RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01569
BRANCH OF SERVICE:  army	SEPARATION DATE:  20080401

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2, Information Technology Specialist, medically separated for “bilateral ankle pain with left heel pain due to left calcaneus stress reaction,” with a disability rating of 10%.  

CI CONTENTION:  The CI contended his bilateral ankles, his heel and a back condition.  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 - 20080227	VARD - 20081119	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Ankle Pain with Left Heel Pain due to Left Calcaneus Stress Reaction	5099-5003	10%	Healed Stress Fracture of the Talus, Left Ankle	5299-5271	0%	20081016	
			Right Ankle Strain	5299-5271	0%	20081016	
			Left Calcaneus Stress Fracture Associated with Healed Stress Fracture, Talus, Left Ankle	5299-5283	0%	20081016	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Bilateral Ankle Condition.  The PEB combined the right ankle, left ankle, and left heel conditions as a single unfitting condition coded analogously to 5003 (arthritis, degenerative) and rated 10%.  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The panel also noted that “bundling,” the combining of two or more major joints may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The panel’s initial charge in this case was therefore directed at determining if 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 panel 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 panel 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 right ankle and left ankle conditions are presented together, and the evidence for the left heel condition is presented separately.  Attendant recommendations regarding separate unfitness and rating are presented in the rating discussion.

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the bilateral ankle pain began in the second week of basic training.  A 13 August 2007 lower extremity nuclear medicine bone scan revealed findings suspicious for stress fractures of the left calcaneus and talus bones.  Bilateral ankle X-rays on 19 October 2007 were normal.  The 10 December 2007 physical therapy (PT) physical examination documented a normal gait.  The bilateral ankle examination revealed no tenderness or erythema (redness).  Bilateral ankle active range of motion (ROM) was dorsiflexion of 20 (20 normal) and plantar flexion of 50 (45) degrees.  The anterior drawer (assesses anterior talofibular ligament [ATFL]) and talar tilt (assesses calcaneofibular ligament [CFL]) tests were negative.  The 11 January 2008 PT measured bilateral ankle active ROM was dorsiflexion of 20 (20) and plantar flexion of 50 (45) degrees.  On 14 January 2008, PT measured repetitive (X3) ROM with a goniometer for the MEB.  Pain limited right ankle active ROM was dorsiflexion of 15/15/15 (20) and plantar flexion of 45/45/45 (45) degrees.  Pain limited left ankle active ROM was dorsiflexion of 10/10/10 (20) and plantar flexion of 55/55/55 (45) degrees.  

In the 28 January 2008 MEB NARSUM, 2 months before separation, the CI complained of constant, 5-7/10 bilateral ankle pain.  He reported progressive worsening over the first 2 weeks of basic training with no specific trauma.  The CI denied ankle instability or swelling.  “Has previously had relief of his symptoms with a 30-day convalescent leave, however, returning from his 30-day convalescent leave to training his symptoms returned and remained at the same intensity level.”  Symptoms were exacerbated by prolonged standing and running and improved with rest.  The physical examination documented a normal heel-toe gait.  The bilateral ankle examination revealed anterior joint line tenderness with no erythema, swelling, instability, or impingement.  The examiner recounted the PT bilateral ankle active ROM values of dorsiflexion of 20 (20) and plantar flexion of 50 (45) degrees.  The examiner recounted the findings of the X-rays and bone scan.  The diagnosis listed bilateral ankle pain secondary to overuse injuries.  The 16 October 2008 bilateral ankle X-rays were unremarkable.  

In the 16 October 2008 VA Compensation and Pension (C&P) examination, 7 months after separation, the CI complained of pain in his feet since discharge.  Symptoms were exacerbated by standing, walking, and running.  He denied weakness, swelling, fatigability, flare-ups, incoordination, excess fatigue, lack of endurance, or use of prescription pain medications, special shoes, inserts, heel cups, braces, or assistive devices.  His normal activities of daily living and occupation were unaffected, and he had no functional limitations with standing or ambulation.  The physical examination documented a normal gait.  The bilateral ankle examination revealed no pain on malleoli (distal medial tibia and lateral fibula bony prominences) compression, heat, effusion (fluid collection), or edema (excess tissue fluid swelling).  Pain free bilateral ankle active ROM was dorsiflexion of 20 (20) and plantar flexion of 30 (45) degrees.  There was no change in ROM with repetitive motion (X3) due to weakness, coordination, fatigue, endurance, or pain.  The examiner recounted the findings of the X-rays.  The impression listed right ankle strain and healed left ankle talus stress fracture.

The panel directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the panel must first consider whether each ankle condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 10% rating under an analogous 5003 code (arthritis, degenerative) citing bilateral ankle pain, associated left heel pain due to left calcaneus stress reaction, normal X-rays, normal ROM, and rated IAW USAPDA pain policy (slight/constant).  The VA assigned a assigned a 0% rating for the right, and a 0% rating for the left ankle under an analogous 5271 code (ankle, limited motion of) based on the C&P examination 7 months after separation, citing a non-compensable evaluation is assigned unless there is moderate limited motion of the ankle.  There was no deformity for consideration under 5270 (ankle, ankylosis), 5272 (subastragalar or tarsal joint, ankylosis of), or 5273 (os calcis or astragalus, malunion of).  There was no excision of the astragalus for consideration under 5274 (astragalectomy).  Panel members agreed that the ROM values more closely approximated the moderate (10%) than the marked (20%) rating under 5271 (ankle, limited motion of).  The panel agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  The panel concluded that the evidence did provide sufficient grounds for recommending separate disability ratings in this case.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the right ankle condition, and 10% for the left ankle condition, coded 5099-5003.

Left Heel Condition.  According to the STR and the MEB NARSUM, the left heel pain began in the second week of basic training.  A 13 August 2007 lower extremity nuclear medicine bone scan revealed findings suspicious for stress fractures of the left calcaneus and talus bones.  The 10 December 2007 PT examination documented a normal gait.  The bilateral foot examination revealed no pes cavus (claw foot), no pes planus (flatfoot), and full ROM.  

In the MEB NARSUM the CI complained of constant, 5-7/10 left heel pain.  He reported progressive worsening over the first 2 weeks of basic training with no specific trauma.  Symptoms were exacerbated by prolonged standing and running and improved with rest.  The physical examination documented a normal heel-toe gait.  The foot examination revealed left heel and bilateral dorsal midfoot tenderness.  There was no erythema, swelling, pes planus, or mechanical malalignment.  The examiner recounted the findings of the X-rays and bone scan.  The diagnosis listed left calcaneus stress reaction secondary to overuse injury.  The 16 October 2008 left foot X-rays were unremarkable.  In the VA C&P examination the CI complained of pain in his feet since discharge.  Symptoms were exacerbated by standing, walking, and running.  The physical examination documented a normal gait.  The left foot examination revealed no calcaneus tenderness, ulcerations, callosities, edema, instability, abnormal wear patterns of the shoes, or evidence of abnormal weight bearing.  The Achilles tendon was aligned and was not painful with manipulation.  Pain free toe active ROM was dorsiflexion of 30 and plantar flexion of 30 degrees.  There was no change in ROM with repetitive motion (X3) due to weakness, coordination, fatigue, endurance, or pain.  The examiner recounted the findings of the X-rays.  The impression listed healed left calcaneous stress fracture.  

The panel directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the panel must first consider whether the left heel condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 10% rating under an analogous 5003 code (arthritis, degenerative) citing bilateral ankle pain, associated left heel pain due to left calcaneus stress reaction, normal X-rays, normal ROM, and rated IAW USAPDA pain policy (slight/constant).  The VA assigned a assigned a 0% rating under an analogous 5283 code (tarsal, or metatarsal bones, malunion of, or nonunion of) based on the C&P examination citing a non-compensable evaluation is assigned in the absence of moderate symptoms associated with malunion or nonunion of the tarsal or metatarsal bones.  There was no weakness for consideration under 5277 (weak foot).  There was no evidence of sensory pathology for consideration under 5279 (metatarsalgia).  There was no deformity for consideration under 5276 (flatfoot), 5278 (claw foot), 5280 (hallux valgus), 5281 (hallux rigidus), 5282 (hammer toe), 5283 (metatarsal bones malunion/nonunion of), or 5284 (foot injuries, other).  The panel agreed a 10% rating was not supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  The panel concluded that the evidence did provide sufficient grounds for recommending a separate disability rating in this case.  

BOARD FINDINGS:  In the matter of the right ankle condition, the panel majority recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the left ankle condition, the panel majority recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the left heel condition, the panel determined the condition was not unfitting.  The single voter for dissent recommended no change and did not elect to submit a minority opinion.  There were no other conditions within the panel’s scope of review for consideration.  

The panel 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	
Right Ankle Pain 	5099-5003	10%	
Left Ankle Pain 	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150615, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170008529, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure