RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXX CASE: PD1200525 BRANCH OF SERVICE: ARMY BOARD DATE: 20130418 SEPARATION DATE: 20020227 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PVT/E-1 (92G/Food Service Specialist) medically separated for right Achilles tendon avulsion. The CI sustained her right Achilles tendon avulsion condition during her 8th week of basic training in October 2001. After operative repair and a period of convalescent leave, the CI’s right Achilles tendon avulsion condition could not be adequately rehabilitated for her to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The right Achilles tendon avulsion condition, characterized as “right Achilles tendon avulsion status post repair” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB (IPEB) adjudicated right Achilles tendon avulsion as unfitting rated 20% with likely application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals, and was medically separated with a 20% disability rating. CI CONTENTION: “I was given an automatic 20% for an Achilles tendon rupture. It was not an Achilles tendon rupture, a piece of my heel bone was broken off, still attached to the tendon, and shot up through my calf muscle like a torpedo. I was made to wait two day before they sent me to the doctor, and then was scheduled for emergency surgery. This left me with 3cm of atrophy in my calf muscle. (cont. in item 12) They had to place pins in the bone to hold my foot together. Currently, I live with pain, irreversible nerve damage and osteoarthritis. This request for review is due to incorrect information from the beginning. This was not an Achilles tendon rupture, it was much more and caused much more damage than that.” SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The rating for the unfitting right Achilles tendon avulsion condition is addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records. RATING COMPARISON: Service IPEB – Dated 20011217 VA - (~9 Mos. Post-Separation) Condition Code Rating Condition Code Rating Exam Right Achilles Tendon Avulsion 5271 20% Right Achilles Tendon Rupture Status Post Repair 5271 20% 20021122 No Additional MEB/PEB Entries Other x 0 20021122 Combined: 20% Combined: 20% Derived from VA Rating Decision (VARD) dated 20020305 (most proximate to date of separation [DOS]). ANALYSIS SUMMARY: Right Achilles Tendon Avulsion Condition. The narrative summary (NARSUM) notes that following X-ray confirmation of an avulsion fracture of the right Achilles tendon, the CI underwent surgical repair for the condition. On follow-up exam following convalescent leave, she reported pain only with weight bearing and not while sitting comfortably. Pain was judged to be minimal and intermittent. The MEB physical exam noted a well-healed posterior ankle scar. Range-of-motion (ROM) was 0 degrees of dorsiflexion and 45 degrees of plantar flexion. There was a palpable screw head that was mildly tender. Sensation was intact. Pulses were 2+ and plantar strength was 5/5 with a palpably intact Achilles tendon. X-ray study performed at the time showed an orthopedic screw in good position with healing of the bony fragment to the calcaneus. The examiner opined that the CI should have “a near full recovery of her ankle function after approximately 6 to 9 months.” The VA originally based its rating on the MEB’s findings in the absence of further data. However, a VA Compensation and Pension (C&P) exam was performed about 9 months post- separation, at the CI’s request. Report of that exam stated that it was done because the CI had disagreed with the previous evaluation contending that there was hardware that had avulsed in the calf. She also mentioned calf atrophy, constant pain and swelling. Physical exam at that time revealed marked tenderness over the distal aspect of the tendon and the posterior calcaneus. ROM was recorded as dorsiflexion to neutral and plantar flexion to 40 degrees. Some discomfort on extremes of dorsiflexion was noted. Squeezing of the calf produced plantar flexion. Calf measurements were 33 cm on the right and 35 cm on the left. Another X- ray study performed in November 2002 described the orthopedic screw embedded in the calcaneus with well corticated bony density abutting the superior calcaneus at the expected site of the Achilles tendon insertion. The examiner concluded that there was no evidence of hardware having avulsed into the calf. While acknowledging the CI’s complaints of numbness and tingling of the entire right leg and her mention of episodes of pain in the left foot, he thought it unlikely that any of these symptoms were associated with the surgical repair of the right Achilles tendon. Subsequent C&P (neurology) exam performed in May 2003, about 15 months post separation, while confirming the 2 cm smaller circumference of the right calf muscle felt that the atrophy was most likely secondary to disuse after wearing immobilization device for an extended period of time. There was some weakness noted in the right foot but it was felt to be unlikely that it was due to a proximal radiculopathy. Electromyogram (EMG) study showed no abnormality according to a later C&P exam performed in December 2004. The Board directs attention to its rating recommendation based on the above evidence. The PEB characterized the condition as right Achilles tendon avulsion with surgical repair and coded it as 5271 (ankle, limited motion of). Citing the ROM measured during the MEB exam and the stated expectation of full recovery for civilian life, they rated the disability at 20% for marked limitation of motion. The VA initially rated the condition in the same manner as the PEB, basing its decision on the MEB which was the only evidence available at the time. It subsequently amended its description of the condition to “right Achilles tendon rupture, status post repair with hardware and with calf atrophy” but maintained the rating at 20% for marked limitation of motion. The Board considered these exams and adjudications and concurred with the characterization of the limitation of movement as “marked”, thus justifying the 20% maximum allowable rating under 5271. The Board considered the timing of the surgery and MEB exam within 2 months of surgery and considered the VA exam 13 months post operatively (9 months post-separation) as having the highest probative value for permanent separation rating. Members also discussed a possible rating under 5262 (tibia and fibula, impairment of). A rating higher than 20% under this code (for ‘moderate’ ankle disability) would require a characterization of the ankle disability as “marked.” With relatively normal gait described in the VA exam most proximal to separation, and reasonably intact plantar flexion, all members agreed that the ‘marked’ 30% rating was not supported under 5262. The Board could find no route to a higher rating and thus after due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right Achilles tendon avulsion condition. The Board concluded therefore that this condition could not be recommended for additional disability rating. BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. In the matter of the right Achilles tendon avulsion with surgical repair and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows: UNFITTING CONDITION VASRD CODE RATING Right Achilles Tendon Avulsion with Surgical Repair 5271 20% COMBINED 20% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120603, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxx, DAF Director of Operations Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxxxx, AR20130009620 (PD201200525) I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation and hereby deny the individual’s application. This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail. BY ORDER OF THE SECRETARY OF THE ARMY: Encl xxxxxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)