RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-03866
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20050425

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Security Forces Journeyman, medically separated for “[bilateral] ankle pain, moderate” with a disability rating of 10%.

CI CONTENTION:  She entered the service completely healthy and separated with declining physical and mental health conditions which have worsened.  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 - 20050309	VARD - 20060828	
Condition	Code	Rating	Condition	Code	Rating	Exam	
[Bilateral] Ankle Pain, Moderate	“5271-5299”	10%	Right Ankle Pain	5271	0%	20060225	
Bilateral Foot Pain Secondary to Pes Planus with Hallux Deformity
(EPTS without Service Aggravation)	Cat II
Not Rated	Bilateral Flat Feet	5276	30%		
Adjustment Disorder	Cat III	Depression with Mixed Adjustment Disorder	9434-9435	30%	20060227	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

[Bilateral] Ankle Pain.  The panel first clarifies that, although the PEB rated only a right ankle condition, the formal PEB proceedings, as elaborated below, acknowledged coexisting left ankle pain; and, a preponderance of evidence from the service treatment record (STR) and MEB narrative summary (NARSUM) implicated a bilateral ankle condition.  Members thus agreed that fitness and rating consideration for an overall bilateral ankle condition, to potentially include additional left ankle rating, was fairly conceded as being within the scope of these proceedings.  

According to the STR and MEB NARSUM, the CI developed bilateral ankle pain in 2002 that multiple providers attributed to pre-existing bilateral pes planus with inward bowing of the ankles (pes planovalgus).  There was passing mention of a sprain injury to the right ankle in 2003, but there was no directed STR entry for such and no other details in evidence.  All provider entries in the STR addressed bilateral ankle pain without note of differing severity, with two exceptions.  A primary care note in April 2004 noted left ankle pain greater than the right, and an emergency department note in November 2004 addressed only right ankle pain that was attributed to a complication of recent bilateral joint injections (no note of other trauma).

Imaging (including MRI of each ankle) revealed no bone, tendon, or ligament pathology and there were no surgical indications.  There was ample documentation in STR provider entries of grossly normal range of motion (ROM) of both ankles, with no contrary observations.  Most providers did not address painful motion, although an early entry (October 2003, 18 months before separation) documented “good” bilateral ankle ROM without painful motion.  Some entries addressing the foot condition (see below) noted that there was no pain with foot motion, which logically would encompass contiguous ankle motion, although the latter was not specified and remains speculative.  There was STR documentation of a normal gait and joint strength but no joint impingement.  There were no contrary entries and no documentation of joint instability or other VASRD-ratable findings.

The 27 September 2004 MEB NARSUM orthopedic addendum, 7 months prior to separation, documented “mild discomfort in bilateral ankles” (no differentiation of severity) as reported at the time of the 21 July 2004 last office visit, 2 months earlier.  Documented functional limitations included running, heavy lifting, and prolonged walking or standing.  A concurrent physical examination was missing from the available records, but one was documented in a preliminary NARSUM addendum by the same orthopedist on 22 June 2004, 3 months earlier, with no evidence of interim injury or exacerbation.  That bilateral physical examination recorded a normal gait and no joint tenderness or note of swelling, impingement, instability, or other positive findings.  Ankle ROM was not addressed other than noting that foot extension was painless.  There was no measured ankle ROM in the available STR evidence.

The profile at separation specified bilateral ankle pain.  The commander’s performance statement addressed general physical limitations without addressing specific diagnoses or separate severity of any conditions.  The MEB’s AF Form 618 submission did not include an ankle condition and none was adjudicated by a 9 November 2004 Informal PEB.  The AF Form 356 proceedings for the formal PEB (charted above) documented that the CI testified “her right ankle is more painful than the left” and referenced an October 2003 “severe strain” of the right ankle that could not be corroborated as above.  There was no distinct elaboration of the PEB’s rationale for adjudicating only the right ankle as unfitting.  

At the 25 February 2006 VA Compensation and Pension (C&P) joints examination, 10 months after separation, the CI reported daily bilateral ankle pain (right worse than left) precipitated by prolonged standing or walking (“1- 2 blocks” tolerance).  The examiner opined that the ankles “do not limit occupational or daily activities,” and noted full time (sedentary position) employment in addition to educational pursuits.  The physical examination (all findings bilateral) recorded a normal gait, mild edema, and normal (5/5) joint strength.  There was no note of tenderness, impingement, instability, or other positive findings.  Measured ROM (all bilateral) was dorsiflexion to 20 degrees (normal) and plantar flexion to 45 degrees (normal), specifying no painful motion and no ROM degradation with repetition.  The C&P general examination a week later noted bilateral ankle pain, right worse than left, which the CI stated was “increasing tremendously” and was aggravated by standing or walking.  The examiner corroborated a normal gait and deferred to the preceding joint examination. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right ankle condition 10%, analogously coded “5271-5299” (limitation of ankle motion), citing “moderate ... pain.”  Based on this AF Form 356 documentation, members agreed that the Formal PEB’s de facto adjudication was that the coexisting left ankle condition was not separately unfitting.

The VA rated each ankle condition 0%, coded 5271, based on the C&P joints examination, citing failure to satisfy the moderate criterion for a minimum 10% rating.  The panel noted that the CI appealed these ratings and a subsequent decision (9 February 2010, approaching 5 years after separation) conceded separate 10% ratings citing “painful on use.”  Although these revised ratings were effective to the date of separation based on the date of appeal, the cited evidence was not temporally probative to separation (November 2007 - February 2010).  

The panel first considered if the left ankle was subject to rating as unfitting, either separately or in combined effect with the right ankle.  It was acknowledged that there may have been a significant injury affecting only the right ankle that could account for greater severity and disability, and noted that the Formal PEB testimony and post-separation VA evidence indicated that the right ankle symptoms were worse than those for the left.  It remained, however, that the STR clinical evidence, the MEB NARSUM evidence, and the profile all portrayed bilateral ankle pain that was incompatible with the physical requirements of military service.  Members thus agreed that undue speculation would be required to conclude that the limitations imposed by either ankle would not have precluded continued military service.  The preponderance of evidence supported a conclusion that the left ankle, as well as the right one, was reasonably justified as unfitting and ratable.  

Having so agreed, members turned to deliberation of the appropriate rating recommendation, either as a bilateral condition or as separate joint conditions.  The panel noted that VASRD §4.71a permits a bilateral joint rating under criteria of code 5003 (degenerative arthritis), 10% for “2 or more major joints” in the absence of criteria for separate ratings of 10% each.  Members agreed that in this case there was not sufficient evidence for any criterion that would support a minimum 10% rating for either ankle.  Although the PEB’s 10% rating was under code 5271, it appeared to equate pain with ROM limitation, and there was no service evidence for any significant ROM limitation.  The only ROM evidence compliant with VASRD §4.46 (accurate measurement) was that from the post-separation C&P joint examination that documented normal bilateral ankle ROM without painful motion (reflected in the VA 0% ratings).  

The panel carefully considered whether there was satisfactory evidence of painful motion to support a minimum 10% rating for each ankle (IAW VASRD §4.59), but members agreed that there was not.  There was no indication of painful motion by any STR provider or in the MEB NARSUM, and the repeated documentation of painless foot motion strongly suggested that the same was true for the accompanying ankle motion.  In the only examinations specifically addressing painful motion, by a service provider and by the VA C&P examiner, it was specifically excluded.  

There was no ankylosis, nonunion, malunion, or other ratable criterion in evidence that would support a 10% rating under any applicable ankle joint code available in VASRD §4.71a.  The panel considered higher rating for functional impairment under code 5299-5262 (analogous to tibia and fibula, impairment), but members agreed that this was not justified by the evidence, i.e., normal gait and mobility, and no specified civilian occupational limitations.  The panel was thus left to conclude that, although it was willing to concede the left ankle as unfitting and eligible for rating, the maximum rating that could be supported was a bilateral 10% rating under criteria of code 5003.  Since this would not be advantageous to the 10% rating conceded by the PEB for the right ankle alone, a recommendation to that effect would be moot.  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 [bilateral] ankle condition.

Contended PEB Condition:  Bilateral Foot Pain Secondary to Pes Planus with Hallux Deformity.  The CI denied any foot complaints at the time of her enlistment examination and no deformities were identified by that examiner, although pes planus was not explicitly excluded.  Service provider entries documented an onset of bilateral foot pain in basic training.  She was diagnosed by podiatry with congenital “pes planovalgus foot deformity” and later with “mild” hallux valgus (HV, a bunion deformity of the big toe), that was also opined to be congenital.  The degree of pes planus was characterized as “mild” by the majority of examiners and on X-ray interpretations (including post-separation VA studies), although one podiatrist characterized it as “severe.”  Both the pes planus and HV were designated as existing prior to service (EPTS), with an early opinion by podiatry that it was not compatible with military service, but the CI was offered a trial of orthotics and conservative treatment.  A surgical option was raised, but not pursued in lieu of the MEB.  The condition was managed with frequent temporary profiles limiting running and rigorous military requirements.  The clinical course indicated that symptoms would resolve while profiled, but would recur when returned to full duty that required lengthy periods of standing and walking.

Provider entries in the STR documented bilateral plantar tenderness, but normal subtalar ROM and no foot pain with ROM or manipulation.  There was no documentation of other deformity, abnormal alignment, or interference with gait, persistent swelling, callosities, or other VASRD-ratable findings.  The 27 August 2004 MEB NARSUM, 8 months prior to separation, documented the absence of current foot pain.  It had been described as “nearly resolved” by the same provider in a clinical note a month earlier.  The CI was profiled during this period.  The MEB NARSUM orthopedic addendum (same as above) documented “significant improvement” of the foot condition.  The Informal PEB opined that the pes planus was congenital and EPTS with no permanent service aggravation (PSA) but “incompatible with the rigors of military service.”  The CI’s appeal was directed at the ankle and other conditions without contesting pes planus, and the Formal PEB adjudication for pes planus remained unchanged.  

The panel directed attention to its recommendation(s) based on the above evidence, and its first charge was an assessment of the fairness of the PEB’s determination that the pes planus condition was EPTS without PSA.  The panel’s recommendation is premised on, and the PEB’s decision was subject to, DoDI 1332.38 (E3.P4.5.2.2.2, Hereditary and/or Genetic Diseases).  This states, “Any hereditary and/or genetic disease shall be presumed to have been incurred prior to entry into active duty.  However, any aggravation of that disease, incurred in the line of duty, beyond that determined to be due to natural progression shall be deemed service aggravated.”  

The panel agreed that, despite the lack of definitive evidence corroborating a pre-existing pes planus, there was compelling evidence that a congenital condition was present.  This was opined repeatedly by service specialists and other providers, with no opinion to the contrary; and, the early surfacing of symptoms precluded an opportunity for acquired pes planus.  The panel was thus left to judge whether there was sufficient evidence of PSA.  Members ultimately agreed that a preponderance of evidence supported a conclusion that there was no sufficiently severe service aggravation that would have logically resulted in a permanent worsening of the natural clinical progression.  The CI was spared a good deal of the usual physical rigors inherent to military service by temporary profiles over the course of her active duty.  When symptoms were aggravated by resumption of full duties, a profile was reinstated.  There was no direct trauma or foot injury in service, no clinical or radiographic evidence of worsening severity of the pes planus throughout service, and symptoms were minimal at the time of separation.  After due deliberation, considering all the evidence and the applicable standards of DoDI 1332.38, the panel agreed that there was insufficient cause to recommend a change in the PEB adjudication for the pes planus (with associated HV) condition.

Contended PEB Condition:  Adjustment Disorder with Depressed Mood.   The panel’s main charge is to assess the fairness of the PEB’s determination that the contended MH condition was not unfitting (Category III).  There was no performance-based evidence from the record that there was mental health (MH) impairment significantly interfering with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB Category III adjudication for the adjustment disorder, so no additional disability rating is recommended.

BOARD FINDINGS:  In the matter of the [bilateral] ankle condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the bilateral pes planus with hallux deformity, the panel recommends no change in the PEB adjudication that it existed prior to service and was not permanently aggravated by service.  In the matter of the contended adjustment disorder with depressed mood, the panel recommends no change from the PEB determination as Category III.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends that there be no modification or re-characterization of the CI’s disability and separation determination.

SAF/MRB
3351 Celmers Lane
JBA NAF Washington, MD 20762-6435

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Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-03866.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.