RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03670
BRANCH OF SERVICE:  Army	BOARD DATE:  20150624
SEPARATION DATE:  20030203

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-1 (Medical Specialist) medically separated for left anterior tibialis tendonitis (a repetitive use or high force injury to the muscle that lifts, or dorsi-flexes, the foot).  This condition could not be adequately rehabilitated to meet the requirements of her Military Occupational Specialty or physical fitness standards, so she was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The left leg condition, characterized as “chronic left anterior tibialis tendonitis,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501, no other conditions were submitted by the MEB.  The PEB adjudicated “left anterior tibialis tendonitis” as unfitting, rated 0%, with likely application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD).  The CI did not concur with the PEB, but waived a formal hearing and submitted a written appeal for reconsideration.  The administrative PEB made an administrative correction to the case, but did not change either the disability or the rating.  The CI submitted no further appeals and was medically separated.

CI CONTENTION:  His condition continues to worsen and negatively impact his daily activities.  His complete submission is at Exhibit A.

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:

Service Admin PEB – Dated 20021022	VA - (7 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Anterior Tibialis Tendonitis	5024	0%	Left Anterior Tibialis Tendonitis	5024-5271	10%	20030902	
Other MEB/PEB Conditions x 0 (Not in Scope)	Other x 10	
Combined:  0%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20031223.

ANALYSIS SUMMARY:

Left Anterior Tibialis Tendonitis.  The CI was first seen for an ankle issue on 17 January 2001 after a left ankle sprain 2 months earlier in basic training.  The ankle showed swelling, but was stable and had full range-of-motion (ROM).  She was referred to physical therapy (PT) where she was noted to have a slight limp and reduced ROM.  However, she reported that she was able to pass her physical fitness run.  An ankle X-ray was remarkable only for soft tissue swelling.  Her pain persisted leading to an orthopedic evaluation on 7 December 2001.  Her ankle was stable on examination with normal strength; tibialis anterior tendinitis was diagnosed.  At a follow-up examination one month later, her gait and ROM were normal.  The ankle remained stable.  She continued PT and light duty without resolution.  An injection on 20 March 2002 provided temporary relief until the anesthetic wore off.  She was noted to have a global decrease in her ROM due to pain.  In orthopedics on 7 May 2002, she was noted to have failed to progress in treatment and to have been on a profile for over a year.  She was referred to MEB.  She had tenderness over the anterior tibialis tendon, but normal ROM.  The commander’s statement dated 21 August 2002 documented that the CI was able to perform her duties as a nuclear medicine specialist in-Garrison, but could not deploy.  The narrative summary was dated 17 September 2002, almost 5 months prior to separation.  It noted that multiple X-rays and a magnetic resonance imaging had all been negative.  She was noted to have been compliant with therapy and further improvement was not anticipated.  At a primary care appointment on 21 October 2002, the ROM was measured for an appeal to the Board and is charted below.  Motion in all directions was painful.  At the VA Compensation and Pension (C&P) examination performed on 2 September 2003, 7 months after separation, the CI reported continued ankle pain which was aggravated by walking over an hour.  On examination she ambulated well.  She had full ROM and some tenderness over the inside ankle (the site of the anterior tibialis tendon).  No comment was made regarding stability.  However, a second VA C&P for the joints on 24 October 2003 documented a reduced ROM (as charted below), normal gait without instability, and a normal heel and toe walk without difficulty.  The goniometric ROM evaluations in evidence 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)	Ortho ~9 Mo. Pre-Sep	PC ~3 Mo. Pre-Sep	VA C&P ~7 Mo. Post-Sep	VA C&P ~8 Mo. Post-Sep	
Dorsiflexion (20 Normal)	20	0	“FAROM”	10	
Plantar Flexion (45)	45 (60)	10-15	“FAROM”	15	
Comment	Tender to palpation.  Painful motion not documented	Eversion and inversion nml	Tender to palpation	Nml heel and toe walk w/o difficulty	
§4.71a Rating	0%	10-20%	0%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition at 0%, coded 5024 (tenosynovitis).  The VA rated the ankle at 10%, coded 5024-5271 (limited motion of the ankle), citing the second VA C&P.  While the ROM obtained on 21 October 2002 could support a 20% rating, this limitation is an outlier from all the other times it was measured.  Typically, the ROM was normal or slightly reduced.  The Board determined that the ROM obtained on the second VA C&P was not atypical for the CI.  In addition, painful motion was documented on some of the visits, supporting the use of VASRD §4.59 (painful motion).  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 anterior tibialis tendinitis 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.  The Board surmised from the record or PEB ruling in this case that no prerogatives outside the VASRD were exercised.  In the matter of the left anterior tibialis tendinitis condition, the Board unanimously recommends a disability rating of 10%, coded 5024 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends modifying the case determination as follows, effective the date of medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Left Anterior Tibialis Tendinitis	5024	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140409, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

MEMORANDUM FOR Commander

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXXX, AR20160003064 (PD201403670)

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