RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX.	CASE:  PD-2015-01210
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070202

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E-5, Construction Equipment Repair, medically separated for “left ankle pain,” with a disability rating of 10%.  

CI CONTENTION:  The applicant requests all conditions be considered.  The applicant’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 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 confined to 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 - 20061212	VARD - 20071031	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Ankle Pain (Left)	5271	10%	S/P Posterior Tibialis Tendon Tear, L Ankle	5271	0%	20071016	
Low Back Pain	Not Unfitting	Mild Annular Bulging, L2/3, L3/4, L4/5	5242	10%	20070501	
Neck Pain	Not Unfitting 	Mild Degenerative Changes C5-6, C6-7	5242	10%	20070501	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Left Ankle Condition.  The record shows that at the age of 15 in 1990, several years prior to service, the CI was in a motorcycle accident.  He was admitted for several weeks and sustained a loss of consciousness from a closed head injury (CHI).  He also had fractures of the thoracic spine, pelvis, right wrist, and left collar bone at the sternum.  He was evaluated by an orthopedic surgeon as part of the MEPS process on 30 October 1992 and was not restricted from accession.  

According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left ankle condition began in October 2004 after a fall from a 5-ton truck on 15 October 2004, sustaining a partial tear of the left posterior tibialis tendon and flexor digitorum longus tendon.  The CI presented for care the following morning noting pain in his calf and foot with walking, but he was able to bear weight.  He denied a “pop” (indicative of a tear) or immediate swelling.  On examination, there was no swelling or discoloration.  He was tender to palpation and had difficulty rising on his toes.  The ankle was stable.  X-rays were normal.  He was treated with medications, an ankle brace, and crutches.  The CI apparently had an MRI which showed a tear of the left posterior tibialis tendon.  He was seen several more times and then released without limitations by orthopedics on 1 November 2004, 2 weeks after the injury.  No comment was made on either a neck or back injury at any of the four appointments in evidence proximate to the injury.  A line of duty determination also only cited the ankle injury.  The CI was released from active duty (REFRAD) on 16 March 2005.  It was noted that this was not due to a physical disability.  The record then falls silent until 15 February 2006 when the CI was seen in physical medicine (PMR) for neck and back pain attributed to the above accident.  No comment was made on the ankle.  The CI was seen for a fit for duty examination on 10 April 2006 to evaluate the neck and back issues.  He reported pain in the left ankle.  On examination, he was noted to have an antalgic gait (abnormal due to pain) and symptomatic flat feet (pes planus).  He was next seen on 27 July 2006 for the NARSUM evaluation for an MEB.  No specific complaints were noted for the ankle, but he was tender along to inside of the ankle on examination.  The range of motion (ROM) was from 10 degrees dorsiflexion (toes up) to 35 degrees plantar flexion (toes down) with VA normal values of 20 and 45 degrees, respectively.  He was noted to have an antalgic gait favoring the left foot.  An X-ray on 8 August 2006 showed a healing stress fracture of the heel bone (calcaneus).  The CI was evaluated in the podiatry clinic on 30 August 2006 and reported numbness of the last three toes on the left foot which extended up the front outside part of his leg.  On examination there was no swelling, tenderness or instability noted.  Slight muscle atrophy of the leg was present.  The ROM was recorded as normal and without pain, but measured at 10 degrees dorsiflexion and 50 degrees plantar flexion.  There was decreased sensation to the plantar aspect (sole) of the 3rd, 4th, and 5th digits.  Strength was reported as slightly decreased, but equal bilaterally.  The numbness was determined to not be related to foot/ankle pathology and of uncertain etiology.  An X-ray was read as showing no pathology.  On 19 September 2006, the CI was noted in primary care to have a normal gait.  Despite treatment, the ankle condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “left ankle tibialis posterior tendon and flexor digitorum longus tendon grade 1 tear with chronic pain” for PEB adjudication.  At the MEB NARSUM exam on 26 October 2006, 3 months before separation, the CI reported continued chronic pain in the left ankle with mild limitation of function.  The CI reported that he was treated with a cast and walker for 6 weeks.  The record shows that he was treated with a brace and crutches and returned to duty without restrictions after 2 weeks.  The MEB physical examination was based on the prior examinations documented above.  The CI was seen in primary care on 21 March 2007, 7 weeks after separation, and found to have a normal physical examination.  On 19 April 2007, 2 months after separation, at a neurology evaluation, he reported ongoing left ankle pain with limping after “distance” walking.  His gait was normal on his heels and toes although painful.  An MRI on 8 May 2007 of the ankle noted that the (previously injured) posterior tibialis tendon and flexor digitorum longus tendons were normal.  Fluid was noted near a different tendon; the tendon itself was normal though.  In neurology on 25 May 2007, the motor function of the ankle was normal.  Heel walking was painful.  

At the VA Compensation and Pension (C&P) examination performed on 16 October 2007, 8 months after separation, the CI reported that he was treated with a half cast for 2 months.  The CI reported pain on a daily basis with weight bearing of any duration greater than 1 hour and difficulty with climbing steps.  He denied use of any assisted devices.  The physical exam showed an antalgic gait with a left limp, but he moved about the office “satisfactorily” without an assistive device and was able to get on the examination table without difficulty.  There was no swelling, pain to palpation or ligament laxity.   The ROM was near normal and pain free.  He could walk on his toes and heels without difficulty.  The ankle was stable.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5271 code (limited motion of the ankle), citing mild limitation of motion.  The VA assigned a 0% rating also using the 5271 code based on the VA C&P examination 8 months after separation, citing no painful or limited motion and stating that motion was within normal limits.  There was no limitation of dorsiflexion or plantar flexion that supported a rating under the VASRD diagnostic code for limitation of motion (5271).  The left ankle limitation of motion recorded at the time of the MEB NARSUM examination was mild.  However, there was an antalgic gait supporting a 10% rating for functional loss (§4.40).  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 condition.  

Contended PEB Conditions: Neck and Low Back Pain.  The Board’s main charge is to assess the fairness of the PEB’s determination that lumbar and cervical spine conditions were not unfitting.  The PEB noted that these conditions were not a result from his fall in October 2004 and that he had significant trauma at the age of 15 with subsequent neck and back pain.  Despite this, the PEB noted that the CI was able to perform his duties.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The Board noted that these conditions were profiled and were judged to fail retention standards.  The back was implicated in the commander’s statement.  The Board carefully considered the evidence.  As noted above, the CI was seriously injured in a motorcycle accident 2 years prior to accession.  The record shows that the CI was seen for several times low back pain between 1993 and 1995.  He reported problems since the previous injury (in 1990).  On 15 February 1994, he was seen for neck and back pain after he was struck by a hatch the day before.  His examination was unremarkable.  He was then seen on 12 April 1995 reporting back pain and again the motorcycle accident was cited.  There are no further entries for either neck or back pain until after the CI had been activated and released from active duty.  A VA note dated 15 December 2005, 9 months after REFRAD, recorded that the CI had low back pain while deployed.  This was associated with moving and loading tents.  Subsequently, the CI was seen frequently for neck and back pain and typically reported that these both dated to the fall from a vehicle while deployed.  As noted, neither neck nor back pain was cited in the clinical encounters proximate to this incident.  A neurology note dated 21 March 2006 recorded that the neck and back pain dated to the motorcycle accident in 1990.  There was no performance-based evidence from the record that either of these conditions significantly interfered with satisfactory duty performance while on active duty.  Although the CI was seen frequently for neck and back pain after REFRAD, the clinical visits in evidence generally show minimal objective findings as do the imaging studies.  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 either contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the left ankle condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended back and neck conditions, 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, 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 20150608, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170005812, XXXXXXXXXXXXXXXXXX. 

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Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.