RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01663
BRANCH OF SERVICE:  Navy	SEPARATION DATE:  20040803

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Hospital Man, medically separated for “right anterior talofibular ligament rupture” with a disability rating of 10%.

CI CONTENTION:  Received a higher rating for his condition from the VA.  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 Medical Evaluation Board (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 - 20040616	VARD - 20041007	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Anterior Talofibular Ligament Rupture 	5099-5003	10%	Residuals, Right Anterior Talofibular and Calcaneofibular Ligament Rupture	5271	10%	20040712	
Right Sinus Tarsi Syndrome	Cat II					
Right Calcaneofibular Ligament Rupture 	Cat II					
Bilateral Pes Planovalgus	Cat III	Residuals, Pes Planus and Hallux Valgus, Right	5280-5276	10%	20040712	
		Residuals, Pes Planus and Hallux Valgus, Left Foot	5280-5276	10%	20040712	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:

Right Anterior Talofibular Ligament Rupture.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s ankle condition began in August 2003 after sustaining a right ankle inversion injury while running.  Right ankle and foot X-rays on 3 September 2003 were normal.  A medical record dated 5 September 2003 indicated the CI had prior mild ankle sprains and complained of toe tingling with “electrical shocks” down the foot and up into the leg.  Physical examination revealed mild swelling of the lateral and medial ankle with tenderness at the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) and a positive  Tinel’s sign (to determine nerve irritation).  Right ankle X-rays on 26 September 2003 demonstrated soft tissue swelling without fracture.  

At a primary care visit on 3 November 2003, right ankle dorsiflexion was 5 degrees (normal 20) and plantar flexion was 30 degrees (normal 45).  The examiner noted the CI had right foot paresthesia along the plantar aspect that did not follow the anatomic distribution.  An MRI on 7 November 2003 showed evidence of old, chronic ATFL and CFL tears and a decreased signal at the sinus tarsi (tunnel between the talus and calcaneus containing structures for ankle stability), but no findings accounting for the tarsal tunnel syndrome (compression of the posterior tibial nerve resulting in neuralgia).  Limited duty for 8 months was authorized on 21 November 2003.  

On 2 December 2003, a civilian podiatrist evaluation revealed exquisite discomfort in the lateral aspect of the anterior right ankle.  The CI had ligament laxity and pain with manipulation of the joint, consistent with ligamentous injury, but minimal discomfort over the sinus tarsi itself.  There was some pain with palpation of the peroneal tendons and he had a negative gastrocnemius equinus (inability to dorsiflex or toe up).  There was no other fixed deformity and the neurologic evaluation was grossly intact with no radiculopathy present. At a follow-up visit on 16 February 2004, the podiatrist opined that the CI had very significant impairment that would not allow for continued military service since he would not be able to run, march, hike, or stand for prolonged periods.  Additionally, no surgical procedure would be highly successful.  A subsequent podiatry visit on 29 April 2004 showed pain upon palpitation of the right ATFL and CFL and sinus tarsi with a positive right anterior drawer test (for laxity).  

The 19 May 2004 MEB NARSUM examination, 3 months prior to separation, noted CI complaints of right lateral ankle instability and sinus tarsi syndrome.  Physical examination showed ATFL, CFL and sinus tenderness and a positive anterior drawer test.  Bilateral pes planovalgus (flatfoot) was also present.

At the 12 July 2004 VA Compensation and Pension (C&P) evaluation, 1 month before separation, the CI reported right ankle stiffness, stabbing pain and swelling.  He could not run, jump, march, walk/stand for prolonged periods, or kneel without causing right ankle and bilateral foot pain.  Physical examination showed a limp on the right side as well as bilateral foot tenderness, but no deformity.  Dorsiflexion was to 20 degrees and plantar flexion to 45 degrees with painful motion.  Right foot X-rays on 12 July 2004 were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right ankle condition 10%, analogously coded 5099-5003 (arthritis, degenerative).  The PEB also listed sinus tarsi syndrome on the right, and right calcaneofibular ligament rupture as related Category II conditions that contributed to the primary unfitting condition, but were not separately ratable.  Panel members agreed the impairment from these conditions were properly subsumed under the overall rating for the right anterior talofibular ligament rupture IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  The VA rated the right ankle condition 10%, coded 5271 (ankle, limited motion), based on the C&P evaluation, citing painful motion.  Members noted that the clinical findings were related to chronic right ATLF, CFL and sinus tarsi tears.  All of those structures are related to the ankle and foot and, therefore, use of code 5284 (foot injuries, other) is reasonable.  The panel agreed that  a “moderately severe” 20% disability rating was supported by:  right foot pain with some instability due to the chronic ATFL and CFL tears; right foot tenderness over the sinus tarsi and paresthesias; and limited, but not markedly so, right ankle ROM.  Additionally, the CI walked with a limp on the right side and could not run, jump, march, walk/stand for prolonged periods, or kneel without causing right ankle or bilateral foot pain.  When deliberating whether the right foot injury warranted a “severe” 30% rating, members noted that imaging studies and clinical findings did not demonstrate a fracture, malalignment, or deformities.  Additionally, the CI did not undergo surgery, and was able to walk and perform activities of daily living; thus, the panel could not find sufficient evidence to support a 30% rating.  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 right ankle condition, coded 5284.

Contended PEB Condition:  Bilateral Pes Planovalgus.  The panel’s main charge is to assess the fairness of the PEB’s determination that the Category III contended condition (not separately unfitting and not compensable or ratable) was not unfitting.  The CI had bilateral pes planus with bilateral inward rotation of the superior portion of the heels and marked pronation, and was noted to have moderate, asymptomatic pes planus at the service entry examination.   The contended condition did not result in formal limited duty nor was it implicated by the Non-Medical Assessment.  The bilateral pes planovalgus was mentioned by one podiatry examination and in the MEB NARSUM prior to separation, but no specific complaint or treatment was in evidence other than right ankle orthotics.  The C&P evaluation noted bilateral foot tenderness and that the CI experienced right ankle and bilateral foot pain with walking.  However, 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 there was insufficient cause to recommend a change in the PEB fitness determination for the Category III contended condition, so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the right ankle condition, the panel recommends a disability rating of 20%, coded 5284 IAW VASRD §4.71a.  In the matter of the sinus tarsi syndrome on the right, and right calcaneofibular ligament rupture conditions, the panel recommends no change from the PEB determinations as Category II not unfitting conditions.  In the matter of the bilateral pes planovalgus conditions, the panel unanimously recommends no change from the PEB determination as a Category III not unfitting condition.  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 as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Anterior Talofibular Ligament Rupture	5284	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161027, 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 11 May 18 ICO XXXXXXXXXXXXXXXXXX   
	(c) PDBR ltr dtd 11 May 18 ICO XXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 08 May 18 ICO XXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 11 May 18 ICO XXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 11 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: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.  

     b. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 100 percent rating (increased from 10 percent) effective date of discharge. 

     c. XXXXXXXXXXXXXXXXXX, former USN: 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 40 percent disability rating (increased from 20 percent) effective date of discharge.

     e. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge.
 
2.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.

                                  XXXXXXXXXXXXXXXXXX
                                  Acting