RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00101
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030323

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Multichannel Transmission Systems, medically separated for “left ankle pain” with a disability rating of 10%.   

CI CONTENTION:  The CI made no specific contention, although he compared his PEB rating with his VA rating and noted he had two more surgeries.  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 - 20021125	VARD - 20031216	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Ankle Pain	5271	10%	Postoperative Residuals, Reflex Sympathetic Dystrophy w/Plantar Fasciitis, Tarsal Tunnel Syndrome, Calcaneal Spur, Fracture of Ankle and Tibial Neuropathy	8599-8520	40%	20021107	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Left Ankle Pain.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s condition began in January 2000 after stepping in a pothole during unit physical training.  On 7 February 2000 a bone scan demonstrated mild focal stress reactions in the left ankle and plantar calcaneus.  X-rays of the left ankle revealed a small plantar calcaneal spur on the left.  The CI underwent surgery (a left plantar fascia fasciotomy (release)) on 2 March 2001 for “left plantar fasciitis.”  Thereafter, the CI developed pain and paresthesias.  Evaluation revealed findings consistent with left tibial nerve compression causing a left tibial demyelinating and axonal neuropathy consistent with tarsal tunnel syndrome.  On 18 October 2001, the CI underwent surgery for “left tarsal tunnel syndrome/nerve entrapment left foot.”  The CI reported improvement until February 2002 when symptoms recurred with acute pain to the medial and plantar foot.  The CI denied medial ankle pain, but noted significant swelling on a daily basis.  An electrodiagnostic study dated 29 April 2002 was abnormal and showed tarsal tunnel syndrome with axonal loss on the left with neuropathic pain secondary to injury.  A podiatry examination dated 9 August 2002 noted a positive Tinel’s test (to determine nerve irritation) of the left posterior tibial nerve and color changes of purple-white spots.  The question of reflex sympathetic dystrophy (RSD) (pain, swelling and vasomotor dysfunction of an extremity) was assessed and Neurontin (Gabapentin for nerve pain) was recommended with continued physical therapy along with a rigid orthosis and canvas ankle laces (a lace up ankle brace).  On 29 July 2002, magnetic resonance imaging (MRI) studies showed a “lateral talar osteochondral fracture” and a “tiny medial talar osteochondral injury,” appearing chronic in nature.  The examination also revealed a “chronic appearing navicular marrow vs cystic change.”  Following surgery, further treatment did not result in improvement sufficient to allow unrestricted duty and he was processed for MEB.

During 9 August 2002 MEB examination (recorded on DD Forms 2807-1 (dated 17 July 2002) and 2808) 6 months prior to separation, the CI reported continued swelling, numbness, soreness, and stiffness.  Physical examination showed a well-healed scar and decreased ROM secondary to surgeries.  The examiner’s diagnosis was chronic left foot pain post-surgery for tarsal tunnel syndrome.  At the 14 August 2002 MEB NARSUM, 7 months before separation, the examiner recounted the history post-surgery as stated above.  The CI wore a prescribed rigid orthotic and a canvas ankle support to alleviate discomfort during ambulation.  Physical examination showed a well-healed 13 cm scar from the “medial malleolar area down to the calcaneus to the plantar surface of the foot over the distal head of the calcaneus.”  Range of motion (ROM) of the left foot was dorsiflexion 10 degrees (20 normal) and plantar flexion 25 degrees (45 normal).  Inversion was 0-5 degrees, eversion was 0-1 degree with discomfort.  ROM was limited by discomfort.  The CI had an antalgic gait of the left leg.  The examiner stated the CI had received maximum conservative and surgical treatment and the prognosis for recovery for return to duty was “severely guarded and poor.”  

The 16 August 2002 NARSUM addendum examination, the podiatry examiner indicated the CI’s neurovascular status was intact with “tenderness to palpation at the left posterior tibial nerve with a positive Tinel sign.”  The CI had a well-healed surgical scar with color changes (purplish with some white patches).  He had full ROM of the ankle, subtalar and metatarsophalangeal joints.  The examiner noted an MRI was significant for a talar dome lesion on the dorsal lateral aspect and a navicular cyst; both were symptomatic on palpation.  There was also a fibular malleolar cyst, which on palpation was asymptomatic.  The MRI revealed normal tendons with a diagnosis of “possible reflex sympathetic dystrophy.”  A physical medicine evaluation dated 23 October 2002 noted multifactorial left ankle pain with components of chronic sprain involving the deltoid and long plantar ligaments, chronic neuropathic pain secondary to left tibial neuropathy across the tarsal tunnel, and autonomic instability secondary to the aforementioned, which caused edema and vasomotor changes. 

The 23 October 2002 MEB NARSUM examination, 4 months prior to separation, noted complaints of continued diffuse pain of the ankle and foot.  The CI described the pain as “a dull ache affecting all structures at and below the left medial malleolus.”  The severity was described as 6-7/10 (10 being the worst pain), which increased with exercise (walking, running or jumping).  Medications for pain included Motrin (a nonsteroidal anti-inflammatory drug) and Tylenol #3 (acetaminophen, a pain reliever, and codeine, a narcotic).  Physical examination showed mild edema of the left foot and ankle with a well-healed scar.  There was no discoloration or allodynia in the foot or ankle.  Examination revealed tenderness to palpation in the “inferior calcaneus in the base of the fifth metatarsal.”  Neurological examination was basically normal at 5/5 in the lower extremities, except a decreased sensation to light touch and pinprick.  The examiner indicated there was “give-way weakness consistent with painful derangement of the left ankle,” deep tendon reflexes were normoflexive and symmetric bilaterally.  Due to increased pain in the ankle, flexion tests (Babinski and clonus) were not performed.

At a 7 November 2002 VA physical examination, 4 months before separation, the CI reported escalating pain with discoloration of the foot and constant swelling of the foot and ankle.  He wore a soft brace to “eliminate pain along the outer aspect of his foot.”  The CI stated the pain was 7/10 at all times and increased to 10/10; was not relieved by Motrin, and was awakened by the pain during the night.  Physical examination showed a well-healed 2.5 cm post-surgical scar over the dorsal surface of the left foot.  The CI had tenderness to light palpation around the incisional area and the medial lateral aspect of the left foot.  The examiner stated, “There is discoloration of red to purple from below the medial malleolus down through the entire portion of the medial lateral left foot.  There was a 1+ to 2+ non-pitting edema and no keloid formation.”  Neurologic examination revealed an antalgic gait favoring the left foot.  Motor examination indicated “strong foot dorsiflexion on the right and unable to dorsiflex foot secondary to pain on the left.”  Babinski testing was negative (downward movement of the great toe when the sole is stroked) and there was no ankle clonus (beating of the foot).

Computerized tomography dated 23 May 2003 demonstrated a corner fracture of the talar dome on the lateral aspect of indeterminate age, but there was no union.  A bone scan showed nonspecific patchy uptake in multiple joints of the foot, but not within the os calcis. 

At a VA pain management visit on 27 May 2003, 2 months after separation, the examiner noted relative hypesthesia (abnormally decreased sensitivity to stimuli) with pressure allodynia (pain following normal non-painful stimulation) distribution over the area of innervation of the posterior tibial nerve and some medial territory of the superficial peroneal nerve suggestive of neuritis.  There were subjective changes of CRPS (complex regional pain syndrome)/RSD including intermittent coldness, pain with surface stimulation, increased sweating with some subtle supportive finding including pressure allodynia, vascular mottling and hair growth differences of the great toes, which was likely early stage 2.  A bone scan report was possibly consistent with CRPS.  At a podiatry visit on 25 June 2003 the examiner indicated an osteochondral fracture needed repair.  

At the 26 August 2003 VA Compensation and Pension (C&P) Feet examination, 5 months after separation the CI still complained of chronic pain with intensity of 4-7/10.  He contended the pain was aggravated by the weather.  He complained of stiffness, occasional swelling and fatigability in the left foot and ankle area.  He also had stated he had lack of endurance and treatment included using crutches to alleviate pain in his left foot.  The examiner noted his condition affected his occupation (he had not worked since discharge) and daily activities due to using crutches and difficulty walking.  Additionally he had difficulty driving and took analgesics for pain.  The ROM of the left foot was dorsiflexion 10 degrees and plantar flexion 20 degrees.  The CI underwent excision of the talar dome lesion of the left foot on 9 June 2004.  Subsequent surgery, performed on 9 May 2005, consisted of an osteochondral transplant with a fresh talar graft.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 10%, coded 5271 (ankle limitation of motion), citing limitation of motion, breakaway weakness secondary to pain, a normal neurological examination and muscle strength of 5/5 throughout both lower extremities.  The VA rated the postoperative residuals, reflex sympathetic dystrophy with plantar fasciitis, tarsal tunnel syndrome, calcaneal spur, fracture of ankle and tibial neuropathy condition 40%, coded 8599-8520 (sciatic nerve, paralysis of-moderately severe), based on the C&P examination 4 months before separation, citing multiple foot ailments and surgeries resulting in a diagnosis of RSD (reflex sympathetic dystrophy) at the moderately severe level.
The panel considered if the limitation of motion was “moderate” or “marked” when considered under 5271, limitation of ankle motion.  The panel agreed that the ROM examinations proximate to separation were consistent with the “moderate” limitation of motion required for the 10% rating under this code.  The panel members noted the VA rated the CI based on postoperative residuals including reflex sympathetic dystrophy, which was alluded to in the MEB referral to the PEB as persistent tarsal syndrome with axonal loss and neurotrophic pain with autonomic instability, which represents the RSD.  Therefore, members determined the RSD was in scope.  However, post-separation the CI was noted to have a talar dome fracture that apparently existed since the time of the original injury.  Members then discussed rating options beyond ankle limitation of motion.  While the VA rated analogously for the sacral nerve, the posterior tibial nerve was primarily involved, although there were changes suggestive of CRPS based on bone changes of the foot.  Therefore, use of the code 8625 (posterior tibial nerve neuritis) is not unreasonable and the condition at the maximum warrants a 20% rating.  More importantly, the CI sustained a significant foot injury for which he underwent two surgical procedures while on duty and a subsequent procedure post-separation once a talar fracture was identified.  Panel members determined the foot/ankle injury represented severe foot injury, which included elements of a neuritis, a fracture of the talar dome, and changes of other bones in the foot as well as subtle skin findings of suggestive of reflex sympathetic dystrophy.  Members deliberated whether the 30% rating using code 5284 (foot injuries, other), which can also be achieved by use of 5271 at 10% and 8625 for 20%, was more applicable than the 40% VA rating that relates to foot dangling and dropping, movement of muscles below the knee and weakening of flexion of the knee.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the left ankle pain condition, coded 5284.  

BOARD FINDINGS:  In the matter of the left ankle pain condition, the panel unanimously recommends a disability rating of 30%, coded 5284 IAW VASRD §4.71a.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Ankle Pain	5284	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160224, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170014678, XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXXX.

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

Sincerely,					      
Enclosure