RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXXX	CASE: PD-2017-03174
BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20051231

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Advanced Signals Analyst, medically separated for “left ankle instability” with a disability rating of 20%.

CI CONTENTION: Review requested of the left ankle, left shoulder and carpal tunnel conditions as well as other 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 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 - 20051116	VARD - 20060411	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Ankle Instability	5299-5003-
8699-8622	20%	
Left Ankle Peroneal Tendon Tear, Status Post Augmentation	

5271	

20%	

20060216	
Sural Nerve Injury, Left Ankle	Cat II					
Loss in Range of Motion [ROM] of Left
Ankle and Hindfoot	Cat II					
Post-Traumatic Arthritis, Left Ankle	Cat II					
Left Shoulder Impingement Syndrome	Cat III	Left Shoulder Flap Tear Status Post Repair	5201	20%	20060216	
Left Shoulder Superior Labrum from
Anterior to Posterior (SLAP) Repair	Cat III					
Bilateral Carpal Tunnel Syndrome (CTS)	Cat III	CTS, Right Hand	8515	10%	20060216	
		CTS, Left Hand	8515	10%	20060216	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 80%	

ANALYSIS SUMMARY:

Left Ankle Instability. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent a left ankle reconstruction in February 2004 after a series of ankle sprains. Healing was complicated by a post-operative infection that required incision and drainage and a skin graft in July 2004. Following the infection, decreased sensation was noted in the sural nerve distribution. He had a second surgery for a left lateral ligament reconstruction in May 2005, with minimum post-surgical left ankle instability but continued

lateral ankle pain, with subsequent physical examinations noting peroneal tendinopathy and a positive Tinel’s sign (irritated nerves) over the sural nerve.

The 21 September 2005 MEB NARSUM examination, 3 months prior to separation, noted complaints of ongoing ankle pain and loss of range of motion (ROM) that prevented performance of a physical readiness test (PRT). The CI was unable to run, could only walk 1/2 mile without pain, and had difficulty squatting and lifting. Physical examination showed a large area of skin graft in the superior aspect of the surgical incision posterior to the lateral malleolus. Left ankle ROM testing showed plantar flexion of 30 degrees (normal 45) and dorsiflexion of 10 (normal 20). The ankle was stable, but there was a positive Tinel’s sign at the top of the incision with loss of sensation along the lateral border of the foot; muscle strength was normal. Ankle X-rays showed post-surgical changes with minor degenerative changes.

At the 16 February 2006 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported constant ankle pain, aggravated by standing or walking, but with improved stability since surgery. Wearing boots was helpful and he was given a cane but did not use it due to wrist problems. Physical examination showed an antalgic gait favoring the left leg, as well as swelling, tenderness and numbness along the lateral ankle. The CI guarded manipulation and use of the ankle, which exhibited weakened movement and incoordination. Left ankle ROM testing showed plantar flexion of 35 degrees and dorsiflexion of 10 degrees with increased laxity noted during inversion and eversion. Repetitive movement caused increased pain, but no additional loss of motion. Ankle X-rays showed degenerative changes.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the left ankle condition 20%, coded 5299-5003-8699-8622 (degenerative arthritis and superficial peroneal nerve neuritis), and list listed “sural nerve injury,” “significant loss of ROM” and “post-traumatic arthritis,” as related Category II conditions, contributing to the left ankle disability in this case. As noted above, the PEB rated the left ankle condition utilizing a compound code analogous to degenerative arthritis and nerve injury. On this basis, panel members concluded there was not a preponderance of evidence to overcome the presumption that the sural nerve injury and post-traumatic arthritis were each reasonably considered separately unfitting. The panel noted that limitation of motion is a rating factor under codes 5003 and 5271 (limitation of ankle motion), not a diagnosis, and cannot be separately rated apart from the arthritis without pyramiding (VASRD §4.14). Additionally, the PEB characterized the unfitting condition as “left ankle instability;” however, there is no VASRD code for ankle instability, which is rated based on the associated impairment of the joint. Therefore panel members concluded there were two separately ratable unfitting conditions: left ankle arthritis/instability and left sural nerve injury. The VA rated the left ankle condition 20%, coded 5271, based on the C&P examination, citing marked limited motion of the left ankle.

Left Ankle Arthritis/Instability. Despite the VA’s rating, the panel agreed there was no evidence of marked ankle limitation of motion for a rating higher than 10%. The panel considered other ankle and analogous codes but all were less applicable and/or not advantageous to rating.

Sural Nerve Injury. Panel members agreed that a 10% rating was supported analogously coded to tarsal tunnel (8599-8525), a nerve entrapment of the medial aspect of the ankle comparable to the injury of the sural nerve on the lateral aspect of the ankle. A higher rating was not supported IAW VASRD §4.124a, which states that “when the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree.” The panel also considered alternatively rating the left ankle condition under code 5284 (other foot injury), subsuming the arthritis and nerve related impairment, but no greater than a 20% rating was supported for a moderately severe foot injury based on findings of residual pain and instability with an antalgic gait. Panel members agreed that the CI’s foot injury was not better characterized as severe for a higher rating under code 5284 based on no required use of an assistive device for ambulation.

After deliberations, the panel found that whether recommending separate ratings for the ankle joint and sural nerve impairment or for rating the ankle impairment as a whole under code 5284, there was no benefit to the CI. Therefore, no change to the PEB’s adjudication, including coding choice, is recommended.

Contended PEB Conditions: Left Shoulder Impingement Syndrome, Left Shoulder SLAP repair and Bilateral Carpal Tunnel Syndrome (CTS). The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting. The bilateral CTS was not noted on limited duty (LIMDU) forms or implicated by the non-medical assessment (NMA), and did not fail retention standards. There was no performance-based evidence from the record that the bilateral CTS significantly interfered with satisfactory duty performance at separation. Although the left shoulder condition was listed on the April 2005 LIMDU, the panel majority noted the CI was a senior enlisted Sailor in a fairly sedentary rate, and did not find a preponderance of evidence to support recommending the shoulder as unfitting proximate to separation. Additionally, it was not specifically implicated in the NMA and notes in the STR showed the CI was improving after surgery. The PEB noted the left shoulder ROM was “excellent” and residual pain had been improved with a recent injection. The panel majority concluded there was no performance-based evidence from the record that the left shoulder condition significantly interfered with satisfactory duty performance at separation. After due deliberation, the panel majority concluded there was insufficient cause to recommend a change in the PEB fitness determinations for the contended conditions, so no additional disability ratings are recommended.

BOARD FINDINGS: In the matter of the left ankle condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. In the matter of the contended bilateral carpal tunnel syndrome, the panel recommends no change from the PEB determination as not unfitting. In the matter of the contended left shoulder condition, the panel majority recommends no change from the PEB determination as not unfitting, but the single voter for dissent submitted the appended minority opinion. 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.

Minority Opinion

The dissenting member contends there was a preponderance of evidence that the (minor) left shoulder condition was unfitting at separation and eligible for rating based on the following evidence: The left shoulder was noted on the 11 April 2005 LIMDU, 9 months prior to separation, with limitations of no overhead activity and no PRT. The 21 September 2005 MEB NARSUM noted the CI could not lift due to problems with his shoulder, and the 27 September 2005 MEB orthopedic addendum noted that the CI could not perform push-ups. Physical examination showed full ROM with positive impingement signs (painful motion) and further surgery was recommended for subacromial decompression. Shoulder ROM was documented unclearly to the member, but apparently represented 180 degrees of flexion with no documentation of abduction. There was some pain and weakness with supraspinatus (rotator cuff) testing. Impingement testing was positive, but a subacromial injection provided significant pain relief, and a left shoulder X-ray was normal. The 26 October 2005 NMA, 2 months prior to separation, noted the CI was unable to participate in the PRT or physical fitness testing, but did not attribute the limitation to a specific medical condition or conditions.

At the C&P examination, the CI reported left shoulder pain that waxed and waned and was aggravated by any type of strenuous activity. Physical examination showed tenderness, flexion to 130 degrees, abduction to 65 degrees (normal 180), and guarded shoulder movement as well as incoordination. There was increased pain with repetition without additional ROM loss. Left upper extremity strength was graded 4/5, with pain as the limiting factor.

The MEB NARSUM and VA examinations showed evidence of arm movement limited to shoulder level or below, but not limited to 25 degrees from the side to support a 20% rating for the left shoulder and no higher. The dissenting member finds the functional impairment of the left shoulder at separation supports recommending it as an additionally unfitting condition for disability rating, coded 5201 and rated 20% IAW VASRD §4.71a.

DEPARTMENT OF THE NAVY
SECRETARY OF TIIB NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309
WASHINGTON NAVY YARD, DC 20374-5023

IN REPLY REFER TO:
1850
CORB: 003
10 Sep 20

From: Director, Secretary of the Navy Council of Review Boards To:	XXXXXXXXXXXXXX

Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) Ref:	(a) DoDI 6040.44
1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation to the Department of the Navy on 13 Aug 2020 for appropriate action.

2.	On 27 August 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) accepted the recommendation of the PDBR of no change to your characterization of separation or disability rating assigned by the Department of the Navy's Physical Evaluation Board.

3.	The Secretary's decision on your PDBR application is final and is not subject to appeal or additional review by the Board for Correction of Naval Records.