RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02111
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20090411

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an E6, Aviation Machinist Mate, medically separated for “left ankle pain status post (s/p) subtalar fusion” with a disability rating of 20%.

CI CONTENTION:  The CI contends that the VA rated his unfitting condition at a higher percentage and requests the Board review all his conditions.  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 - 20081224	VARD - 20090608	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Ankle Pain, S/P Subtalar Fusion	5299-5272	20%	Osteoarthritis S/P Fracture Left Ankle	5010-5271	20%	20090121	
Osteoarthritis Foot, Multiple Joints of the Foot	Cat II					
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Left Ankle Pain, S/P Subtalar Fusion.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent a left subtalar joint arthroscopy with debridement and microfracture (bone breaching of defect to allow stem cell influx to form new cartilage) with conversion to an open procedure in November 2007.  A 6 March 2008 left lower extremity magnetic resonance imaging (MRI) study revealed a subtalar joint cartilage defect, a calcaneus osteophyte (bone spur), and talus (ankle bone that articulates with tibia, calcaneus and navicular) and calcaneus (heel bone) bone marrow edema.  The 30 May 2008 left foot X-rays revealed irregularity of the posterior subtalar joint and a possible healed calcaneal fracture.  Due to continued sharp left lateral foot pain, weakness and decreased range of motion (ROM), the CI opted for surgical intervention.  On 2 June 2008, the CI underwent a left bone block allograft (cadaver tissue transplant) subtalar arthrodesis (surgical joint fixation/fusion) and calcaneal osteotomy (surgical bone cutting).  The 17 July 2008 left ankle X-rays showed a subtalar joint fixation screw and evidence of early fusion.  The 3 October 2008 left ankle X-rays showed disuse osteopenia (less than peak bone mineral density), subtalar fusion with evidence of continued fusion, and no loosening, infection or hardware complications.  At the time of the orthopedic clinic appointment on 7 October 2008, 6 months prior to separation, the examiner recorded diffuse mild swelling, satisfactory alignment, healed incisions and no incision tenderness.  The ROM showed “significant limitation of the ankle, dorsiflexion and plantar flexion, no inversion or eversion.”  Pulses and sensation were normal.  The X-rays showed a healed arthrodesis site.  

During the 19 November 2008 MEB NARSUM examination, 5 months before separation, the CI reported daily left ankle pain that was exacerbated by activity to include standing, squatting, kneeling, climbing, walking, running and sports.  The left ankle examination revealed well-healed wounds and calcaneus and lateral malleolus (distal lateral fibula bony prominence) tenderness.  The ROM was dorsiflexion of 5 degrees (normal 20 degrees) and plantar flexion of 45 degrees (normal 45 degrees) with no subtalar motion.  Pulses were normal and the CI had “some sensation deficit in the sural nerve distribution and some numbness on the side of his foot.”  The diagnoses listed left ankle pain and osteoarthritis of multiple foot joints.  

At the 13 January 2009 VA Compensation and Pension (C&P) examination, 3 months before separation, the CI reported daily sharp, aching left lateral ankle pain, rated at 5-6/10.  The CI reported his pain level was down from a previous 7-8/10.  The CI also reported improvement with Instability postoperatively.  Symptoms were exacerbated by cold weather, weight bearing and prolonged walking (> 15-20 min.); and relieved by elevation, rest, heat packs and medication (Ultram).  He reported painful flares with mild swelling three times a week lasting ½-2 hours.  Physical examination revealed a numb, flat, purple scar (6cm X 5cm) and lateral malleolus and calcaneal fibular ligament tenderness.  There was no swelling, erythema (redness), angulation or ligamentous laxity.  There was pain with dorsiflexion and active ROM was dorsiflexion of 20 degrees (normal 20 degrees) and plantar flexion of 15 degrees (normal 45 degrees).  With repetitive (X3) ROM, there was no weakness, excess fatigability or incoordination.  Strength, sensation and deep tendon reflexes (DTRs) were normal.  The examiner recounted the findings of the X-rays and MRI.  The diagnoses listed left ankle fracture s/p surgery (X2), instability improved from ankle fusion and osteoarthritis.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 20%, coded 5299-5272 (subastragalar or tarsal joint, ankylosis of), the maximum rating for this code.  The Category II condition (osteoarthritis multiple joints of the foot) was considered to contribute to the unfitting ankle condition and was properly subsumed in the PEB rating.  The VA rated the osteoarthritis S/P fracture left ankle condition 20%, coded 5010-5271, (arthritis, due to trauma analogous to ankle, limited motion of) based on the VA C&P examination 3 months before separation, citing left ankle osteoarthritis status post fracture, X-ray findings and ROM with pain.  The CI underwent a left subtalar arthrodesis and imaging showed a subtalar fusion and intact orthopedic hardware.  There was no deformity for consideration of a higher rating under 5270 (ankle, ankylosis) or 5275 (lower extremity bone shortening of).  Therefore, VASRD §4.71a offers no applicable joint code which would yield a rating higher than the 20% adjudicated by the PEB.  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 ankle condition.  

BOARD FINDINGS:  In the matter of the left ankle condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  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 20150729, 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:

		- XXXXXXXXXXXXXXXXXX, former USMC
		-XXXXXXXXXXXXXXXXXX, former USMC
		-XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN

	
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	     				  Acting