RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01205
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20030803

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Information Systems Technician, medically separated for “chronic bilateral ankle instability,” rated 10% each, with a combined disability rating of 20%.

CI CONTENTION:  The CI contended for his ankles, PTSD and for multiple injuries suffered during his time as a Navy Seal.  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination 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(s) at the time of separation.  The panel 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 panel 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 - 20030527	VARD - 20031015	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Ankle Instability
	5299-5271	10%	Left Ankle Instability and Degenerative Change, S/P Operative	5010-5271	20%	20030812	
	5299-5271	10%	Right Ankle Instability and Degenerative Change, S/P Operative	5010-5271	20%	20030812	
Right*
 Ankle Instability and degenerative Changes …	Cat II					
Mild Instability Right Shoulder	Cat III	Biceps Tendonitis of Right Shoulder	5099-5024	0%	20030812	
Mild Degenerative Change, Left Knee		S/P Patellar Tendon Surgery with Tendonitis and Degenerative Changes of Left Knee	5010	10%	20030812	
Patellar Tendon Avulsion, Left Knee						
Olecranon Bursitis, Left Elbow		S/P Olecranon Bursitis Left Elbow	5019	0%	20030812	
Biceps Tendonitis, Right Shoulder		Biceps Tendonitis of Right Shoulder	5099-5024	0%	20030812	
Depressive Disorder NOS		Depressive Disorder NOS	9435	0%	20030812	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Bilateral Ankle Instability, [Right].  According to the service treatment record (STR), the 30 May 2002 Medical Evaluation Board (MEB) narrative summary (NARSUM) and the 24 January 2003 MEB NARSUM, the CI sustained a right ankle injury while performing physical training in August 1996.  He also reported multiple previous ankle sprains that were undocumented.  The CI underwent two surgeries of the right ankle, the first in September 2000 for debridement of degenerative changes and the second in March 2001 for instability, with additional debridement.  The CI was placed on 8 months limited duty (LIMDU) on 5 September 2001 for chronic bilateral ankle instability.  At that time the CI was involved in rehabilitation for the right ankle.  

The MEB NARSUM examination, 14 months prior to separation, noted complaints of chronic bilateral ankle pain with decreased range of motion (ROM) and instability.  The physical examination showed a normal gait.  There was mild tenderness of the anterior ankle bilaterally (anterior talofibular ligament).  There was bilateral crepitus and ankle ROM was dorsiflexion (DF) 15 degrees and plantar flexion (PF) 40 degrees bilaterally.  Ankle X-rays in March 2002 showed degenerative changes bilaterally.  

The 4 June 2002 MEB orthopedic addendum, 14 months prior to separation, noted a history of right ankle injury with continued symptoms.  Physical examination showed right ankle ROM of DF 5 degrees with the knee in extension and 10 degrees with the knee flexed and PF 25 degrees.  The surgical scars were well healed and the ankle was stable.  The MEB orthopedic surgeon indicated there was no further surgical treatment available and that the CI was unfit due to the right ankle.  The JDETS (with notes dated up to August 2002) recommended that although the CI was not sea duty assignable, he could perform in an appropriate job ashore and was therefore fit for duty.  According to the 31 October 2002 JDETS note, the CI requested reconsideration of his ankles and requested a 30% rating due to constant pain in the ankles causing inability to function in his primary Rate.  The JDETS also noted that since the MEB the CI had undergone additional procedures on the left ankle.  The PEB terminated the medical board on 18 November 2002 for convalescence from recent surgery (left ankle) and any subsequent treatment.  The medical board was to be resubmitted with another orthopedic addendum.  A 16 December 2002 memorandum to the record outlined a LIMDU schedule for the CI to participate in three hours of comprehensive rehabilitation daily, which was to be his primary responsibility during the period of LIMDU.  

The MEB NARSUM examination, 6 months prior to separation, noted complaints of bilateral ankle pain, stiffness, instability and pain with walking.  Physical examination showed a normal gait.  There were well healed ankle scars.  There was swelling and tenderness over the anterior ankle.  Right ankle ROM was DF 5 degrees and PF 25 degrees.  There was no evidence of instability.  The MEB NARSUM determined the CI was unfit due to chronic bilateral ankle instability. The 12 February 2003 MEB orthopedic addendum, 6 months before separation, noted that there was no change to the assessment of the right ankle condition.  The CI submitted an appeal of the NARSUM dated 15 February 2003, noting the five ankle surgeries to the right and left ankle in the past 2 years and no other conditions.  He again maintained that he was unable to perform the duties of his primary Rate and should be found unfit.  The May 2003 JDETS noted the CI’s contentions and indicated the CI had bilateral ankle pain with minimal activity.  The JDETS also noted that the undated non-medical assessment (NMA) indicated the CI was unable to perform the duties of his primary Rate (Navy SEAL) or his reassigned Rate (Information Systems Technician) and that he was prohibited from participation in physical fitness assessment (PFA), shipboard duty or overseas duty and was determined the CI was unfit.  

At the 12 August 2003 VA Compensation and Pension (C&P) evaluation, 2 weeks after separation, the CI reported bilateral ankle instability.  The physical examination noted a normal gait and posture and cited the 24 January 2003 MEB NARSUM examination of the ankles.  

The panel directed attention to its rating recommendation of the right ankle condition based on the above evidence.  The PEB adjudicated the bilateral ankle instability [right] condition as unfitting, Category I, with a 10% rating, coded 5299-5003 (arthritis, degenerative).  The PEB also cited “right ankle instability and degenerative changes, status post Brostrum procedure and loose body removal” as a Category II condition, contributing to the unfitting condition.  In this case the unfitting right ankle condition and the Category II right ankle condition reflect the same disability and any disability related to the “right ankle instability and degenerative changes…” condition is subsumed in the 4.71a rating of the unfitting right ankle condition.  The VA rated the right ankle instability 20%, coded 5010-5271 (traumatic arthritis- limited ankle motion), based on the C&P examination 2 weeks before separation (which referenced the MEB NARSUM), citing marked limited motion.

The PEB assigned a 10% rating for imaging evidence of arthritis of a single joint with painful, limited motion under 5003.  The panel reviewed to see if a higher rating was supported under any applicable code.  The panel considered if the limitation of motion was “moderate” or “marked” when considered under 5271, limitation of ankle motion.  The panel agreed that the examinations proximate to separation were consistent with “moderate” limitation of motion required for the 10% rating under this code based on the normal gait noted at both MEB NARSUM examinations and the VA examination (gait was not addressed at the MEB orthopedic examinations).  The panel considered alternative VASRD ankle and analogous codes, but all were less applicable or not advantageous to rating.  There was therefore no higher than a 10% rating available for the right ankle condition.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right chronic ankle instability condition.  

Chronic Bilateral Ankle Instability, [Left].  According to the STR and the MEB NARSUM, the CI sustained a left ankle sprain in November 2000, which was documented as a re-injury, as well as multiple previous ankle sprains that were unreported.  The CI was placed on 8 months limited duty (LIMDU) on 5 September 2001 for chronic bilateral ankle instability.  He underwent surgery for left ankle instability repair and debridement in November 2001.

The MEB NARSUM examination noted complaints of chronic bilateral ankle pain with decreased ROM and instability with physical examination of the bilateral ankles as noted above under the right ankle discussion.  The MEB orthopedic addendum noted continued left ankle symptoms.  The surgical scars were well healed the ankle was stable to testing.  There was a palpable mass on the outer aspect of the left ankle that was mildly tender.  Left ankle X-rays showed degenerative changes.  The MEB orthopedic surgeon indicated there was no further surgical treatment available and that the CI was unfit due to the left ankle.  Left ankle X-rays on 26 July 2002 showed swelling adjacent to the lateral malleolus and on 29 July 2002 the CI underwent surgery with excision of the painful soft tissues found to be the stump of the tendon used during the reconstruction in November 2001.  His post-operative course was complicated by a wound infection and X-rays 16 August 2002 showed soft tissue swelling and a joint effusion, without radiographic evidence of osteomyelitis.  The CI underwent another procedure on 18 August 2002 for incision and drainage of an abscess.  As elaborated above under the right ankle discussion, the JDETS (with notes dated up to August 2002) recommended that the CI was fit for duty in an appropriate job ashore and the CI requested reconsideration for his ankles and requested a 30% rating due to constant pain in the ankles causing inability to function in his primary Rate.  The 31 October 2002 JDETS also noted the additional procedures on the left ankle since the MEB.  The PEB terminated the medical board on 18 November 2002 for convalescence from the recent left ankle surgeries and maximal medical improvement was achieved.  A 16 December 2002 memorandum to the record outlined a LIMDU schedule for the CI to participate in intensive rehabilitation [left ankle] daily.  

The MEB NARSUM examination noted complaints of bilateral ankle pain, stiffness, instability and pain with walking.  Physical examination showed a normal gait.  There were well healed ankle scars.  There was swelling and tenderness over the anterior ankle.  Left ankle ROM was DF 10 degrees and PF 25 degrees.  There was no evidence of instability.  The MEB NARSUM determined the CI was unfit due to chronic bilateral ankle instability.  The 12 February 2003 MEB orthopedic addendum, 6 months before separation, noted there was no change in the musculoskeletal conditions addressed in the first orthopedic addendum other than the left ankle.  The MEB orthopedic examiner noted that the CI eventually recovered from both of recent procedures of the left ankle with no evidence of a remaining mass.  The physical examination noted left ankle ROM of 65 degrees (normal 65 degrees – DF 20 and PF 45) and DF 15 degrees.  There was no evidence of instability.  Subtalar motion was good and sensation was intact except over the scar.  The MEB orthopedic addendum indicated the CI was not fit for full duty due to “his multiple musculoskeletal injuries.  As noted above, the CI appealed the NARSUM in a letter dated 15 February 2003, noting the five ankle surgeries to the right and left ankle in the past 2 years and did not refer to any other conditions.  He again maintained that he should be found unfit.  The May 2003 JDETS noted the CI’s contentions and indicated the CI had bilateral ankle pain with minimal activity.  The JDETS also noted that the NMA indicated the CI was unable to perform the duties of his primary Rate or his reassigned Rate and was prohibited from PFA, shipboard duty or overseas duty and recommended the CI was unfit.  

At the VA C&P evaluation the CI reported bilateral ankle instability.  The physical examination noted a normal gait and posture and cited the MEB NARSUM examination of the ankles.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the left chronic ankle instability condition as unfitting, Category I, with a 10% rating, coded 5299-5003 (arthritis, degenerative).  The VA rated the left ankle instability condition 20%, coded 5010-5271 (traumatic arthritis-limited ankle motion), based on the C&P examination (which referenced the MEB NARSUM), citing marked limited motion.  The PEB assigned a 10% rating for imaging evidence of arthritis of a single joint with painful, limited motion, coded under 5003.  By the same rating rational as elaborated above for the right ankle condition, there was no rating higher than 10% available with any alternative VASRD ankle and analogous codes.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left chronic ankle instability condition.  

Contended PEB Conditions: Mild Instability, Right Shoulder; Mild Degenerative Change, Left Knee; Olecranon Bursitis, Left Elbow; Patellar Tendon Avulsion, Left Knee, Treated Surgically Prior to Enlistment [EPTS]; Biceps Tendonitis, Right Shoulder; Depressive Disorder, NOS.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  These conditions did not carry attached duty limitations (LIMDU), were not implicated in the non-medical assessment and were not judged to fail retention standards, nor was there any performance-based evidence from the record that the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the chronic bilateral ankle instability [right] and chronic bilateral ankle instability [left] IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudications.  In the matter of the contended mild instability, right shoulder; biceps tendonitis, right shoulder; olecranon bursitis, left elbow; depressive disorder, NOS, mild degenerative change, left knee and patellar tendon avulsion, left knee, EPTS conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.   

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150601, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44

      In accordance with reference (a), I have reviewed the cases listed below and approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN