RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02148
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080523

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E2, Medical Specialist, medically separated for “right ankle pain” with a disability rating of 10%.

CI CONTENTION:  The CI contends for her unfitting ankle condition and she requested that all of her conditions be reviewed.  The CI’s 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 - 20080501	VARD - 20090103	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Ankle Pain	5099-5003	10%	Chronic Right Ankle Sprain	5271	0%	20081209	
Right Calcaneal ... Stress Changes	Subsumed Above	No VA Code or Rating	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Right Ankle Pain (Subsuming Right Calcaneal Stress Reaction).  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI sprained her right ankle (inversion injury) in September 2007 during basic training.  This resulted in chronic pain and subjective instability.  Magnetic resonance imaging, that included a follow-up contrast study, was interpreted as normal; although, the NARSUM orthopedist identified some anterior talofibular (ATF) ligamental thickening consistent with chronic strain.  A bone scan demonstrated uptake consistent with a stress reaction in the right calcaneus.  There was no outpatient STR evidence probative to rating or separate fitness considerations for the ankle or foot.  Surgery was not indicated; conservative treatment did not result in sufficient improvement to allow a timely resumption of training; and, the CI was referred for MEB.

The 14 April 2008 NARSUM examination, 5 weeks before separation, documented pain (not elaborated or localized) “approximately 60-70% of the time” that limited standing to 30 minutes and prohibited running and general soldiering requirements.  The physical examination recorded normal joint strength and alignment, tenderness over the ATF, “discomfort with palpation” of the calcaneus, and objective joint stability.  Measured range of motion (ROM) was dorsiflexion to 10 degrees (normal 20) and plantar flexion to 50 degrees (normal 45), without clarifying painful motion but specifying no degradation with repetitions.  

The NARSUM specified that the CI “has been removed from initial entry training due to sustaining right ankle sprain with chronic pain  ... also developed mild stress changes to the right calcaneus ....”  The MEB’s DA Form 3947 submission separately listed “chronic right ankle sprain” and “right calcaneal pain due to mild stress changes,” each failing retention standards.  The permanent L3 profile was for “right foot and ankle pain;” and, the commander’s performance statement referenced only “stress reaction in her right heel.”

A 9 December 2008 VA Compensation and Pension (C&P) examination, 6 months after separation, documented constant ankle pain with subjective instability that was exacerbated by prolonged standing and walking.  There was no mention of heel pain and the CI was fully employed as an instructor.  The physical examination recorded a normal gait without brace or assistive device, normal joint strength and alignment, objective joint stability, no ankle tenderness, and “minimal” heel tenderness.  Measured ankle ROM was normal in all planes, specifying the absence of painful motion, and foot ROM was noted to be grossly normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB combined the separately submitted MEB diagnoses as a single unfitting condition (see rating chart).  The resulting 10% rating was under code 5099-5003 (analogous to degenerative arthritis), with the PEB’s DA Form 199 decision citing “rated as periarticular pathology” and referencing VASRD §4.59 (painful motion) in support of the minimum compensable rating.  The VA’s 0% rating under code 5271 (ankle, limited motion) cited the absence of ROM limitation or painful motion per the C&P findings.  

An issue confronting the panel in this case was the fact that two distinct diagnoses (potentially separately ratable conditions) were subsumed by the PEB under a single rating.  If each of these could be reasonably justified as separately unfitting, which is the panel’s default position unless a preponderance of evidence indicates otherwise, then each would be subject to separate disability rating.  The NARSUM suggested that it was the ankle condition that forced MEB proceedings, and that the calcaneal diagnosis emerged concurrently or subsequently.  Especially in that context, members agreed that it was difficult to conclude that the calcaneal condition in itself would have resulted in MEB referral and separation.  The STR and the post-separation clinical course from the VA evidence, commiserate with clinical expectations, established that the ankle condition was chronic whereas the calcaneal condition was transient.  Members additionally agreed that, even if each condition were conceded as separately unfitting, they could not be separately rated without violation of VASRD §4.14 (avoidance of pyramiding); thus, the calcaneal condition would be appropriately subsumed under a single rating with the unfitting ankle condition.  The PEB’s descriptor “periarticular pathology” reflected the same logic.  

Having agreed that separate ratings were not justified, the panel considered whether a rating higher than the PEB’s 10% could be supported.  There was no evidence for ROM limitation or any other ratable criterion that would justify a rating higher than 10% under any other applicable code.  This included consideration of analogous rating under code 5262 (tibia and fibula, impairment of) which offers ratings for contiguous ankle disability, but, members agreed that the analogous application of this fracture code was not sufficiently justified in a case such as this which satisfies compensable criteria under more applicable codes.  Also considered was code 5284 (foot injuries, other), but members agreed that the functional impairment in evidence (corroborated by the C&P occupational information) could not be reasonably characterized as more than “moderate” disability, the 10% criterion of code 5284.  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 of the right ankle (and calcaneus) condition.

BOARD FINDINGS:  In the matter of the right ankle condition (subsuming the right calcaneus stress reaction) 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 20150605, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170010050, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

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.

Sincerely,