RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03988
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070509

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Chemical, Biological, Radiological, and Nuclear Specialist, medically separated for “chronic right ankle pain, status post partial excision of a giant cell tumor of the tibiotalar joint (11 Jan 07) with residual pain and loss of ankle dorsiflexion due to mechanical causes,” and “left distal hallux pain secondary to hallux extensive development of granulation tissue on the nail bed that remains unhealed, bleeding and painful despite treatment,” rated 10% and 10%, respectively, with a combined disability rating of 20%.  

CI CONTENTION:  His conditions continue to worsen and negatively impact his daily activities.  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 based on 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 - 20070425	VARD - 20071109	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Ankle Pain, …	5015-5099 5003	10%	Residuals, Status Post Excision of Giant Cell Tumor, Right Ankle	5015-5271	20%	20070618	
Left Distal Hallux Pain ….	7899-7804	10%	Plantar Fasciitis, Status Post Left Distal Phalanx Dorsal Exostectomy, Left Foot	5299-5284	10%	20070618	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Right Ankle Pain, Status Post Partial Excision of a Giant Cell Tumor of the Tibiotalar Joint.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right ankle condition began in October 1996 after spraining his right ankle.  He had recurrent ankle sprains and in July 2006 diagnostic imaging (MRI) revealed a large mass.  The right ankle mass was surgically removed on 11 January 2007 (4 months prior to separation) and identified as a giant cell tumor (giant cell pigmented vilonodular synovitis).  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “right ankle chronic sprains” and “giant cell tumor excision” for PEB adjudication.  

At the Physical therapy MEB formal range of motion (ROM) examination dated 21 February 2007, 3 months prior to separation, the CI had active right ankle dorsiflexion to 4 degrees after repetition (normal 20) and plantar flexion 18 degrees (normal 45) and limitation was due to pain.  Passive ROMs were dorsiflexion to 9 degrees and plantar flexion of 30 degrees.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated 22 February 2007, 3 months prior to separation, the CI reported a painful, chronically swollen right ankle, use of an ankle brace, and a remaining tumor at his right Achilles area.  Physical examination showed right ankle/foot tenderness with a palpable mass in the Achilles tendon.  

The MEB NARSUM examination on 5 March 2007, 2 months prior to separation, noted complaints of right ankle pain.  Physical examination showed a well healed surgical scar with minimal right ankle effusion.  There was painful range of motion of the ankle and subtalar joints.  An addendum dated 30 March 2007 (1 months prior to separation) reported abnormal MRI findings of cartilage thinning, synovial thickening, edema, arthritic changes and talar dome lesions which could represent further mass from the giant cell tumor.  There was mild muscle atrophy reported and the CI was ambulating with a cane and not using the CAM walker.  

At the 18 June 2007 VA Compensation and Pension (C&P) evaluation, performed 2 months after separation, the CI reported right ankle pain with prolonged walking or standing, 75 percent loss of ankle motion, use of a cane, abnormal gait, difficulty bearing weight on his right foot and he could only stand for a few minutes before he had to sit down.  Physical examination showed right ankle swelling with a purplish hue of the entire foot.  There was slight (4+/5) weakness on the right knee flexion.  The CI “did not have any range of motion notable on examination of the right ankle.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right ankle condition 10%, coded 5015-5099 5003 (Bones, new growths of, benign - Arthritis, degenerative), citing pain and loss of ankle dorsiflexion due to mechanical causes “rated as analogous to degenerative arthritis with some loss of ankle motion.”  The PEB description of “due to mechanical causes” was likely application of AR 635-40 in effect at the time, and use of the passive ROMs.  The VA rated the right ankle condition 20% coded 5015-5271 (Bones, new growths of, benign - Ankle, limited motion), based on the VA C&P examination 2 months after separation, citing talar dome irregularities, no notable ankle ROM, and some atrophy of the right lower leg.  

The Board agreed that the active ROM examinations proximate to separation detailed above were consistent with a marked limitation of motion supported by the presence of an abnormal gait, swelling, use of a cane, and muscle atrophy which warranted the maximum 20% rating under the VASRD diagnostic code for limitation of motion (5271).  The Board 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 and alternative rating as moderately severe (20%) would offer no benefit.  

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 chronic right ankle pain condition, coded 5015-5271.  

Left Distal Hallux Pain.  According to the STR and MEB NARSUM, the CI’s left great toe condition began in October 2006 due to boot irritation.  In December 2006 he had surgical nail removal (distal phalanx dorsal exosectomy) with regrowth of the nail.  Hallux dorsiflexion and drainage did not resolve.  The MEB forwarded “left hallux distal phalanx nail dystrophy” for PEB adjudication.  

The MEB NARSUM examination on 5 March 2007, 2 months prior to separation, noted complaints of left hallux distal phalanx pain with hallux dorsiflexion and continued drainage.  Physical examination showed a minimal amount of bleeding and drainage at the left hallux distal phalanx nail plate with a purplish tint color to the distal phalanx.  There was a left hallux dorsiflexion contracture at the hallux interphalangeal joint.  

At the 18 June 2007 VA C&P evaluation, performed 2 months after separation, the CI reported a raised left great toenail due to a bone spur and a requirement for arch supports due to pain.  He had occasional blood and pus oozing out of the toenail area.  Physical examination showed mild diffuse tenderness to palpation and a raised nail on the first toe.  X-rays were normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left distal hallux pain condition 10%, coded analogously to 7804 (Scars, superficial, painful on examination), citing unhealed painful nail granulation with bleeding.  The VA rated the left foot condition 10% coded analogously to 5284 (Foot injuries, other -- moderate), based on the VA C&P examination 2 months after separation, citing requirement for arch support, tenderness, raised great toe nail, and no valgus.  

There was no higher rating under VASRD §4.118 (Schedule of ratings–skin) codes, and alternative rating under §4.71a (Schedule of ratings–musculoskeletal system) codes would not rate higher than the 10% awarded by the PEB.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left distal hallux pain condition.  

BOARD FINDINGS:  In the matter of the chronic right ankle pain condition, the Board unanimously recommends a disability rating of 20%, coded 5015-5271 IAW VASRD §4.71a.  In the matter of the left distal hallux pain condition and IAW VASRD §4.118, the Board unanimously recommends no change in the PEB adjudication.  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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Right Ankle Pain, Status Post Partial Excision of a Giant Cell Tumor of the Tibiotalar Joint	5015-5271	20%	
Left Distal Hallux Pain	7899-7804	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140916, 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 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX, AR20160017750 (PD201403988)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.  

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:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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:

			       
						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA