RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-03652
BRANCH OF SERVICE:  MARINE CORPS 	SEPARATION DATE:  20061115

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Anti-Tank Assaultman) medically separated for a right ankle condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was placed on limited duty (LIMDU) and referred for a Medical Evaluation Board (MEB).  The “pain in joint involving ankle and foot” and “reflex sympathetic dystrophy (RSD) of the lower limb,” conditions were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “chronic right ankle pain” as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining “status post (s/p) treatment regional sympathetic distribution to right ankle” condition was determined to be category III, a condition that is not separately unfitting and does not contribute to the unfitting 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 20060831	VA* - (~3 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Ankle Pain	5299-5003	10%	Arthritis, Right Ankle	5271	20%	20070201	
S/P Treatment for RSD to Right Ankle	Cat III	No VA Placement	
Other x 0 (Not In Scope)	Other x 4	
RATING:  10%	COMBINED RATING:  50%	
*Derived from VA Rating Decision (VARD) dated 20070523 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Chronic Right Ankle Pain Condition.  The narrative summary (NARSUM) notes the CI sustained an ankle sprain during physical training in February 2004.  He was initially treated conservatively without benefit.  Magnetic resonance imaging of the right ankle 23 June 2005 showed no abnormalities of the bones, tendons, or ligaments.  An orthopedic evaluation 25 July 2005 noted tenderness of the anterior and lateral aspects of the ankle with painful motion, normal sensation and vascular function.   Impingement syndrome was diagnosed and the CI was casted for 6 weeks, followed by physical therapy (PT).  The CI had arthroscopy of the ankle 9 June 2006 with the post-operative diagnosis of impingement syndrome.  At a PT visit 24 July 2006 range-of-motion (ROM) was dorsiflexion of 7 degrees (normal 20) and PF of 40 degrees, with painful motion and reduced muscle strength graded 3+/5 (can move against gravity, limited by pain.   Following surgery, at an orthopedic follow-up 1 August 2006 the CI reported continued localized ankle pain.  The ankle exam noted normal sensation and vascular function with limited ROM.  

At the MEB exam 2 August 2006, 3 months before separation, the CI reported.  The MEB physical exam noted chronic right ankle pain aggravated by activity.  

At the VA Compensation and Pension (C&P) exam 1 February 2007, 3 months after separation, the CI reported chronic right ankle pain, aggravated by activity.  He reported the pain was relieved by medication; he could function with the pain; and, the condition caused no incapacitation.  He reported he was not receiving any treatment for the condition at the time of the exam.  The VA examiner indicated the CI was able to walk, climb stairs, garden, and push a lawn mower.  The exam noted normal posture and gait.  The CI was not using a cane or a crutch.  There was guarding of movement of the right ankle.  Ankle ROM was DF 10 degrees and PF 30 degrees, with painful motion.  Pain was increased with repetition of ROM, but there was no additional loss of ROM.  Motor and sensory exam was normal.  Right ankle X-rays showed the CI to have degenerative arthritis.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the ankle condition 10%, coded 5299-5003.  The VA rated it 20%, coded 5271 (limited ankle motion).  The Board agreed that the ankle condition met a 10% rating coded according to 5003 rating criteria for one major joint with imaging evidence of degenerative arthritis, the highest available rating for a single major joint with this code.  The Board next considered the VA coding choice of 5271.  The rating criteria for 5271 are subjective, with 10% rating for `moderate’ limited ankle ROM, and 20% for `marked’.  Quantitative ROM was noted at the PT exam, 4 months before separation and at the C&P exam, 3 months after separation.  Although these exams are of equal distance from the date of separation, the pre-separation PT exam was 6 weeks after surgery.  At the C&P exam after separation, the CI was much improved and noted no current treatment of the ankle condition and pain relief with medication.  He reported no incapacitation and the exam noted mild to moderate decreased ankle ROM and a normal gait.  The Board agreed that evidence in record supports characterizing the residual ankle limited ROM as `moderate’ and not `marked’.  Additionally, there was no evidence of ankle deformity, malunion, or ankylosis to support higher rating.  Therefore, the Board determined that the ankle condition met a 10% rating and no higher, including consideration of functional loss.  After due deliberation, and in consideration of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the ankle condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the right ankle RSD condition was not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  

RSD Condition.  As noted in the discussion of the right ankle above, the CI was casted 25 July 2005 for 6 weeks due to persistent ankle pain following an ankle sprain.  After the ankle cast was removed the CI was diagnosed with RSD of the ankle.  The CI was started on medications for RSD, specifically for nerve-related pain (gabapentin) and an antidepressant (Pamelor).  At an orthopedic follow-up visit the examiner noted the CI had stopped the medications due to the side effect of drowsiness.  The CI was evaluated and treated for the RSD by pain management.  A primary medicine note 2 February 2006 noted that the CI lacked classical signs of RSD of increased sensitivity to pain (hyperesthesia and allodynia), or pain with temperature changes, swelling, or abnormal skin changes (hyperhidrosis) and noted that the CI’s pain was more localized, rather than global of the lower extremity.  The CI had sympathetic blocks with substantial improvement in his “atypical” ankle pain symptoms.  An orthopedic visit 21 April 2006 noted that the RSD was “nearly completely resolved” and surgery of the ankle was planned for impingement syndrome.  A neurological consult 27 April 2006 noted that “a majority of the RSD symptoms have resolved”, but localized anterolateral ankle pain remained.  On the exam no typical signs of RSD were noted, such as abnormal pain sensitivity, vascular, or skin changes.  The neurologist noted the CI had been treated with maximal therapy for RSD by pain medicine and recommended follow-up with the orthopedic specialist.  The CI underwent arthroscopic surgery 9 June 2006.  Following the surgery, orthopedic follow-up visits in June and August 2006 noted that localized ankle pain persisted, but the painful dysesthesias had resolved.  

The right ankle RSD was listed on the limited duty board (LIMDU) 1 August 2006.    The non-medical assessment (NMA) 1 August 2006 noted that the CI’s physical limitations impaired his duty performance, but did not mention a specific diagnosis, and the limitations, due to either the chronic right ankle pain s/p arthroscopic surgery or to the RSD symptoms, would overlap significantly and be indistinguishable.  The Joint Disability Evaluation Tracking System, or JDETS, 30 August 2006 noted “RSD resolved”.  The Board considered that the evidence in record supports that the CI lacked many of the classical signs and symptoms of RSD and that atypical pain symptoms resolved following treatment.  The residuals of the right ankle after arthroscopic surgery were localized pain and limited ankle ROM and the Board recommended a rating IAW VASRD §4.71a above.  IAW VASRD §4.14 (avoidance of pyramiding) these same symptoms cannot be utilized to satisfy criteria for a second rating under a different diagnosis.  At the time of separation there was no persistent evidence of additional symptoms of RSD that could be recommended as separately unfitting and rated IAW VASRD §4.124a (neurological conditions).  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 the RSD condition and so no additional disability rating is recommended.

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 chronic right ankle pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended right ankle RSD condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  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 20140804, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 6 Jan 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXXX, former USMC  
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC 
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN

				XXXXXXXXXXXXXXX
	     			Assistant General Counsel
				(Manpower & Reserve Affairs)