RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01166
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070416

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E4, Personnel Administrative Specialist, medically separated for “chronic pain, right ankle…,” with a disability rating of 10%.

CI CONTENTION:  The CI requested a review of 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 - 20070213	VARD - 20150616	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Right Ankle…	5099-5003	10%	Right Lateral Collateral Ligament Sprain Status Post Arthroscopic Modified Bronstrom Repair	5271	10%	20150608	
Anxiety	Not Unfitting	Posttraumatic Stress Disorder	9411	50%	20150611	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:     

Chronic Pain, Right Ankle.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI initially injured her right ankle in basic training in 2002 and recovered satisfactorily; but, she re-injured it dismounting a truck in July 2004 during training when her unit was mobilized to Iraq.  She did not recover sufficiently for deployment and was placed in medical hold.  Magnetic resonance imaging (MRI) at that time was normal and a bone scan yielded non-specific findings (uptake at the head of the first metatarsal and mild uptake around the tarsal bone and ankle).  The CI continued to complain of pain that was unresponsive to a trial of casting with progressive weight bearing.  A diagnosis of complex regional pain syndrome (CRPS) was suspected.  A podiatry consultant noted a congenitally abnormal joint angle predisposing to injury (pes varus-adductus) with “mild intrinsic ... instability,” and surgery was proposed.  A final orthopedic consultant (contemporary with the NARSUM) noted that a repeat MRI was normal without evidence of occult fracture or any structural issue; documented a stable joint to stress testing; and, opined that there was a “volitional component” to the CI’s persistent gait disturbance (intermittent during gait cycle and no correlating shoe wear).  The examination additionally recorded normal strength testing (5/5 all groups), and range of motion (ROM) was assessed as “mild decreased dorsiflexion.”  The orthopedist suspected a nerve injury (superficial peroneal), and opined that surgical intervention was not indicated.  Having failed conservative treatment, the CI was referred for an MEB.  The MEB forwarded “joint pain, ankle” for PEB adjudication.  

The NARSUM examination on 29 August 2006 (8 months before separation) documented persistent pain (unquantified) with a half-mile walking tolerance and inability to run.  The physical examination recorded an antalgic gait, dorsal foot tenderness, and distal sensory deficits.  The NARSUM referenced ROM measurements by physical therapy from two weeks earlier: dorsiflexion to 10 degrees (normal 20) and plantar flexion to 35 degrees (normal 45).  

Evidence showed the CI underwent surgical intervention over 4 years after separation.  The first VA Compensation and Pension (C&P) examination even more temporally remote from separation (8 years) documented “constant” ankle pain and recorded ROM measurements of dorsiflexion to 10 degrees and plantar flexion to 35 degrees.  

The Board directed attention to its rating recommendation based on the above evidence.  The Board noted that the earliest VA evaluation was over 8 years after separation.  As elaborated above, the Board’s assessment must be derived from evidence that can be reasonably interpreted to reflect disability at the time of separation.   Therefore the evidence from the Service record was assigned the determinant probative value with respect to the Board’s recommendation.  

The PEB rated 10% under code 5099-5003 (analogous to arthritis, degenerative) citing the US Army Physical Disability Agency (USAPDA) pain policy.  The VA’s 10% rating (based on the temporally remote C&P evidence) was under code 5271 (limitation of motion) citing “moderate” limitation.  Code 5271 confers a 20% rating for “marked” limitation, but members agreed that the PEB ROM evidence (50% loss of dorsiflexion and modest reduction in plantar flexion) was not reasonably characterized as marked limitation.  Given the absence of ankylosis, nonunion, or malunion, VASRD §4.71a offers no applicable ankle code which would yield a rating higher than 10% for this case.  Board members considered that the CRPS or nerve injury component could justify alternative rating under a VASRD §4.124a peripheral nerve code.  The applicable code in this case is 8722 (superficial peroneal neuralgia) which confers a 20% rating for “severe" impairment.  VASRD §4.124 (neuralgia, cranial or peripheral), however, stipulates a maximum rating of “moderate” (10% under 8722) for pain without motor deficit.  The Board agreed that “severe” nerve impairment was not supported by the evidence regardless.  Therefore, alternate nerve code rating was not advantageous.  Members additionally agreed that separate ratings for joint and nerve impairment, or for separate ankle and foot conditions, could not be recommended without violation of VASRD §4.14 (avoidance of pyramiding).   

Finally, given the degree of functional impairment (specifically the gait disturbance) in evidence, members considered alternate rating under code 5284 (foot injuries, other) which confers ratings of 10% for “moderate,” 20% for “moderately severe,” and 30% for “severe” disability.  Members agreed, however, that “moderate” was a fair assessment of the disability in evidence (especially with the probative value mitigation of the gait evidence per the above orthopedic assessment); thus, this option was also not advantageous.  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 of the right ankle condition.  

Contended Condition: Anxiety.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that the 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 contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the right ankle condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended anxiety 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 20150609, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander

20 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170001465 (PD201501166)

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, I accept the Board’s recommendation and hereby deny the individual’s application. This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA