RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXXXX	CASE: PD-2017-04005
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20091025

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Infantryman, medically separated for “left ankle, loss of motion” and “left foot pain,” rated 10% each, with a combined disability rating of 20%.

CI CONTENTION:  No specific contention was made.  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 - 20090717	VARD - 20100316	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Ankle Loss Of Motion	5010-5271	10%	Degenerative Disease, Status Post Fracture and Surgery with Scar Left Ankle	7805-5271	10%	20091203	
Left Foot Pain	5284	10%	Pes Planus and Plantar Fasciitis, Left Foot	5276-5284	10%	20091203	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 30%	

ANALYSIS SUMMARY:

Left Ankle Loss of Motion. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent a left ankle lateral reconstruction and microfracture of a talar dome (articular surface of the talus) osteochondral lesion of the on 7 June 2007. He declined additional surgery for an accessory navicular bone because he wanted to deploy. During his deployment from December 2007 to February 2009, he could not walk on uneven terrain due to pain, and was assigned as a vehicle commander with mobility limitations for the duration of the deployment. He was evaluated after redeployment and imaging, to include X-rays and MRI, showed degenerative changes, a stable osteochondral defect, and chronic ligament injury.

At an orthopedic visit on 3 March 2009, 8 months prior to separation, the CI reported instability and primarily lateral ankle pain. The provider noted tenderness over the anterior talofibular ligament and dorsiflexion (DF) was recorded “to about slightly past neutral plantar flexion [PF] about 25?” At a follow-up on 17 March 2009, he complained of diffuse posterolateral ankle pain worsened by walking. Physical examination showed mild tenderness over the lateral ligaments and the prominent navicular bone. Active ankle ROM was full with no instability and excellent resisted ankle strength in all planes of motion. At an orthopedic surgical consult on 24 April 2009, a foot and ankle specialist could not guarantee that additional surgeries would return the CI to his desired level of activity as an infantryman.

During the 6 May 2009 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months before separation, the examiner noted left ankle tenderness with motion. The MEB NARSUM examination, 5 days later, recorded complaints of left ankle pain. Physical examination showed a normal gait and lateral Achilles tendon and talofibular ligament tenderness. After repetition, dorsiflexion was to 16 degrees (normal 20) and PF to 39 degrees (normal 45), limited by pain.

At the 3 December 2009 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported left ankle achiness at rest, with increased pain while standing and walking; he had a brace, but did not use it. Physical examination showed the ability to heel and toe walk, a slight limp on the left, ankle crepitus, diffuse tenderness greater along the lateral aspect, and no effusion. Strength was normal, and plantar flexion was to 60 degrees and DF to 0-1 degree “with a stretching sensation…, although it was not really pain;” there was no loss of motion with repetition.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the left ankle condition 10%, analogously coded 5010-5271 (ankle, limited motion of), citing moderate loss of motion. The VA also rated the left ankle condition 10%, but dual coded 7805-5271 (other scars-limited ankle motion) based on the C&P examination, citing moderate limited motion of the ankle. Panel members noted that the MEB ankle ROM measurements supported a 10% rating, while the VA results supported a 20% rating. However, there was no elaboration by the VA examiner on the apparent relative absence of DF and the measurement appeared inconsistent with the rest of the record. Marked limitation of DF was not identified by the orthopedic notes in the STR, except for possibly the examination on 3 March 2007; however, this descriptive ROM was not compliant with VASRD guidelines. At the orthopedic appointment 2 weeks later, full active ROM was noted, and at the MEB NARSUM, ROM measured with a goniometer and repeated three times (VASRD compliant), showed moderately reduced ankle ROM at the most. Panel members concluded that the limitation of the CI’s ankle motion supported a 10% rating for moderate limitation, but was not frequently or permanently consistent with a “marked” limitation for a 20% rating. The panel considered alternative VASRD ankle and analogous codes, but all were less applicable and/or not advantageous to 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 left ankle condition.

Left Foot Pain. According to the STR and MEB NARSUM, the CI was diagnosed with “fallen arches” in December 2003. Orthotics were ordered, but they did not arrive before he deployed. At the April 2009 orthopedic foot and ankle specialist examination, the provider noted pes planus that increased with standing. The hind feet went into valgus alignment with weight bearing on both feet, but he was unable to perform a left heel rise and had a weak right heel rise.

At the 11 May 2009 MEB NARSUM examination, the examiner found that the medial arches flattened moderately with weight bearing. The C&P examination noted the CI was diagnosed with plantar fasciitis in 2003 and was given orthotics which provided relief. He reported a significant amount of foot pain first thing in the morning, which improved with continued

ambulation, but recurred at the end of the day. He was able to work and the condition did not affect normal activities. Physical examination showed a slight limp favoring the left side (injured ankle), and pes planus with pronation on his gait. There was pain to pressure over the proximal arch at the insertion of the plantar fascia on the heel, with the left more tender than the right. There was good alignment of the Achilles tendon and no calluses on the bottom of the foot, and he was able to heel and toe walk without difficulty.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the left foot condition 10%, coded 5284 (foot injuries, other), citing moderate foot injury. The VA also rated the left foot condition 10%, but dual coded 5276-5284, based on the C&P examination, citing moderate symptoms. Panel members agreed that a 10% rating was supported for left foot pain causing a “moderate” foot injury, but there was no evidence to support characterizing the foot injury as “moderately severe” for a higher rating based on a normal gait or slight limp, and no required use of an assistive device. The panel considered if rating the foot pain analogously to 5310 (group X muscle injury (includes the PF) IAW VASRD
§4.73 (muscle injuries) supported a higher rating, but as noted for the 5284 criteria (which are also subjective and comparable), a 10% rating was warranted for evidence of “moderate” injury, but did not for “moderately severe” foot injury under this code. While both the MEB NARSUM and VA examinations documented pes planus, panel members determined that a 10% rating, but no higher, was supported under code 5276 for moderate pes planus with pain on manipulation or use of the feet without swelling, marked deformity, or calluses for higher rating. There was therefore no higher than a 10% rating supported under any applicable VASRD code. 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 left foot condition.

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 left foot condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. 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.

	PD-2017-04005

AR20190012687, XXXXXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXXX

	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.

	PD-2017-04005