RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME: XXXXXXXXXXXXXXXXXXXXX	CASE: PD-2015-00693
BRANCH OF SERVICE: AIR FORCE	SEPARATION DATE: 20060621

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Tactical Aircraft Maintenance Craftsman, medically separated for “left ankle pain,” with a disability rating of 10%.

CI CONTENTION: “Please review 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 - 20060406		VARD - 20061214	
Condition	Code	Rating		Condition	Code	Rating	Exam	
Left Ankle Pain	5271	10%		Left Ankle Strain	5299-5271	20%	20060929	
Shellfish Allergy	Cat III		No VA Placement	
COMBINED RATING: 10%		COMBINED RATING OF ALL VA CONDITIONS: 20%	

ANALYSIS SUMMARY: According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left ankle condition began in July 2003 while playing basketball when he rolled his left ankle. An X-ray was negative and he underwent physical therapy without relief of pain. Magnetic resonance imaging (MRI) of the left ankle in October 2003 demonstrated findings consistent with an anterior talofibular ligament (ATFL) tear, which was treated with bracing without benefit. In April 2004 he underwent ankle arthroscopy that improved his symptoms. In July 2004 he reinjured his ankle while running. In September 2004 he complained of a painful left ankle with a little bit of tingling and numbness in the top of his left foot. Pain did not resolve with injections, bracing, ultrasound therapy or physical therapy. The podiatrist noted the CI had capsulitis and sinus tarsi syndrome marked by pain in the left anterior ankle and along the intermediate dorsal cutaneous nerve with some neuritis. An MRI in November 2004 showed mild thickening of the ATFL consistent with chronic injury along with no evidence of acute soft tissue or osseous injury.  In December 2004 because of lateral instability

of the left foot, he underwent primary repair of the ATFL with a left Brostrom procedure to stabilize the ankle. Postoperative healing was satisfactory and he was back to normal activities by March 2005. However, pain continued on dorsiflexion and in June 2005 he underwent an ankle arthrotomy (an open joint procedure) of the left ankle and excision of an exostosis (bone spur) of the anterior tibia and a chondroplasty of the talar dome. In August 2005 the CI had a very painful left ankle with burning, numbness and shooting pain. On examination there was tenderness on palpation along the posterior tibial nerve and the deep and anterior peroneal nerves. Treatment thereafter consisted of Neurontin (gabapentin for nerve pain), ibuprofen (a nonsteroidal anti-inflammatory drug (NSAID)), Lortab (hydrocodone, a narcotic), Anodyne therapy (infrared to increase circulation and reduce pain) and a steroid/anesthetic injection. An MRI in August 2005 showed a stable appearance of the left ankle with post-surgical changes in the subtalar region with minimal ATFL thickening. In November 2005 he underwent a lateral ankle stabilization with a tendon transfer. However, in January 2006 the CI continued to have pain along the lateral ankle where he had the surgery. Treatment consisted of Medrol (methylprednisolone, a steroid), Lortab, and diclofenac, an NSAID.

At the NARSUM examination dated 1 March 2006, 3 months prior to separation, the CI reported he was limited in his ability to perform any kind of walking and his symptoms were worse with wearing shoes. On examination his left ankle demonstrated some well healed surgical scars. He had mild swelling inferior to the medial and lateral malleoli (inner and outer ankle). He was tender underneath both malleoli, but had no bony tenderness. He was able to dorsiflex his ankle to 15 degrees and extend it to 30 degrees. The examiner opined that because of the number of surgeries the CI had undergone and the poor response he had to those surgeries, it was doubtful the he would improve much further with surgical intervention. At a podiatry evaluation on 14 March 2006 there was a lack of motion in the dorsiflexion direction and the posterior lateral soft tissue was very tight. A nerve on the dorsal aspect of the foot was affected and when hit pain went down into the foot. Additionally there was a painful spot on the lateral calcaneus where the tendon was probably anchored, which the CI indicated was done with an absorbable screw. An MRI in May 2006 demonstrated post-surgical changes along the lateral aspect of the ankle. There were no signs of tendon impingement or other osseous or soft tissue abnormality to explain the CI’s symptomatology.

At the VA Compensation and Pension (C&P) examination on 29 August 2006, performed 3 months after separation, the CI reported four surgical procedures on the left ankle and pain all day every day at 4/10 in severity. He had flare-ups four to five times a day to 6/10 that lasted 10 minutes to 1 hour. He also noted his ankle was always swollen and he had decreased ROM all of the time, but did not have frequent rolling. He had numbness and tingling if he tapped on a certain spot on his anterior ankle and had burning pain over the ankle. He also indicated that his podiatrist talked about doing another surgery to release a tendon. On examination he had a normal gait and multiple well-healed scars over the left ankle that were darkly erythematous, freely moveable that were not adhered to underlying tissue and non-tender. There was tenderness about the entire left ankle. No edema or deformity was present. Dorsiflexion was to 0 degrees with pain at 0 degrees and plantar flexion was 55 degrees with no pain. Left ankle inversion was decreased as was eversion. Repetitive motion was marked by increased pain. Strength and sensation were normal. The ankle was stable and there was no laxity. The examiner’s diagnosis was left ankle strain with history of ATFL repair surgery times four with continued chronic pain and decreased ROM.

The range of motion (ROM) examinations in evidence which 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)	MEB ~4 Mo. Pre-Sep	VA C&P ~3 Mo. Post-Sep	
Dorsiflexion (20 Normal)	15	0	
Plantar Flexion (45)	30	55	
Comment	Mild swelling and tenderness below both malleoli	Left ankle inversion and eversion were decreased; pain with repetitive motion	
§4.71a Rating	PEB 10%	VA 20%	

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 10% rating, coded 5271 (ankle, limited motion of). The VA assigned a 20% rating, coded 5299-5271 based on the VA C&P examination 3 months after separation, citing chronic pain and decreased ROM. The Board agreed that the ROM examination proximate to separation detailed above was consistent with a moderate limitation of motion for the 10% rating under this code. However, at the VA examination 3 months after separation and more proximate to separation by 1 month, the dorsiflexion was 0 degrees, which favored a marked limited ROM of the ankle, but plantar flexion was 55 degrees, which demonstrated no limitation of motion. Board members discussed the VA limited dorsiflexion to 0 degrees in the absence of an accident or injury, while the CI was reported to have a normal gait. Alternatively, the Board considered whether a higher rating IAW VASRD §4.7 was supported under the VASRD code for other foot injuries (5284), but the majority favored the rating was more appropriate for the ankle based on the majority of the findings related to the ankle. Following a detailed discussion of gait analysis and despite the evidence of four surgical procedures and a possible future surgical procedure as well as multiple less than successful therapies and regarding the functional impairment, the Board majority felt that PEB made the right determination based on the CI’s limited ROM prior to 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 condition.

Contended PEB Condition-Shellfish Allergy. The Board’s main charge is to assess the fairness of the PEB’s determination that Category III (conditions that are not separately unfitting and not compensable or ratable) shellfish allergy was not unfitting. The shellfish allergy was not profiled or implicated in the commander’s statement and was not mentioned in the NARSUM or in any STR documents nor was it listed in the Medical Board Report. To the contrary, innumerable entries related to allergies were annotated NKDA (no known drug allergies) and other responses to non-drug allergies were none or no depending on how the question was worded. There was no performance based evidence from the record that shellfish allergy condition significantly interfered with satisfactory duty performance at separation. After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the shellfish allergy condition; and so no additional disability rating is recommended.

BOARD FINDINGS: In the matter of the left ankle condition and IAW VASRD §4.71a, the Board majority recommends no change in the PEB adjudication. The single voter for dissent recommended modification to 20% and submitted the appended minority opinion. In the matter of the contended shellfish allergy 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, 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 20150604, w/atchs Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record

Minority Opinion. The minority voter notes that while code 5271 reflected a limited ROM of the ankle, the CI’s injury would be better rated using code 5284 IAW VASRD §4.7 (Higher of two evaluations) since the original injury was to the talofibular ligament, which links the ankle and the foot. At the NARSUM examination the CI reported difficulty walking and wearing shoes. Prior to separation, the CI underwent four surgical procedures on the ankle/foot including a chondroplasty of the subtalar dome (a component of the hindfoot) and a podiatrist raised the possibility of an additional procedure of a tendon release to ameliorate his symptoms. The fact that CI had 0 degrees dorsiflexion on the VA examination suggests that despite four surgeries, the foot/ankle injury and the possibility of another surgical procedure, a tendon release, ought to be considered moderately severe and rated 20% using code 5284 or in the alternative 5271- 5284. Therefore, the minority voter recommends the Board’s findings be modified and the ROP be amended to read:

In the matter of the left ankle pain condition, the Board recommends a disability rating of 20%, coded 5284 or 5271-5284 IAW VASRD §4.71a.

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	
Left Ankle Pain	5284 or
5271-5284	20%	
	COMBINED	20%	

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

Dear XXXXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-00693.

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 appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Principal Deputy Assistant Secretary 
(Manpower and Reserve Affairs)

Attachment:
Record of Proceedings