RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01769
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20070814

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Infantryman, medically separated for “bilateral achilles tendinosis” with a disability rating of 0%.  

CI CONTENTION:  He requested a full review of his (medical) separation.  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 - 20070703	VARD - 20081016	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Achilles Tendinosis	5024	0%	Bilateral Chronic Achilles Tendinopathy	5024-5271	0%	20080721	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Bilateral Achilles Tendinosis.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s onset of bilateral Achilles tendinosis (degenerative injury without an immune response) condition began in approximately December 2005 or January 2006 without an apparent injury or accident.  At a clinic visit on 13 April 2006 the CI presented with pain in both Achilles tendons for 3 months, which increased in the morning and with running and climbing stairs.  On examination, the Achilles tendons were not tender.  Treatment consisted of a nonsteroidal anti-inflammatory drug (NSAID) and a profile.  At a physical therapy clinic visit on 9 May 2006 there was minimal tenderness of the Achilles tendons.  Straight leg heel raising and hopping were painful bilaterally, left greater the right.  A trial of iontophoresis was instituted.  On 19 June 2006 the CI reported his right ankle was better.  At the 25 July 2006 physical therapy visit the CI complained of left ankle pain.  On examination the active range of motion (ROM) was within functional limits and there was minimal tenderness of the left Achilles tendon.  On 17 August 2006 the CI reported left ankle pain on the bottom third of the Achilles tendon and right ankle joint pain marked only by stiffness in the morning.  At the 25 October 2006 physical therapy clinic visit the CI reported he was doing “good” with no pain in the right ankle, and pain only in the left ankle.  At the 14 November 2006 physical therapy visit he reported doing “a lot better” and the heel cushion was “working.”  As a result, he was able to run 10 minutes on the treadmill (approximately one mile).  At the 22 January 2007 physical therapy visit the CI stated the pain level was 6/10 (10 being the worst pain) on the left and 4/10 on the right.  His profile had expired and he believed running two to four miles set him back.  Orthotics in the boots worked out well; however, in his shoes, Achilles tendon pain persisted.  

At the 12 April 2007 MEB NARSUM examination, 4 months prior to separation, the CI reported bilateral Achilles tendon pain, the left 4/10 and the right 1/10, which was activity-associated.  The examiner noted bilateral ankle ROM was dorsiflexion of 30 degrees (normal 20) and plantar flexion of 45 degrees (normal 45).  Subtalar ROM was within normal limits of 45 degrees varus and 10 degrees valgus.  The ankles were stable to anterior drawer testing and subtalar inversion.  The Achilles tendon of each extremity was tender and was localized to a point approximately 2.5 cm proximal to the insertion of the tendon.  There were no protuberances, palpable defects, or motor or sensory deficits.  The extremities were warm and well perfused with palpable pulses and brisk capillary refill into the toes.  

At the 23 July 2008 VA Compensation and Pension (C&P) examination, 11 months after separation, the CI reported bilateral Achilles pain which began when deployed as a result of jumping off a Humvee.  Every morning he experienced bilateral ankle pain and stiffness that lasted approximately 45 minutes.  He had difficulty walking on any kind of incline or going up or down stairs.  He had treatment by a podiatrist since separation who placed him in a CAM (controlled ankle motion) boot with a built up heel for the left foot first; however, after several weeks his left heel got worse.  He reported the right side was not as bad as the left.  Physical examination showed increased wear on the outside of both shoes.  Ankle ROMs were dorsiflexion from 0 to 20 degrees and plantar flexion from 0 to 45 degrees.  Ankle ROMs were not limited by pain, weakness, lack of endurance on repetitive use, incoordination, or fatigability.  On standing the CI had bilateral calcaneal varus with the Achilles just medial to the midline.  He had increased bony prominences over the calcaneal tubercles of both heels and had calluses on the first and little toes of both feet.  He was tender over the Achilles, more so on the left than the right.  There were no toe, skin, or tissue abnormalities.  He had normal arches with no tenderness over the medial aspect of the plantar fascia, directly over the plantar aspect of his heels, or with dorsiflexion of the toes that would put a stress on the plantar fascia.  No abnormal weight bearing was noted.  X-rays of the feet in May 2008 showed no bony or soft tissue abnormalities noted.  An MRI of the left heel was read as a left Achilles partial thickness tear.  The examiner noted that “it is likely as not likely that he has a partial thickness tear on the right as well.” 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral Achilles tendinosis condition 0%, coded 5024 (tenosynovitis), which is rated as degenerative arthritis (code 5003) without loss of mechanical motion, citing tenderness of the tendons without ankle limitation of motion.  The VA also rated the bilateral foot condition 0%, coded 5024-5271 (tenosynovitis-ankle, limited motion of), citing range of motion of both ankles was within normal limits with dorsiflexion to 20 degrees and plantar flexion to 45 degrees.  

The PEB combined the left Achilles tendinosis and the right Achilles tendinosis conditions as a single unfitting condition.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The panel’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  

The panel first considered whether the left Achilles tendinosis, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Panel members agreed that the evidence reasonably justified that the functional limitations of the left Achilles tendinosis condition contributed to the CI’s inability to perform his military duties; and, accordingly a separate disability rating is recommended.  Members noted that VASRD §4.59 (painful motion) states, in part: “With any form of arthritis, painful motion is an important factor of disability, the facial expression, wincing, etc., on pressure or manipulation, should be carefully noted and definitely related to affected joints.  The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased.”  The CI had tenderness of both lower extremities at 2.5 cm from the insertion of the Achilles tendon, which comports with VASRD §4.59 reference to "pressure or manipulation," which was in the area identified by MRI as the partial tear of the left Achilles tendon.  The CI reported 4/10 pain with activity in the left Achilles tendon based on the MEB NARSUM examination most proximate to separation.  Members agreed that a 10% rating under code 5024 was warranted for painful motion.  Because the CI had a normal ROM of the left ankle, code 5271 does not offer a higher rating option, nor does any other ankle code.  While the Achilles tendon arises from the gastrocnemius and soleus muscles, use of muscle code 5311 (Group XI) likewise does not offer a higher rating option.  

The panel next considered whether the right Achilles tendinosis, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Panel members agreed that the evidence reasonably justified that the functional limitations of the right Achilles tendinosis condition did contribute to the CI’s inability to perform his military duties; and accordingly a separate disability rating is recommended.  Tenderness of the Achilles tendon was reported at the NARSUM examination, but the CI indicated his pain level was only 1/10 with activity.  Eleven months post-separation the VA examiner noted Achilles tenderness, but more so on the left than the right.  While there was a left partial Achilles tear confirmed by MRI, there was no right ankle MRI; therefore it would be speculative as to whether there was a partial tear of the right Achilles tendon.  Members agreed that the evidence did not support a rating higher than the 0% provided by the PEB using code 5024.  There was full ROM at both the NARSUM and VA examinations; therefore, use of code 5271 does not offer a higher rating option, nor does any other ankle code.  While the Achilles tendon arises from the gastrocnemius and soleus muscles, use of muscle code 5311 (Group XI) likewise does not offer a higher rating option.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left Achilles tendinosis condition, coded 5024, and a disability rating of 0% for the right Achilles tendinosis condition, also coded 5024.  

BOARD FINDINGS:  In the matter of the left Achilles tendinosis condition, the panel recommends a disability rating of 10%, coded 5024 IAW VASRD §4.71a.  In the matter of the right Achilles tendinosis condition, the panel recommends a disability rating of 0%, coded 5024 IAW VASRD §4.71a.  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 the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Achilles Tendinosis, Left	5024	10%	
Achilles Tendinosis, Right	5024	0%	
COMBINED 	10%	

The following documentary evidence was considered:
Exhibit A.  DD Form 294, dated 20170319, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180008173, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

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. 

Sincerely,					      
Enclosure