RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXX	CASE: PD-2017-04859
BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20081113

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Voyage Management Systems Operator, medically separated for “chronic debilitating right foot pain” and “tarsal tunnel syndrome, right ankle, status post tarsal tunnel release,” rated 10% each, with a combined disability rating of 20%.

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 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 - 20080729	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Debilitating Right Foot Pain	5299-5003	10%	
No VA Examination in Evidence	
Tarsal Tunnel Syndrome, Right Ankle, Status Post Tarsal Tunnel Release	8625	10%		
Symptomatic Os Trigonum, Right
Ankle, Status Post Excision	Cat II		
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: NA	

ANALYSIS SUMMARY:

Chronic Debilitating Right Foot Pain and Right Ankle Tarsal Tunnel Syndrome. The evidence for the right foot and right ankle conditions are presented together (since they were inextricably interrelated) but with separate rating recommendations. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s right foot and ankle conditions began in August 2003 after he was diagnosed with a severe ankle sprain. The pain persisted despite rehabilitation and conservative measures, and in April 2005, he underwent removal of a painful os trigonum (accessory bone behind the talus) and bone fragments from the posterior talus of the right ankle. Ankle X-rays in October 2006 showed some degenerative changes with marginal osteophytes, but no definitive loose body. An MRI in October 2006 demonstrated a tiny, 2-mm ossification posterior to the talus, which represented either a non-fused ossification center or intra-articular loose body.

At an orthopedic visit in January 2007, the CI was given support socks to limit swelling and a lace- up ankle brace to assist with limitation of motion by reducing some of the degenerative symptomology. In January 2007, he received a steroid injection trial in the ankle, with no pain relief, and a second injection into the posterior tibial sheath, 2 weeks later, with only initial relief. An ankle CT scan in July 2007 demonstrated numerous posterior talus bone fragments likely constituting a multipart dominant os trigonum ossification center or an old comminuted, nonunion fracture. An additional injection in the ankle in October 2007 provided no relief. Electrodiagnostic studies showed somewhat slow right peroneal nerve conduction around the ankle, but minimal neuropathy of the posterior tibial nerves. The CI underwent a right ankle tarsal tunnel release over the posterior tibial nerve on 23 January 2008, and the postoperative course was marked by continued right ankle pain with prolonged standing as well as paresthesias not relieved by physical therapy (PT).

The 6 June 2008 MEB PT range of motion (ROM) study, 5 months prior to separation, showed dorsiflexion to 10 degrees (normal 20) and plantar flexion to 55 degrees (normal 45). The CI’s gait was non-antalgic to the right, but with increased pronation. During the 17 June 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), he reported a painful right ankle and the examiner noted surgical scars on the right medial and lateral ankle areas. The 2 July 2008 MEB NARSUM examination, 4 months before separation, noted complaints of chronic right ankle pain with radicular symptoms to the right medial foot after standing for 10 minutes. Physical examination showed a well-healed hypertrophic incision that was exquisitely tender, and paresthesias in the medial plantar nerve distribution. A Tinel's test (for nerve irritation) was positive and he was unable to perform a single leg heel raise secondary to pain. The hind foot was neutral and there was swelling along the posterior medial and lateral aspects of the right ankle. Anterior drawer and talar tilt tests were stable. Electrophysiologic studies on 15 August 2008 revealed findings that were most remarkable for the absence of medial and lateral plantar sensory responses in the right foot with evidence of some chronic reinnervation in the tibialis anterior muscle. There was no VA examination proximate to separation in evidence.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the right foot condition 10%, analogously coded 5299-5003 (arthritis, degenerative), and listed “symptomatic os trigonum, right ankle, status post excision” as a related Category II condition. Panel members agreed that this diagnosis was intrinsic to the right foot pain and that a separate rating could not be supported without pyramiding (VASRD §4.14); thus, it was appropriately subsumed in the same rating. The PEB also rated the right ankle condition 10%, coded 8625 (posterior tibial nerve neuritis-mild). Panel members first considered the right foot condition and noted that while the CI had limited dorsiflexion of 10 degrees, a rating of 10% for limitation of ankle motion was the maximum rating available under code 5271 as well as other ankle codes. The panel then considered the rating for the tarsal tunnel syndrome, and agreed that while the CI had pain and paresthesias, a rating higher than 10% under code 8625 was untenable since a moderate condition likewise warranted a 10% rating, and there was no evidence that the pain or paresthesias rose to a severe level. Since the PEB separately rated the right foot pain component 10% and the tarsal tunnel syndrome 10%, for all intents and purposes, the combined rating of 20% was equivalent to the optional use of code 5284. 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 right foot and right ankle conditions.

BOARD FINDINGS: In the matter of the right foot condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. In the matter of the right ankle condition and IAW VASRD §4.124a, 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.

DEPARTMENT OF THE NAVY
SECRETARY OF TI!E 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 Sep20

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 ofno 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.