RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02175
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070217

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Parachute Rigger, medically separated for “chronic right ankle pain” with a disability rating of 0%.  “Myotonic dystrophy” was determined to have existed prior to service (EPTS) and was not rated.  

CI CONTENTION:  Review all conditions.  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 - 20061108	VARD - 20070822	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Ankle Pain	5271	0%	Residuals S/P Right Ankle Fracture	5271	0%	20070727	
Myotonic Dystrophy	8099-8023	EPTS	Myotonic Dystrophy	8099-8023	30%	20070727	
Erectile Dysfunction	Not Unfitting	Erectile Dysfunction	7599-7522	0%	20070727	
Hypothyroidism	Not Unfitting	Hypothyroidism	7903	10%	20070727	
Chip Fracture, Left Foot	Not Unfitting	Ecchymosis, Left Foot	7899-7813	NSC	20070727	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  40% 	

ANALYSIS SUMMARY:  

Chronic Right Ankle Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent right ankle surgery in August 2003 to repair the distal fibula and medial malleolus after a motorcycle accident.  During the 12 June 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months prior to separation, the CI reported his ankle never healed correctly after surgery. Physical examination revealed mild pain with inversion/eversion and loss of dorsiflexion and plantar flexion.  Edema was not present and neurological function of the lower extremities was intact.  There was no mention of ankle deformity.  

The 15 June 2006 MEB NARSUM, 8 months prior to separation, noted complaints of pain with an intensity of 9/10 with swelling when walking on graded terrain, running, or attempting high impact activities.  There was minimal pain with nonaggressive ambulation.  Physical examination recorded identical findings to the MEB examination above.  The 20 June 2006 NARSUM addendum documented ankle pain and weakness limiting range of motion (ROM) and most weight bearing activities.  Physical examination showed tenderness of the ankles and muscle strength decreased to 4/5 with fasciculation and marked weakness along the four planes of motion with resistance.  Mild edema along the ankle joint was noted.  

ROM recorded by physical therapy on 24 October 2006, 4 months prior to separation, documented dorsiflexion of the right ankle at 0 degrees (normal 20) compared to 8 degrees on the left.  Plantar flexion of the right ankle was 37 degrees (normal 45) compared to 51 degrees on the left.  Painful motion was noted during passive testing only.  

At the 27 July 2007 VA Compensation and Pension (C&P) examination, 5 months after separation, the CI reported pain in his ankles describes as cramping in nature with occasional sharpness.  He did not report any swelling or instability, nor did he use any assistive device for ambulation.  Physical examination revealed no tenderness or swelling and a normal gait.  Plantar flexion measured 45 degrees and dorsiflexion was 15 degrees.  There was no objective evidence of pain on ROM and no additional limitation in motion after three repetitions.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right ankle condition 0%, coded 5271 (limited motion of ankle), citing mild pain and slightly decreased ROM with measurements limited by pain.  The VA also rated the right ankle condition 0%, coded 5271, based on the C&P examination, citing painless ROM of the right ankle.  A non-compensable evaluation was assigned because there was not moderately limited motion.  

A 10% rating under the 5271 code is for moderate limitation of motion of the ankle.  The panel noted the PT examination showed near normal plantar flexion but significantly reduced dorsiflexion of the right ankle.  However, the C&P examination documented full plantar flexion and mildly reduced dorsiflexion of the right ankle, and absence of painful motion.  At the time of the MEB NARSUM the CI reported ankle pain and weakness in most weight bearing activities, but the C&P examination did not record similar findings and instead evidenced continued improvement since the time of the NARSUM.  The panel majority agreed the C&P examination offered greater probative value.  The limitation of ankle motion described by the VA C&P examination was slight and did not approach the “moderate” stipulation required for a 10% rating under diagnostic code 5271 for limitation of ankle motion.  There was insufficient evidence of painful motion with functional loss supporting a 10% rating (based on §§4.59, 4.40, and 4.45).  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority concluded there was insufficient cause to recommend a change in the PEB adjudication for the right ankle condition.  

Myotonic Dystrophy.  According to the STR and MEB NARSUM, the CI was diagnosed with myotonic dystrophy by electro-diagnostic studies on 21 September 2005.  This was confirmed by a DNA study at the Baylor Diagnostic Lab in Houston, Texas, and by genetics studies at the University of Oklahoma.  His symptoms consisted of dystonia in the hands, biceps, toes, jaw, and tongue.  He also had muscle pain in the forearms, hands, jaw, and tongue.  The CI took muscle relaxants and pain medication that provided some relief.  

During the MEB examination the CI reported he was under thyroid treatment due to myotonic dystrophy.  Physical examination showed bilateral dystonia (contractions) of the hand after gripping, with a slow return of the fingers to extension.  His biceps also showed slow return to relaxation after contracting the muscle.  However, there was full muscle strength throughout and full grip strength.  Upper extremities were neurologically intact.  The MEB NARSUM noted complaints of myotonic dystrophy.  The CI was under the care of a pain management specialist and was prescribed oxycodone five times a day, which decreased his pain significantly.   Physical examination was recorded from the MEB examination noted above.  

At the 22 August 2006 specialty care consult, 6 months prior to separation, the CI reported chronic pain and “Can’t release grip after grasping an object.”  It was noted that the CI had difficulty releasing his grip intermittently for 6 years since the age of 16.  He was evaluated by physical medicine and was noted to have myotonic discharges.  He reported that initially at age 16 cramping of his fingers involved just the 4th and 5th digits bilaterally, but it slowly grew over time and now included all of his fingers and wrists when placed in flexion.  Gripping was now more intense and he also noted similar troubles with his jaw muscles and with his tongue.  The muscles tended to cramp.  Over time the cramping and inability to release his muscle and contraction became worse, as did the pain that accompanied these contractions.  Physical examination showed full strength and reflexes in all of his extremities.  Cramping at the jaw, tongue, and the right bicep as well as the finger and wrist was observed.  There was no atrophy of the muscles of the extremities.  The remainder of the neurologic exam was normal.  

At the C&P examination the CI reported muscle cramps of the hands, jaw, ankles, and calves, and he continued to take narcotic medication for pain.  The neurologic examination was unremarkable.  He had normal motor strength throughout.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB did not rate the EPTS myotonic dystrophy, citing no evidence of permanent service aggravation.  The VA rated the myotonic dystrophy 30%, coded 8099-8023, based on the C&P examination, citing minimum rating of 30% for ascertainable residuals.  

The panel first considered the nature of the condition. The literature indicates that myotonic muscular dystrophy is characterized by two types, type I and type 2, and they are both caused by abnormally expanded stretches of DNA.  Both types are inherited in an autosomal dominant pattern, meaning it takes only one gene carrying the abnormal expansion to cause symptoms of the disease.  If one parent has the disorder, every child of that person has a 50% chance of inheriting the flawed gene that carries the condition.  Type I is the most common type.  The natural history is relatively benign, with progressively slow decline in physical ability over time, correlating with the duration of disease and the number of repeated stretches of the DNA in the blood.  The panel notes that the condition at separation demonstrated normal muscle strength and grip, and cramping and pain were primary symptoms.  According to the CI, his symptoms began 9 years earlier (age 16), and evidence showed a predictably slow and consistent increase with the natural progression of the disease.  

The panel acknowledged that, IAW 1332.38, a presumption of service aggravation may only be overcome by clear and unmistakable evidence that the natural progression of a pre-existing condition was unaltered by any consequence of military service, and unanimously agreed that in this case the evidence met that standard.  The panel concluded there was insufficient cause to recommend a change in the PEB determination that the myotonic dystrophy condition was EPTS and not permanently service aggravated, and therefore this condition could not be recommended for disability rating.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the myotonic dystrophy condition.  

Contended PEB Conditions:  Erectile Dysfunction, Hypothyroidism, and Chip Fracture of the Left Foot (Talus/Ankle).  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  None of the conditions were profiled, implicated in the commander’s statement, or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions 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 any of the contended conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the right ankle condition and IAW VASRD §4.71, the panel majority recommends no change in the PEB adjudication.  The single voter for dissent recommends modification to 10% and did not elect to submit a minority opinion.  In the matter of the myotonic dystrophy condition and IAW VASRD §4.124a the panel recommends no change in the PEB adjudication.  In the matter of the contended erectile dysfunction, hypothyroidism, and chip fracture of the left foot conditions, the panel recommends no change from the PEB determinations as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.   Therefore, the panel recommends 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 20170227, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180015056, 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,					       

Enclosure