0-35 degrees (Normal 45 degrees).  There was no heat, redness, or swelling of the ankle nor was there any muscle atrophy or change in sensory perception of the foot identified.  Pain, weakness, lack of endurance, fatigue or incoordination did not impact further on the ROM.  

The Board directed its attention to its rating recommendation based on the following evidence.  The PEB assigned a 0% rating using code 5010 (arthritis due to trauma) for right ankle pain.  The VA assigned a 10% rating using code 5271 (ankle, limited motion) for the right ankle injury with post traumatic arthritis, calcification and heel spur.  The Board sought a route to a higher rating and considered application of a 10% using code 5010-5271 based on the VA examination, which was the examination most proximate to separation.  However, the two prior examinations by an orthopedic surgeon noted a more marked limitation of motion with pain on plantar flexion suggestive of a 20% rating.  The Board discussed the probative value of each of the examinations and reviewed the STR evidence to determine how improvement might have occurred between the 3 months pre-separation examination and the a month pre-separation examination. However, the record was silent on whether any medication, treatment, and/or diminished duty requirements contributed to improvement in the ROMs.  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 pain condition.  

Contended PEB Conditions.  

Sleep Apnea Requiring CPAP.  The condition manifested by snoring was profiled a U3 with the limitation of no deployment or assignment to quarters without electricity, was mentioned in the commander’s statement and was judged to fail retention standards.   However, with CPAP, the CI had relief of the sleep apnea and indicated at the VA examination he did not “snore as loudly as before,” did not have any problems falling asleep at work and had not experience any accidents during his waking hours before or after initiation of treatment for sleep apnea.  Furthermore, the CI had access to electricity in CONUS and as a satellite operator/mechanic should be able to have access to electricity.  The aforementioned was reviewed and considered by the Board.   There was no performance based evidence from the record that the sleep apnea significantly interfered with satisfactory duty performance.  

Gastroesophageal Reflux Disease. The condition was not profiled, mentioned in the commander’s statement, and was not judged to fail retention standards.  An upper GI series revealed a small sliding hiatal hernia with associated B-ring and gastroesophageal reflux was elicited during the examination.  The VA examination indicated the CI was prescribed Aciphex in November 2002 and since then he was not aware of any side effects from the medication or complications from the condition.

Rectal Bleeding Secondary to Internal Hemorrhoids.  The condition was not profiled, mentioned in the commander’s statement, and was not judged to fail retention standards.  The CI had persistent rectal bleeding for 2 weeks in November 2002 with a known history of gastroesophageal reflux disease. Colonoscopy revealed a rectal polyp and first degree internal hemorrhoids, which were to be treated with Preparation H.  Biopsy results demonstrated polypoid fragments of rectal mucosa with hyperplastic changes.  In March 203 he had a barium enema for left lower quadrant abdominal cramping, rectal bleed and a tender left lower quadrant without rebound or referred pain revealed no evidence of colonic obstruction, annular constricting lesion(s) or significant diverticulosis in the colon, although one or two diverticula of the left colon were seen on spot radiographs. There was a slightly granular appearance of the mucosa in most areas of the colon that could have represented a normal, baseline appearance for the CI, but was somewhat atypical compared to normal examinations raising the findings of early inflammatory bowel disease (IBD) could be quite subtle on this type of examination.  Further clinical investigation, should there be any significant possibility of IBD, was to be considered.  At the VA examination, the CI indicated he was advised to use stool softeners and was not aware of any complications of the condition.  

Mild Hearing Loss.  At a VA audiology examination on 14 July 2003 the CI indicated his hearing changed since 2002 and he had constant ringing in the ears. An audiogram dated 19 August 2002 indicated a 15dB loss at 6000 Hz on the left and a 15dB loss at 3000Hz and 4000Hz on the right, but was otherwise within normal limits.  However, in July 2003, he had a 20dB loss at 500 to 4000Hz on the left and an average of 21.25dB loss on the right.  Speech recognition was normal.  The etiology of the bilateral tinnitus was unknown.

After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the any of the contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the right ankle pain condition, the Board unanimously recommends a disability rating of 10%, coded 5010-5271 IAW VASRD §4.71a.  In the matter of the contended sleep apnea requiring CPAP, gastroesophageal reflux, rectal bleeding secondary to internal hemorrhoids, and mild hearing loss conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  

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

CONDITION	VASRD CODE	RATING	
Right Ankle Pain	5010-5271	10%  	
RATING	10% 	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140620, 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
(AH RC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXXX, AR20160004518 (PD201403312)

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,
accept the Board's recommendation to modify the individual's disability rating to 10%
without re-characterization 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:

CF:
( ) DoD PDBR
( ) DVA