RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-03858
BRANCH OF SERVICE:  Army	BOARD DATE:  20150129
SEPARATION DATE:  20080731

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Nodal Network Systems) medically separated for left ankle pain.  The condition did not improve adequately to meet the physical requirements of his Military Occupational Specialty.  The CI was profiled for and was permitted to take the alternate aerobic portion of the Army physical fitness test.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic left ankle pain, status post left ankle stabilization procedure,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two other conditions (see rating chart below) for PEB adjudication.  The Informal PEB adjudicated the left ankle pain as unfitting, rated 10%, with likely application of the VA Schedule for Rating Disabilities (VASRD).  The remaining conditions were found to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “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:

Army IPEB – Dated 20080429	VA* – (~2 Mos. and 3 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Ankle Pain	5099-5003	10%	Left Ankle Strain	5271	10%	20081022	
Plantar Fasciitis	Not Unfitting	Plantar Fasciitis and Tendonitis, Right 	5284	10%	20081022	
		Plantar Fasciitis and Tendonitis, Left 	5284	10%	20081022	
Adjustment disorder	Not Unfitting	Anxiety Disorder with Insomnia	9413	30%	20081004	
Other x 0 (Not In Scope)	Other x 5 	
RATING:  10%	RATING:  60%	
*Derived from VA Rating Decision (VARD) dated 20090223 (most proximate to date of separation (DOS))

ANALYSIS SUMMARY:

Left Ankle Pain.  In November 2005, just prior to deploying overseas, the CI injured his left ankle.  He was bothered by left ankle pain during his year-long deployment, but he was able to successfully complete his tour.  On return to home station, he was found to have a torn anterior talo-fibular ligament (ATFL).  In May 2007, he underwent surgery to repair his left ATFL.  After surgery, he continued to have problems with the left ankle.  Due to the chronic, persistent nature of his ankle symptoms, MEB was initiated.  The MEB physical examination (PE) was on 11 January 2008.  The CI reported constant ankle pain, which was aching in nature, and worse with weight-bearing.  With regard to functional status, he reported that he was unable to get in and out of small places.  He was unable to climb in and out of shelters.  He was unable to run, or do any heavy lifting.  PE of the left ankle revealed some tenderness to palpation over the ATFL and at the distal fibula.  Muscle strength was 4+/5 on eversion, 5/5 on inversion, and 5/5 on plantar flexion.  Left ankle range-of-motion (ROM) was measured and is summarized in the chart below.  On the DD Form 2808, dated 14 January 2008, it is documented that his gait was antalgic secondary to left ankle pain.  

The CI was medically separated from service on 31 July 2008.  On 11 October 2008, 10 weeks later, he had a VA General Medical Compensation and Pension (C&P) exam.  He reported that the left ankle pain had caused pain in his back, hips, and knees due to an alteration in the way he walked.  The examiner documented that the CI had a mild limp on the left ankle as he ambulated.  PE of the left ankle revealed no joint effusion or tenderness.  Left ankle ROM was full, with 20 degrees dorsiflexion and 45 degrees plantar flexion.  Muscle strength was normal. On the same day, he had a VA Orthopedic C&P exam.  The CI reported that his ankle pain was constant, with periodic episodes of sharp, severe pain.  The pain was greatest in the lateral malleolar region.  The left ankle pain prevented him from enjoying recreational activities (i.e. snowboarding), and it interfered with some normal household activities (i.e. shopping).  On PE, the examiner noted that the CI’s gait was antalgic.  PE of the left ankle revealed pain with inversion and eversion.  There was no significant evidence of ligamentous instability, varus strain, or valgus strain.  There was no warmth, synovial fluid, effusion, or muscle weakness.  Left ankle dorsiflexion was 15 degrees, and plantar flexion was 40 degrees.  With repetitive movement there was increased pain, fatigue, weakness, lack of endurance, and loss of coordination.  Pain was the most significant factor.  

The ROM evaluations, which the Board weighed in arriving at its recommendation, are summarized in the chart below.

Left Ankle ROM
(Degrees)	MEB ~7 mos. Pre-Sep
(20080111)	VA C&P ~2½ mos. Post-Sep
(20081011)	
Dorsiflexion (20 Normal)	15	15 or 20*	
Plantar Flexion (45)	50	40 or 45*	
		*the CI had two separate VA C&P exams on 20081011, with different ankle ROM results

The Board directed attention to its rating recommendation based on the above evidence.  The Army PEB and the VA chose different coding options for the left ankle condition, but both assigned a 10% disability rating.  The Board determined that the 11 October 2008 C&P exams were just 10 weeks after the DOS and therefore carried significant probative value.  At one of those exams, there was full ROM of the left ankle.  At the orthopedic C&P exam, there was a slight limitation of ankle motion.  The left ankle condition was essentially non-compensable based on the VASRD §4.71a codes for the ankle (5270 through 5274).  However; IAW VASRD §4.40, §4.45, and §4.59, when part of the musculoskeletal system becomes painful on use, it must be regarded as seriously disabled.  A 10% rating is warranted when there is satisfactory evidence of functional limitation due to painful motion of a major joint.  Because there was an increase in joint symptoms with repetitive motion, the Board considered whether a higher rating was justified IAW the legal ruling from DeLuca v. Brown (1995).  The Board determined that the additional functional loss due to increased symptoms with repetitive use was not sufficient to justify a higher rating.  There was no path to a higher rating for the left ankle since there was insufficient evidence of a significantly disabling joint abnormality that would justify a higher rating.  After due deliberation, the Board determined that a disability rating of 10% was appropriate.  Considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board found insufficient cause to recommend a change in the PEB adjudication for the chronic unfitting left ankle pain.

Other PEB Conditions.  Two other conditions (plantar fasciitis and adjustment disorder) were 
adjudicated by the PEB as not unfitting, and therefore not ratable.  The Board’s main charge with respect to these two conditions is to assess the appropriateness of the PEB’s fitness adjudication.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  These conditions were thoroughly reviewed by the action officer and considered by the Board.  

The Board determined that these two conditions (plantar fasciitis and adjustment disorder) were not specifically profiled, nor were they judged to fall below retention standards.  There was no indication from the record that these conditions significantly interfered with satisfactory duty performance.  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 plantar fasciitis and adjustment disorder conditions. Therefore, no additional disability ratings are 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, unfitting left ankle pain, and IAW VASRD §4.40, §4.45, §4.59, and §4.71a, the Board recommends by majority decision no change in the PEB adjudication.  In the matter of the plantar fasciitis and adjustment disorder conditions, 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 20140825, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

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 XXXXXXXXXXXXXXX, AR20150011217 (PD201403858)

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:

Encl		     XXXXXXXXXXXXXXX
			     Deputy Assistant Secretary of the Army
			          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA