RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01297
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20040414

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Ships Serviceman, medically separated for “chronic left ankle pain with subtalar arthritis” with a disability rating of 10%.  

CI CONTENTION:  His left ankle should have been rated higher, and he requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the MEB, but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20040112	VARD - 20041021	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Ankle Pain With Subtalar Arthritis	5299-5003	10%	Left Ankle Instability With Arthritis	5010-5271	20%	20040605	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40% 	

ANALYSIS SUMMARY:  

Chronic Left Ankle Pain with Subtalar Arthritis.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s left ankle condition began in September 2002 after he suffered an inversion sprain of the ankle.  A note on 28 September 2002 indicated the CI was treated with an ankle brace for 3-5 days and Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID)).  On 30 September 2002 the CI was seen in the clinic with swelling and ecchymosis (black and blue discoloration) on the left lateral malleolus and severe tenderness of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament, and moderate tenderness over the posterior talofibular ligament.  X-rays revealed no fracture.  On 7 October 2002 the CI complained of persistent pain when walking or running.  Swelling and tenderness of the lateral left ankle persisted.  The CI was given light duty for 21 days and continued treatment with the NSAID.  He was evaluated by physical therapy on 9 December 2002 where he had minimal edema, range of motion (ROM) within normal limits, and a normal gait.  X-rays of the left foot and ankle on 15 January 2003 were normal.  On 18 February 2003 at the sports medicine clinic the CI reported no improvement in pain, which increased with walking.  On examination there was mild swelling of the ankle and dorsum of the foot with slight discoloration with tenderness of the fourth and fifth metatarsals without localization.  The examiner noted that persistent left ankle pain and the foot pain without localization were worrisome for early reflex sympathetic dystrophy.  The CI was recommended for an 8 month limited duty board, rest, and a cast boot.  

On 18 March 2003 there was decreased swelling, but he still had multiple areas of tenderness without localization.  The CI underwent physical therapy and plateaued by 23 April 2003.  An MRI dated 15 May 2003 demonstrated degenerative arthritis involving the middle facet of the subtalar joint; the sinus tarsi, ligaments, and tendons of the ankle appeared normal.  Glucosamine was recommended to treat the condition on 22 May 2003.  The left ankle ROM measurements by a physical therapist on 10 June 2003 were dorsiflexion 0 degrees (normal 20) and plantar flexion 50 degrees (normal 45).  The CI still had difficulty with single leg balance and heel raises.  At a sports medicine clinic visit on 20 July 2003 the left ankle ROM was 0-35 degrees, and the CI had poor proprioceptive control.  At an orthopedic clinic visit on 25 August 2003 the CI received an anesthetic/steroid injection in the subtalar joint without relief of pain.  At the sports medicine clinic on 6 October 2003, the examiner noted no improvement in the left ankle pain.  The subtalar ROM was full and there was tenderness of the ATFL; no laxity was evident.  

The 6 October 2003 MEB NARSUM examination, 6 months prior to separation, noted the CI’s complaint of being unable to walk more than 15-20 minutes without pain and he was unable to run.  Physical examination showed a ROM of 5 degrees dorsiflexion and 35 degrees plantar flexion.  He was tender over the ATFL and had no pain with external rotation.  Subtalar rotation was about 15 degrees and non-painful.  He had a negative drawer test (to determine laxity) and had some difficulty with balance and proprioception, but was able to walk on his tiptoes and heels without difficulty.  

At the 5 June 2004 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported left ankle pain.   He wore a lace-up and Velcro ankle support brace because of the left ankle problem.  Physical examination showed mild swelling of the left ankle and tenderness in the region of his “ACFL” (but more likely it should have been the ATFL).  He had a positive lateral talar tilt test as well as a 1+ anterior drawer.  The ROM of the left ankle showed 5 degrees dorsiflexion and 25 degrees of plantar flexion.  He had no hindfoot or mid foot abnormalities and no tenderness in the Achilles tendon.  The examiner’s impression was chronic left ankle instability.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 10%, analogously coded 5299-5003 (arthritis, degenerative).  The VA rated the left ankle condition 20%, coded 5010-5271 (arthritis, due to trauma, substantiated by X-ray findings - ankle, limited motion of) based on the C&P examination, citing marked limited motion of the ankle.  

The panel majority agreed that the preponderance of the ROM evidence was more reasonably characterized as “marked” limitation of motion consistent with a 20% rating under diagnostic code 5271.  The panel considered the limitation of motion at the time of the NARSUM and VA examinations to be more than moderately limited, especially with the decrement of plantar flexion noted at the VA examination, and more nearly approximated a marked degree of limitation.   Because there was no ankylosis (5270), nonunion, or malunion (5262), VASRD §4.71a offers no applicable joint code which would yield a higher rating.  The panel also considered whether ratings under the VASRD code for other foot injuries (5284) provided for a higher rating (§4.7); however, all panel members agreed that the severe level (30%) was not supported.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 20% for the chronic left ankle pain with subtalar arthritis condition, coded 5271.  

BOARD FINDINGS:  In the matter of the chronic left ankle pain with subtalar arthritis condition, the panel majority recommends a disability rating of 20%, coded 5271 IAW VASRD §4.71a.  The single voter for dissent recommends no change and did not elect to submit a minority opinion.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Left Ankle Pain With Subtalar Arthritis	5271	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160927, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record  

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve Affairs)
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 18 May 18 ICO XXXXXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 07 Jun 18 ICO XXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 05 Jun 18 ICO XXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 13 May 18 ICO XXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 18 May 18 ICO XXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (f) are approved.  The official records of the following individuals are to be corrected as follows:

     a. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     b. XXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.  

     c. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     d. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     e. XXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.  
 
3.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.