RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW
NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00100
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20040426

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Air National Guard E5, Firefighter, medically separated for “bilateral osteochondritis dissecans of talar bones” rated left foot 10% and right foot 0%, with a combined disability rating of 10%.  

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 upon a 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 - 20040308	VARD - 20050504	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Osteochondritis Dissecans of Talar Bones, Left Foot	5283	10%	Osteochondritis Dissecans of the Talar Bone, Left Ankle	5283-5271	10%	20050204	
Bilateral Osteochondritis Dissecans of Talar Bones, Right Foot		0%	Osteochondritis Dissecans of the Talar Bone, Right Ankle	5283-5271	10%		
Myocardial Infarction Secondary to Coronary Disease Status Post Stenting	Not Unfitting 
	Arteriosclerotic Heart Disease, Status Post Myocardial
Infarction and Stent Placement	7005	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Bilateral Osteochondritis Dissecans of Talar Bones (Ankle).  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral osteochondritis dissecans (OCD-loss of blood supply to an area of bone in a joint) of talar bones condition began in March 2002 after fighting a fire.  The CI was diagnosed with OCD of both ankles.  The CI underwent surgical excision on the right and excision of the left ankle lesion was being considered but was postponed due to an intercurrent medical illness (see contended conditions below).  At an orthopedic follow-up visit in January 2004, the CI reported increasing symptoms in the left ankle with progression of the degenerative changes on X-rays and surgery was planned.  The MEB forwarded “bilateral osteochondrosis dissecans of talar bone, status post open reduction and internal fixation of right medical malleolus with currettement [sic] of talar dome lesion” for PEB adjudication.  

Left Foot.  The MEB NARSUM examination on 27 January 2004, 3 months prior to separation, noted complaints of ankle pain aggravated by prolonged standing.  The physical examination of the left ankle and foot was reported as “entirely unremarkable.”  The MEB NARSUM examiner indicated that as a firefighter the CI would continue to have limitations due to the ankle pain and therefore he could not recommend a waiver.  

The 26 November 2004 VA Compensation and Pension (C&P) evaluation noted the CI was employed as a firefighter and a medic since military separation.  He reported no lost work time in the past 12 months.  At the 3 February 2005 VA C&P evaluation, performed 10 months after separation, the CI reported ankle pain graded 7-8/10, with difficulty standing for prolonged periods or running.  He denied instability and did not wear a brace.  He reported flare-ups with additional loss of motion.  He used heat and cold application and pain medication as needed. Physical exam showed normal appearing ankle.  There was no swelling.  There was tenderness of the ankle.  Ankle range of motion (ROM) was dorsiflexion (DF) 10 degrees (normal 20 degrees) and plantar flexion (PF) 20 degrees (normal 45 degrees).  Ankle ROM was equal on both sides.  Ankle X-rays showed the OCD lesion of both ankles.  The VA examiner noted “osteochondritis of the talar dome, both ankles with minor limitation of motion and pain.”  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left OCD of the talar bone condition 10%, coded 5283 (tarsal, or metatarsal bones, malunion of, or nonunion of).  The VA rated the left OCD of talar bones condition 10%, coded 5283-5271 (ankle, limited motion of), and based upon the VA C&P examination 10 months after separation, citing moderate limitation of motion.  The PEB assigned a 10% rating under 5283, and therefore the Board reviewed to see if a higher rating was achieved with any VASRD code.  The Board agreed that the limitation of motion descriptively noted as “full ROM” with pain at evaluations in the STR and DF 10 degrees and PF 20 degrees at the post-separation C&P examination was best characterized as “moderate” and not “marked” when considered under the subjective rating criteria of 5271.  The Board considered alternative VASRD ankle and analogous codes, but all were less applicable and not advantageous to rating.  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 ankle OCD condition.  

Right Foot.  The ankle pain was initially worse on the right and the CI underwent surgical excision of OCD lesion with open reduction and internal fixation with hardware in September 2003 with a good result.  An orthopedic evaluation on 5 March 2003 noted the CI was “essentially pain free” and had full ROM of the right ankle with some continued pain over the site of the surgery.  The CI was released to full duty.  An orthopedic visit in January 2004 noted that the right ankle was much better than before the surgery, but not pain free.  Right ankle X-rays showed a healed OCD lesion and normal joint anatomy.  

The MEB NARSUM examination on 27 January 2004, 3 months prior to separation, noted complaints of ankle pain aggravated by prolonged standing.  The physical examination of the right ankle and foot was reported as “entirely unremarkable” other than the surgical scar on the right ankle.  The MEB NARSUM examiner indicated that as a firefighter the CI would continue to have limitations due to the ankle pain and therefore he could not recommend a waiver.  

At the 3 February 2005 VA Compensation and Pension (C&P) evaluation, performed 10 months after separation, the history was the same as noted above for the left ankle.  The physical examination showed normal appearing ankle except for the surgical scar on the inner ankle.  There was no swelling.  There was tenderness of the ankle.  Ankle range of motion (ROM) was dorsiflexion (DF) 10 degrees (normal 20 degrees) and plantar flexion (PF) 20 degrees (normal 45 degrees).  Ankle ROM was equal on both sides.  There was pain with resistance to ROM.  Ankle X-rays showed an OCD lesion of both ankles.  The VA examiner noted “osteochondritis of the talar dome, both ankles with minor limitation of motion and pain.”  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right OCD of the talar bone condition 0%, coded 5283 (tarsal, or metatarsal bones, malunion of, or nonunion of).  The VA rated the right OCD of talar bones condition 10%, coded 5283-5271 (ankle, limited motion of) based upon the VA C&P examination 10 months after separation, citing moderate limitation of motion.  There was evidence of pain/limited motion of the ankle with abnormal X-ray imaging for a 10% rating coded as 5099-5003 or other related code such as 5009 (arthritis, other) rated according to the same criteria.  There was no limitation of dorsiflexion or plantar flexion that supported a higher rating for marked limitation of motion as elaborated above.  There was no evidence to support characterizing the foot disability as “moderately severe” or “severe” malunion or nonunion of the right talar bone.  The Board considered alternative VASRD ankle and analogous codes, but all were less applicable and not advantageous to rating.  There was therefore no higher rating than 10% available with any applicable VASRD code.  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 right ankle OCD condition, coded 5283-5271  

Contended PEB Conditions:  Myocardial Infarction Secondary to Coronary Artery Disease Status Post Stenting.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The CI had a myocardial infarction (heart attack) in March 2003 with stent placement.  He participated in cardiac rehabilitation until the end of May 2003.  Three follow-up nuclear stress tests prior to separation showed a high exercise capacity of 13 METs (standardized unit of measure for exercise capacity) or greater (firefighter clearance levels 10-12 METS), with “no significant ischemia.”  A follow-up with his treating cardiologist on 8 February 2005, 9 months after separation, indicated the CI was doing well with his most recent stress test showing normal heart function and no significant ischemia.  The commander’s statement dated 4 February 2004 implicated the CI’s bilateral ankle conditions as impairing his duty performance as a firefighter and supported his retention in a non-mobility position and did not implicate the heart condition.  There was no performance based evidence in record that following treatment and an appropriate convalescence period with rehabilitation, the heart condition was unfitting for continued military service.  The VA C&P examination indicated the CI was employed as a firefighter and a medic.  A remote VA record indicated the CI worked as a firefighter for 7 years after separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the heart condition and so no additional disability rating recommended.  

BOARD FINDINGS:  In the matter of the bilateral osteochondritis dissecans of talar bones, left foot condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral osteochondritis dissecans of talar bones, right foot condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the contended myocardial infarction secondary to coronary artery disease status post stenting 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.  
The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Bilateral Osteochondritis Dissecans of Talar Bones, Left Foot	5283	10%	
Bilateral Osteochondritis Dissecans of Talar Bones, Right Foot	5283-5271	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140506, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-00100.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay. 

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  The office responsible for making the correction will inform you when your records have been changed.

Sincerely,

Attachment:
1.  Directive 
2.  Record of Proceedings 

cc:
SAF/MRBR