RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03625
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20050527

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Material Control Craftsman, medically separated for “bilateral ankle pain” with a disability rating of 10%.

CI CONTENTION:  “Please consider all conditions.”  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 - 20050414	VARD - 20060112	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Ankle Pain, Bilateral	5299-5003	10%	Residuals of Right Foot and Ankle Injury	5271	20%	20051012	
			Residuals of Left Ankle Injury	5271	0%	20051012	
Migraine Headaches 	Cat II	Mixed Headaches	8100	10%	20051012	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Bilateral Ankle Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM) the ankle symptoms began approximately 2 years prior to MEB referral.  Bilateral ankle X-Rays in November 2003 demonstrated “slight talar tilts [medially] with weight bearing.”  Evaluation in the podiatry clinic in May 2004 concluded with a diagnosis of bilateral ankle arthropathy and ankle valgus position. The CI was treated with duty limitations, medications, and physical therapy (PT) with some benefit.  Despite treatment, the bilateral ankle condition could not be adequately rehabilitated to meet the physical requirements of the CI’s Air Force Specialty and the CI was referred for an MEB.  The MEB forwarded “bilateral ankle pain” for PEB adjudication.

During a PT examination on 18 August 2004, 9 months prior to separation, the CI reported that using an elliptical trainer caused severe pain for a week.  Examination of her right ankle showed 50 degrees of plantar flexion (45 normal) and that she lacked “20 degrees to neutral of dorsiflexion.”  Strength was decreased in all motions with eversion being the most decreased and her gait was antalgic.  The right ankle was tender to palpation and the skin on the right leg was shiny and taut leading the examiner to opine that the CI might have possible early reflex sympathetic dystrophy. 

At the MEB examination (recorded on DD Forms 2807 and 2808) on 9 September 2004, 9 months before separation, the CI reported right foot and ankle pain with compensatory problems in the left foot and ankle.  On examination she was noted to walk with a limp favoring the right lower extremity.  There was tenderness to the right ankle both medially and laterally.  There was no swelling of the right ankle, but the Achilles tendon was “tight.”  The CI’s left ankle was normal and both ankles were stable. 

During the MEB NARSUM evaluation on 4 November 2004, 7 months before separation, the CI reported duty limiting symptoms including “excruciating pain after walking 500 meters or standing greater than 5-10 minutes.”  On examination the CI had mild swelling in both ankles and there was tenderness to palpation of the anterior ankle joints and ligaments.  Maximum ankle joint dorsiflexion was to the neutral position secondary to pain, but the examiner did not specify which ankle was affected.  There was also pain with inversion and eversion motions, but again the examiner did not specify which ankle was affected.  The examiner noted that the subtalar range of motion (ROM) was painful and all motion to the ankle joint trended towards pain, making examination of the ROM difficult.  The neurology NARSUM addendum, dated 7 December 2004, showed normal gait, motor strength and sensation.  

At the VA Compensation and Pension (C&P) examination on 12 October 2005, performed 5 months after separation, the CI reported that she had bilateral ankle pain with standing or weight-bearing more than 20-30 minutes.  Physical examination showed no swelling of the ankles, but tenderness was present on the medial and lateral malleolar area.  The CI had minimal laxity of the right ankle and no instability of the left ankle.  Her gait was normal.  ROM testing of her right ankle showed that she had 5 degrees of dorsiflexion and 40 degrees of plantar flexion with no significant pain.  Left ankle ROM was within normal limits, but there was some stiffness from 10-20 degrees with dorsiflexion.

The Board first considered if the right ankle condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Board members agreed that the evidence reasonably justified that the functional limitations of the condition contributed to the CI’s inability to perform her military duties and accordingly a separate disability rating is recommended.  The Board next considered if the left ankle condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The Board concluded that there was a preponderance of evidence of the service records that overcame the Board’s presumption that the bundled left ankle condition was reasonably considered separately unfitting.  

The Board next directed attention to its rating recommendations for the unfitting right and left ankle conditions at the time of separation based on the above evidence.  As noted above, the PEB bundled the right ankle with the left ankle and applied a single 10% rating, coded 5299-5003 (analogous to degenerative arthritis).  The VA rated the right ankle 20% (coded 5271, ankle limitation of motion), citing dorsiflexion to 5 degrees based on the VA C&P examination 5 months after separation.  The VA rated the left ankle 0% (coded 5271), citing “normal ROM, with tenderness and some stiffness of dorsiflexion, but without pain” based on the same VA examination. 

Right Ankle Pain.  Members agreed that for the right ankle, the preponderance of ROM evidence was more reasonably characterized as “marked” limitation of motion consistent with a 20% rating under diagnostic code 5271.  The Board considered the limitation of motion at the time of the NARSUM and post-separation VA examination to be more than moderately limited and more nearly approximated a marked degree of limitation.  The Board also considered whether a higher rating was supported under other diagnostic code options.  Because there was no ankylosis (5270), nonunion or malunion (5262), VASRD §4.71a offers no applicable joint code which would yield a higher rating.  The Board also considered whether ratings under the VASRD code for other foot injuries (5284) provided for a higher rating (§4.7); however, all Board members agreed that the severe level (30%) was not supported for the right ankle.  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.

Left Ankle Pain.  There was no limitation of motion of the left ankle joint to support a rating under diagnostic code 5271 (limitation of motion) and the VA C&P examination did not note the presence of painful joint motion.  The NARSUM examination was equivocal and did not identify the ROM of the left ankle; however the NARSUM did note subtalar ROM pain and all ROMs to the ankle joint trended towards pain.  The gait was usually described as normal, but when it was described as abnormal or antalgic, it appeared to favor the right lower extremity.  The Board, based on the NARSUM indication of painful motion of all movements of the ankle with a noncompensable ROM, discussed the use of code 5099-5003 at 10%.  A probative value discussion was carried out since neither the NARSUM examination (7 months pre-separation) nor the VA examination (5 months post-separation) was immediately proximate to separation.  Alternative VASRD ankle and analogous codes were less applicable and not advantageous to a higher rating for the left ankle.  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 left ankle condition, coded 5299-5003.  

Contended PEB Condition-Migraine Headaches.  The Board’s main charge is to assess the fairness of the PEB’s determination that migraine headaches were not unfitting.  The Category II migraine headache condition (a condition that can be unfitting but is not currently compensable or ratable) was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.   The neurology NARSUM Addendum dated 7 December 2004, indicated the CI had headaches for years, but over the prior 6 years the headaches worsened in severity and increased in frequency and were associated with photophobia and sonophobia (light and sound sensitivity), but were rarely debilitating.  Treatment with Imitrex (abortive medication) was effective, but was associated with severe diarrhea; Midrin (pain reliever) was more tolerable, but less effective; and Pamelor (antidepressant medication, also for nerve pain) was prescribed for prophylactic headache treatment.  The neurologist opined that on infrequent occasions (once per month) the headache might be severe enough to interfere with the CI’s duties.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, and 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 migraine headaches and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the right ankle condition, the Board majority recommends a disability rating of 20%, coded 5271 IAW VASRD §4.71a.  In the matter of the left ankle condition, the Board majority recommends a disability rating of 10% coded 5299-5003 IAW VASRD §4.71a.  
The single voter for dissent recommended no change and did not elect to submit a minority opinion.  In the matter of the contended migraine headache condition, the Board unanimously agrees that it cannot recommend it for additional disability rating.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Ankle Pain	5271	20%	
Left Ankle Pain	5299-5003	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140625, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-03625.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.

I have carefully reviewed the evidence of record and the recommendation of the Board.    I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at (210) 565-2273 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.

Sincerely,

Attachment:
Record of Proceedings 

cc:
SAF/MRBR 
DFAS-IN