RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04131
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20070524

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Aviation Machinist’s Mate, medically separated for “ankle, limited motion of”  and “scars, superficial, painful,” rated 10%  and 10%, respectively, with a combined disability rating of 20%.  

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 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 - 20070220	VARD - 20070713	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Ankle, Limited Motion of	5271	10%	Status Post Left Ankle Reconstruction with Traumatic Osteoarthritis and Degenerative Joint Disease	5010-5271	20%	20070320	
Scars, Superficial, Painful	7804	10%	Residual Scars of Left Ankle Status Post  Left Ankle Reconstruction	7802	0%	20070320	
Left Ankle Pain and Stiffness	Category II	
No VA Placement	
Status Post Left Navicular Fracture	Category II		
Status Post Left Subtalar Dislocation	Category II		
Status Post Left Ankle Fracture	Category II		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Ankle, Limited Motion (Left):  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left ankle condition began in July 2005 when a helicopter that his crew was moving ran over his left foot and ankle.  The CI underwent an open reduction internal fixation (ORIF) for a left proximal fibula fracture, a medial malleolus fracture, a navicular fracture and a subtalar subluxation on 16 June 2005.  The CI continued to have significant foot and ankle pain following surgery with severely limited ankle range of motion (ROM), described as “no dorsiflexion whatsoever.”  The CI underwent a second surgical procedure in April 2006 for hardware removal and scarring; degenerative changes of the joint cartilage were noted and the Achilles tendon was lengthened in an effort to increase ankle ROM.  Left ankle X-rays done on 3 August 2006 showed surgical hardware in the ankle and foot and degenerative changes from disuse.  Following surgery, further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “pain in joint involving ankle and foot,” “unspecified closed fracture of ankle,”  “closed fracture of navicular (scaphoid) bone of foot” and “closed dislocation of foot, unspecified part” for PEB adjudication.  

At the initial MEB examination dated 5 September 2006, 9 months before separation, the examiner recorded chronic left ankle pain rated at 2-5/10 with pain over the surgical site of the Achilles tendon lengthening.  Ankle ROM was somewhat improved since surgery with dorsiflexion (DF) limited to 5-7 degrees (normal 20).  

At the MEB orthopedic addendum examination dated 10 November 2006, 7 months before separation, the examiner indicated that the CI had significant traumatic arthritis in the midfoot and subtalar joint.  Functional limitations included an inability to run or do any sports and pain after standing greater than 30 minutes with walking limited to ¼ mile.  The physical examination noted a “flat foot type of gait” with an “antalgic gait.”   There was tenderness to palpitation (TTP) medially and at the incision site but no effusion.  Ankle ROM was DF to 10 degrees and plantar flexion (PF) to 15 degrees (normal 45) with minimal subtalar motion.  Sensation was intact except for patchy decreases due to surgical incisions; strength was minimally decreased.

During the orthopedic clinic appointment (requested by PEB) on 19 January 2007, 4 months before separation, the CI reported continued left ankle and foot pain with  an inability to run, walk greater than ¼ miler, or stand longer than 30 minutes before pain increased.  On examination, there was tenderness over the medial aspect and midfoot and the CI was unable to do a heel rise.  Ankle ROM was DF to 5 degrees and PF to 15 degrees.  

At the VA Compensation and Pension (C&P) examination on 20 March 2007, 2 months before separation, the CI reported constant left ankle pain rated at 7/10 that radiated to the midfoot and worsened with physical activity.  He also had daily incapacitating episodes due to the severity of the pain and painful motion with weakness, tenderness and lack of mobility.  The physical examination showed “slight” abnormal gait without use of assistive devices for ambulation.  There was guarding of ankle movement and traumatic deformity with enlargement of the joint.  Ankle ROM was DF to 15 degrees and PF to 35 degrees, with repetition additionally limiting “the joint function by 5 degrees.”  There was painful motion and tenderness of the left foot and the scar on top of the foot.  The examiner opined that the functional impairment was severe.  Left lower extremity strength was noted as “weak dorsal and plantar flexion,” with normal reflexes and vasculature and no swelling.  Left foot X-rays on 23 March 2007 showed degenerative changes in the mid-foot.  

During the VA orthopedic clinic appointment on 7 August 2007, 3 months after separation, the CI reported left ankle pain rated at 5/10 with pain anteriorly and worse with activity and stairs.  On examination, there was tenderness over the medial malleolus, over the scar along the lateral malleolus, and anteriorly over the tibialis anterior tendon.  Ankle ROM was DF to 15 degrees and PF to 35 degrees with no pain or crepitus noted with ankle motion.  The CI was able to heel and toe walk and the orthopedist indicated that he had “poorly localized anterior ankle pain” that did not appear to be related to the joint itself.  The CI was referred for physical therapy.

At a VA orthopedic follow-up visit on February 2008, 9 months after separation, the CI reported persistent pain graded 5/10 with ambulation.  The examination noted TTP of the medial ankle joint and the proximal foot and painless ROM of the ankle with DF to 20 degrees and PF to 40 degrees.  Strength and sensation of the ankle were normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5271 code (ankle, limited motion), citing moderate limitation of motion.  The VA assigned a 20% rating using the analogous 5010-5271 (arthritis, due to trauma-ankle, limited motion) based on the VA C&P examination 2 months before separation.  The PEB listed left ankle pain and stiffness, status post (s/p) left navicular fracture, s/p left subtalar dislocation, and s/p left ankle fracture as Category II (contribute to the unfitting disability) conditions.  The Board agreed that these conditions were properly subsumed under the Category I ankle condition (IAW §4.14 avoidance of pyramiding; more than one rating based on the same functional impairment is prohibited) and could not be separately rated.  The Board considered the MEB and VA examinations proximate to separation and adjudged that documented ROMs were consistent with a marked limitation of motion supported by the presence of an abnormal gait with guarding and limited DF and PF.  The VA examination further substantiated the maximum 20% rating under code 5271 with Deluca test results showing fatigue, weakness, lack of endurance, incoordination, and pain which additionally limited ROM by 5 degrees.  The Board also considered analogous rating under code 5284 (foot injuries, other) and deliberated between the 10% (moderate) and 20% (moderately severe) rating level considering total disability of the ankle and foot;  members concluded that the 20% for “moderately severe” other foot injury was warranted.  A 20% rating was also supported using 5099-5010 coding for traumatic arthritis of two major joints (ankle and subtalar joint) with occasional incapacitating episodes (or 10% each for ankle and subtalar joint for traumatic arthritis with limited motion).  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 left ankle condition, coded 5299-5284

Scars, Superficial, Painful.  According to the STR, MEB NARSUM and VA C&P examination, the CI had a tender scar due to ankle surgeries following his injury in July 2005 as noted above.  At the MEB orthopedic addendum evaluation, there were findings of TTP medially over the incision and sensation was intact except for some decreased sensation due to multiple incisions.  During the VA C&P examination, the CI reported pain from the left ankle surgical scars which was elicited by pressure applied to the area.  The scars were slightly elevated at dorsum (7.0 cm), medial malleolus (5.2cm), and the lateral aspect of the left leg to ankle (28cm).  At the time of the VA orthopedic visit, the CI reported left ankle pain rated at 5/10, and on examination, there was tenderness of the lateral malleolus along the scar.  At a VA PT visit on 4 October 2007 the examiner noted TTP of the medial and lateral ankle and “scar at surgical site with decreased mobility.”  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the left ankle scar condition as unfitting following the CI’s appeal of the informal PEB findings.  The PEB assigned a 10% rating under the 7804 code (scar(s), unstable or painful), citing painful scarring.  The VA assigned a 0% rating using the 7802 code (scar(s) due to other causes…do not cause limited motion) based on the VA C&P examination 2 months before separation, citing a lack of pain or limited motion.  The Board majority agreed that there was evidence throughout the record that the CI had tender left ankle scars, also noted by the service physical therapist, and that the surgical scars had limited mobility to support a 10% rating under 7804.  There was no evidence of scars of a total area large enough to warrant a higher rating under 7801 or 7802.  There was no higher rating available with any applicable VASRD code for scars at the time of separation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left ankle scar condition.

BOARD FINDINGS:  In the matter of the ankle (limited motion of) condition, the Board unanimously recommends a disability rating of 20%, coded 5299-5284 IAW VASRD §4.71a.  In the matter of the scars (superficial, painful) condition and IAW VASRD §4.118, the Board majority 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	
(Left) Ankle, Limited Motion of		5299-5284	20%	
Scars, Superficial, Painful	7804	10% 	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20141003, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
	         DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 21 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX 
	(c) PDBR ltr dtd 03 May 16 ICO XXXXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 24 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 29 Apr 16 ICO XXXXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 17 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 15 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 13 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 29 Apr 16 ICO XXXXXXXXXXXXXXXXXXXX
	(j) PDBR ltr dtd 13 Apr 16 ICO XXXXXXXXXXXXXXXXXXXX
	(k) PDBR ltr dtd 15 Apr 16 ICO XXXXXXXXXXXXXXXXXXXX
	(l) PDBR ltr dtd 22 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (l) are approved.

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 50 percent disability rating (increased from 10 percent) effect date of discharge. 

     b. XXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 20 percent) effect date of discharge. 
 
     c. XXXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.
     
     d. XXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effect date of discharge.

     e. XXXXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List with a 40 percent disability rating (increased from 10 percent) effect date of discharge. 
 
     f. XXXXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effect date of discharge. 

     g. XXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effect date of discharge.

     h. XXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effect date of discharge.

     i. XXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effect date of discharge.

     j. XXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 40 percent disability rating (increased from 20 percent) effect date of discharge.

     k. XXXXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effect date of discharge.

3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.

	XXXXXXXXXXXXXXXXXXXX
	Assistant General Counsel
	(Manpower & Reserve Affairs)