RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00868
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050623

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Basic Trainee, medically separated for “chronic left ankle pain and instability,” with a disability rating of 0%.  

CI CONTENTION:  “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 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 - 20050616	VARD - 20150916	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Ankle Pain…	5099-5003	0%	Lateral Instability on Left Ankle	5271	0%	20150825	
Bilateral Pes Planus with Pain	Not Unfitting	Flat Feet (Claimed as Bilateral Retropatellar Pain Syndrome)	5257	0%		
Bilateral Retropatellar Pain Syndrome						
		Right Knee Retropatellar Pain Syndrome (Claimed as Bilateral Retropatellar Pain Syndrome)		NSC		
Bilateral Posterior Tibialis Pain Syndrome		Bilateral Posterior Tibialis Pain Syndrome Resolved	5254			
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:    

Chronic Left Ankle Pain.  The PEB adjudicated three conditions as bilateral conditions - pes planus, retropatellar pain syndrome, and posterior tibialis pain syndrome.  In all three cases the PEB combined right and left conditions as a single condition and adjudicated each of the three conditions as not unfitting.  The Board’s initial deliberation was therefore to consider whether there was a preponderance of evidence to recommend any of the three conditions as separately unfitting at separation.  And, if recommended as unfitting, the Board reviewed whether the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings. When considering a separate rating for each condition, the Board considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the bilateral pes planus, bilateral retropatellar pain syndrome, and bilateral posterior tibialis pain syndrome conditions are presented in the contended PEB conditions section below, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left ankle condition began in October 2004 with three inversion injuries during a run.  He also had recurrent inversion injuries to the ankle while trying to train on it injured.  He was given an ankle brace for stability and advised to wear it the whole day.  The CI reported bilateral flat foot pain and pain to his ankles, legs, and knees aggravated by walking and running.  At a podiatry evaluation on 17 February 2005 the examination noted normal strength, sensation, and reflexes bilaterally.  There was tenderness of the peroneal brevis tendon (outer ankle) on the left and tenderness along the course of the posterior tibialis tendon from the inner aspect of the ankles to the insertion in the posterior leg bilaterally.  He was diagnosed with posterior tibialis (bilateral) and peroneal brevis (left only) tendonitis and pes planus (PP – flat feet) and treated with custom orthotics.  Left ankle X-rays on 21 March 2005 were normal showing no arthritis or structural abnormalities.  At the time of the physical therapy clinic appointment on 25 March 2005, 3 months prior to separation, the CI reported buckling to the left ankle.  On examination, the left ankle range of motion (ROM) was dorsiflexion 20 degrees (normal 20 degrees) and plantar flexion of 45 degrees (normal 45 degrees).  Pain with motion was noted.  There was a positive anterior drawer test of the left ankle and general laxity of both ankles.  There was no surgical indication.  Despite improvement in left ankle stability with physical therapy, left ankle pain continued.  The MEB forwarded “lateral instability of the left ankle” for PEB adjudication.  

The MEB NARSUM examination on 16 June 2005, 1 month prior to separation, the CI reported "recurrent persistent foot, ankle, and knee pain, collapsed arches and deformity of the feet, instability of the ankles due to weakening, and persistent numbness and tingling in the affected areas.”  The physical examination showed left ankle instability, with a positive anterior drawer and positive gap with inward pressure (varus stress).  There was tenderness to palpation of both lower legs to the mid shaft of the tibia and symptomatic PP of both feet was noted.  The permanent profile dated 22 April 2005 listed left knee injury, left ankle instability and bilateral PP.  The restrictions included no running, jumping, marching, deep knee bends, squatting or impact activities and specifically implicated the left ankle, with approval of wearing a brace in uniform.  The commander’s statement specifically mentioned the left ankle and left knee, and both “fallen arches.”  

There was no VA Compensation and Pension (C&P) examination performed proximate to separation.  A remote VA C&P examination dated 25 August 2015, more than 10 years after separation, noted the CI had not had any ankle surgery.  At the examination the CI reported four ankle sprains per year and reported using an ankle brace.  The physical examination of the ankle was normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 0%, coded analogous to 5003 (degenerative arthritis), citing “pain (in that there is no rating for ankle instability) slight, intermittent.”  The VA rated the left ankle instability 0%, coded 5271, based on the C&P examination more than 10 years after separation.  

The Board deliberations noted that the left ankle condition was a complex condition with contributing factors from the repeated left ankle sprains, but also with contribution from the pes planus condition which is intertwined with the bilateral posterior tibialis tendon dysfunction (PTD).  Flat foot can be caused or worsened by PTD.  In this case, the CI was noted to have mild bilateral PP on enlistment, so the latter is more likely the case.  However, the left ankle instability was separately unfitting and the remaining contended not unfitting conditions are discussed further below.  There was no limitation of dorsiflexion or plantar flexion that supported a rating under the VASRD diagnostic code for limitation of motion (5271).  However there was evidence of painful motion causing functional loss supporting the 10% rating (based on §4.59, §4.40 and §4.45).  The Board concurred that a 10% rating for functional loss (§4.40, §4.45) due to instability and pain was supported by the evidence of record.  The Board considered alternative VASRD ankle codes, but because there was no ankylosis, nonunion or malunion, §4.71a offers no applicable joint code which would yield a higher rating.  The Board also 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 impairment did not more nearly approximate a moderately severe condition to support a higher rating.  

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 left ankle pain and instability condition, coded 5299-5271.  

Contended PEB Conditions:  “Bilateral pes planus with pain,” “bilateral retropatellar pain,” and “bilateral posterior tibialis pain.”  The Board’s main charge is to assess the fairness of the PEB’s determination that the three conditions listed here were not unfitting.  

Bilateral PP.  Notes in the STR and NARSUM indicated the CI had mild bilateral PP at the time of enlistment that progressed during active duty to “severe” symptomatic PP bilaterally, which was treated with medications, stretching, splints and custom orthotics without relief.  The permanent profile listed bilateral PP, the commander’s statement noted the CI’s fallen arches, and the MEB NARSUM indicated the bilateral PP condition failed to meet retention standards.  The physical limitations noted on the permanent profile of no running, jumping, marching or impact activities would apply to the bilateral PP condition as well as the left ankle and knee conditions.  The MEB NARSUM noted that the CI had been advised that his foot pain may worsen and require surgery in the future.  The Board concluded that there was a preponderance of evidence that the functional impairment of both feet impaired the CI’s duty performance at the time of separation and were therefore eligible for rating.  The Board first considered if each foot was reasonably considered unfitting and based on the same evidence, the Board concluded that there was no way to separate the fitness impact of the left PP condition from the right PP condition and therefore, the Board concluded that there was not a preponderance of evidence of the records that overcame the Board’s presumption that the right and left PP conditions were each reasonably considered separately unfitting and were eligible for rating at separation.  

The MEB NARSUM physical examination, 1 month prior to separation, noted only “symptomatic pes planus of both feet.”  The physical examination noted only bilateral “severe pes planus and symptomatic.”  The remote VA C&P examination, more than 10 years after separation noted there had been no surgery of the feet.  The CI reported pain of the left foot accentuated by use and use of orthotics.  The examination of the CI’s feet were normal in all regards at the C&P examination.  

The PEB adjudicated the bilateral pes planus condition as not unfitting.  The VA rated the left PP condition 0%, based on the C&P examination more than 10 years after separation.  As noted above the remote VA C&P examination has probative value for the Board’s rating recommendation at the time of separation only insofar as it provides information regarding the disability related to the bilateral pes planus conditions at separation.  Relevant information noted at the remote C&P examination included that no foot surgery had been required after separation and there was no evidence of findings supportive of “severe” pes planus IAW VASRD 4.71a rating criteria.  If not present remotely, these findings could not have been present at separation, in the absence of any surgical interventions. The VASRD code for pes planus (5276) provides a 10% rating for “moderate” pes planus with evidence of “pain on manipulation and use of the feet,” not relieved by orthotics, whether unilateral or bilateral.  There was no evidence of “severe” pes planus criteria including “marked deformity,” indication of swelling on use,” or “characteristic callosities” for the next higher evaluation of 20% (unilateral) or 30% (bilateral).  After due deliberation, the Board agreed that the preponderance of the evidence with regard to the functional impairment of the bilateral pes planus condition favors its recommendation as an additionally unfitting condition for disability rating.  Although when unbundled, the Board recommended each foot was reasonably considered unfitting at separation, the bilateral PP is appropriately coded 5276 and meets the VASRD §4.71a criteria for a 10% rating (for bilateral “moderate” PP).  

Bilateral posterior tibialis pain.  The bilateral posterior tibialis pain condition was not permanently profiled or mentioned in the commander’s statement, and was not judged to fail retention standards.  As noted in the left ankle discussion above, the left posterior tibialis tendon dysfunction may have been contributing to residual left ankle pain and or the left PP condition, but there is no evidence in record that supports that bilateral PTD or left PTD was separately unfitting for continued military service.  

Bilateral retropatellar pain.  Notes in the STR and NARSUM indicated the CI reported left ankle pain and then later reported bilateral knee pain with the left being worse than the right.  Notes in the record noted normal left knee exams except for patellar grind.  The MEB NARSUM examination, exam, 1 month prior to separation, noted bilateral knee pain with left worse than right.  The permanent profile listed left knee injury.  However, the commander’s statement noted the CI used a left knee brace, but otherwise did not implicate the left knee as impairing the CI’s duty performance.  The MEB NARSUM indicated that bilateral retropatellar pain syndrome met retention standards.  There was no performance based evidence from the record that the bilateral retropatellar pain syndrome or the left retropatellar pain syndrome 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 bilateral posterior tibialis pain or bilateral retropatellar pain syndromes, and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the left ankle pain condition, the Board unanimously recommends a disability rating of 10%, coded 5299-5271 IAW VASRD §4.71a.  In the matter of the contended bilateral pes planus condition, the Board unanimously agrees that both the right and left pes planus conditions were unfitting and unanimously recommends a disability rating of 10%, coded 5276 IAW VASRD §4.71a.  In the matter of the contended bilateral retropatellar pain syndrome and bilateral posterior tibialis pain syndrome, the Board unanimously recommends no change from the PEB determinations 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	
Chronic Left Ankle Pain	5299-5271	10%	
Bilateral Pes Planus 	5276	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150603, 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 
XXXXXXXXXXXXXXXXXX, AR20170000856 (PD201500868)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization of the individual’s separation.  This decision is final.  

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.   

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:

CF: 
(  ) DoD PDBR
(  ) DVA