RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02114
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070901

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E5, Human Resources Specialist, medically separated for “left lower extremity injury,” with a disability rating of 10%.  

CI CONTENTION:  “Review all 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 - 20070710	VARD - 20100208	
Condition	Code	Rating	Condition	Code	Rating	Exam	
LLE Injury	5271	10%	L Posterior Tibial Tendinopathy…	5271	NSC	N/A	
Coagulopathy…	Not Unfitting (Cat III)	DVT, Left Leg	7121	NSC	N/A	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  	

ANALYSIS SUMMARY:  

Left Lower Extremity (LLE) Injury.  According to the service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s LLE injury condition began in September 2002 after running on a physical fitness test (PFT).  She was noted to have swelling, but her examination was otherwise unremarkable.  X-rays were normal.  She was treated with a splint, but her symptoms persisted.  On 8 November 2002, the CI reported to the emergency room (ER) with increased pain.  She was found to have a deep venous thrombosis (DVT) (a blood clot) and begun on anti-coagulation (blood thinners).  This is discussed further below.  She was incidentally found to be anemic, which was determined to be secondary to insufficient iron intake and treated with iron supplementation.  On 2 December 2002 bone scan studies showed diffuse uptake of uncertain etiology.  On 3 March 2003 a magnetic resonance imagining study (MRI) showed mild inflammation of the left posterior tibial tendon.  At the 21 March 2003 orthopedic examination, the results were reviewed and the CI referred to pain management.  On 25 April 2003, a series of nerve blocks were recommended.  These failed to completely resolve the pain and the CI underwent a reconstruction of the left posterior tendon with grafting in December 2003.  Her post-operative course was uneventful.  On 21 April 2004 she was evaluated in physical therapy (PT) to begin rehabilitation.  She was in a walking boot; left calf atrophy was present.  Both dorsiflexion (toes up) and plantar flexion (toes down) were reduced compared to the right side.  Flexion and extension of the toes were diminished.  In August 2004 at an orthopedic appointment, the CI was noted to be progressing.  The record then falls silent until a pre-deployment screen on 20 April 2005.  The CI was determined to be non-deployable.  On 25 July 2005 at the orthopedic exam the CI noted that she could bike and walk, but not fast enough for the PFT.  She did have trouble wearing a boot and was using a shoe of comfort.  On 16 January 2006, she was noted to have decreased sensation of the inside of the left foot (thought to be a possible complication of the surgery) and limited dorsiflexion of the left great toe (which was not explained by the possible nerve damage).  Maximal medical improvement was thought to have been reached and she was released from care.  The CI was then identified for an MEB.  

On 10 May 2006 the CI underwent formal range of motion (ROM) testing in physical therapy, 16 months prior to separation.  It was noted that motion was painful and that the limitation in dorsiflexion was secondary to muscle tightness.  Dorsi-flexion was limited to (-) 20 degrees (+20 degrees is normal) and plantar flexion was near normal at 40 degrees (45 degrees is normal).  At the 27 February 2007 MEB NARSUM examination, 7 months prior to separation.  The CI reported that she was working in her specialty in garrison, but could not perform her duties in the field.  She reported that this was due to the loss of sensation in her left foot and toes and the inability to bend her toes to put on her boots.  On examination, she was noted to have a severe restriction in the ROM of the left ankle and abnormal sensation over the medial (inside) aspect of the left foot.  Her gait and station were noted to be non-focal (no significant abnormality) though.  The medical officer observed that this is not consistent with the recorded limitation of dorsiflexion of (-) 20 degrees which is significant foot drop.  At the 20 June 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported the history of surgery.  On examination, the ROM of the left ankle and toes was reduced, but not quantified.  The gait was abnormal due to pain (antalgic), but a foot drop was not documented.  The MEB forwarded left posterior tibial tendinopathy to the PEB as medically unacceptable.  

On 1 December 2009 the CI was scheduled for a VA Compensation and Pension (C&P) evaluation, but did not report for the examination.  The first VA evaluation in evidence was 6 years after separation and well outside the 12 month window assigned higher probative value for rating at separation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the LLE injury condition 10%, coded 5271 (ankle, limited motion of), citing numbness and loss of the total passive ROM of the left ankle compared to the right at a moderate level of impairment.  The VA initially did not rate the left ankle condition as the CI did not report for the scheduled examination and the post-separation rating was remote from separation.  The panel considered the evidence.  The numbness was not found to be medically unacceptable by the MEB.  It was noted by the PEB, but not rated nor coded.  The sole rating and coding option were for the limited ROM of the ankle.  The numbness condition is therefore outside the Scope of the Board.  The panel did note though that a separate impairment from the numbness was not recorded and that the limitation in wearing a boot was attributed to difficulty flexing the toes which the orthopedist opined was not related to the numbness (and possible nerve damage in surgery).  The panel determined that the numbness condition would not be unfitting even if it were in scope.  The panel then considered the rating options.  Of the codes specific for the ankle, only limitation in motion is applicable.  The loss of motion is consistent with a marked impairment supporting a 20% rating.  The panel could not explain the level of loss measured with the observation of a “non-focal” gait and an “antalgic gait” without comment on foot drop.  The panel considered the code 5310 (Group X function which includes the posterior tibial tendon) and noted that a moderately severe level of impairment also supported a 20% rating.  The panel noted that the use of an assistive device such as a brace, orthopedic boot, cane, or crutches was not documented at separation.  Also, the CI was able to successfully meet duty requirements, other than the PFT, while in garrison.  Accordingly, a severe level of impairment was determined to not be present at separation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the LLE injury condition, coded 5271.  

Contended PEB Condition:  Coagulopathy Requiring Long-Term Anticoagulation.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was judged to fail retention standards.  However, it was not profiled at separation or implicated in the commander’s statement.  There was no performance-based evidence from the record that the condition 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 the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the left lower extremity injury condition, the panel unanimously recommends a disability rating of 20%, coded 5271 IAW VASRD §4.71a.  In the matter of the contended coagulopathy condition, the panel unanimously agrees that it cannot recommend it for additional disability rating.  There are 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	
Left Lower Extremity Injury	5271	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150730, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170012118, 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 and the counsel your listed on your application, XXXXXXXXXXXXXXXXXXX

Sincerely,	
Enclosure