RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  	CASE NUMBER:  PD1200637
BRANCH OF SERVICE:  Army	BOARD DATE:  20130514
Separation Date:  20020530

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (31F/SENS Switch Operator) medically separated for right ankle pain.  The CI fell into a hole while running and sustained a twisting injury to his right foot and ankle.  He developed a ganglion cyst, which was surgically excised; however, postoperatively he developed a hypertrophied keloidal scar.  Despite extensive conservative treatment, the CI failed to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The MEB forwarded “Ganglion Cyst, Right Foot and Ankle, Status Post (S/P) Excision” and “Painful Keloid, Right Foot and Ankle” to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The PEB adjudicated “Right Ankle Pain Secondary to a Hypertrophic Keloid Scar (10 X 1 cm), S/P Ganglion Excision” as unfitting, rated 10% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and he was medically separated with a 10% disability rating.

CI CONTENTION:  “The rating was given due to the scar on my right ankle when in fact it was found that it was not only the scar but nerve damage from the surgery itself.  I was told that it was most likely CRPS and that it would be hard for them to diagnose because little is known about chronic regional pain syndrome (CRPS).  It has gotten progressively worse and has stopped me from gaining employment.  I completed Vocational Rehabilitation and earned a HRM/BA but still unable to gain employment through that program.  I have been denied increases several times for the ankle (right) but gotten an increase for the scar.  Due to it being hard to prove CRPS I have not gotten a diagnosis for it thusly being denied.  This has made it difficult at times to maintain our mortgage and keep food on the table with just my wife’s income.”

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 ankle 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 respective Service Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20020418 | VA - based on Service Treatment Records (STR)
Condition | Code | Rating | Condition | Code | Rating | Exam
Right Ankle Pain Secondary to a Hypertrophic Keloid Scar status post Ganglion Excision | 7804 | 10% | Residuals of Right Ankle Injury status post  Surgery | 7804-5271 | 10% | STR
No Additional MEB/PEB Entries | Other x 0 | STR
Combined:  10% | Combined:  10%

ANALYSIS SUMMARY:  The Board acknowledges the sentiment expressed in the CI’s application regarding the significant impact that his service-incurred condition has had on his current earning ability and quality of life.  The Board utilizes VA evidence proximal to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12-month interval for special consideration to post-separation evidence.  The Board’s authority as defined in DoDI 6044.40, however, resides in evaluating the fairness of Disability Evaluation System (DES) fitness determinations and rating decisions for disability at the time of separation.  Post-separation evidence therefore is probative only to the extent that it reasonably reflects the disability and fitness implications at the time of separation.

Right Ankle Pain Secondary to a Hypertrophic Keloid Scar status post Ganglion Excision Condition.  In March 2001, the CI injured his right foot and ankle when he stepped into a hole and sustained a twisting injury.  The initial PT consult indicated an antalgic gait, tenderness to palpation (TTP) to the medial and lateral talar dome and the CI was diagnosed with tenosynovitis.  The CI was fitted for an ankle lace-up brace to provide stability for the ankle sprain.  The CI was found to have a right ankle ganglion cyst and was scheduled for an excisional biopsy in August 2001.  Postoperatively, the CI was placed on a 21 day convalescent leave; however, he continued to complain of right ankle pain, tenderness to palpation and swelling.  A CAM walker was ordered for 2 weeks along with nonsteroidal anti-inflammatory drugs (NSAIDs).  The CI was placed on quarters for 30 days.  The CI was given a temporary L2 profile for a ganglion cyst with restrictions of crutches for 4 weeks, no running for 2 months, and a soft shoe profile.  The CI was seen in Medical Clinic for complaints of persistent pain and significant edema at the end of day in the anteromedial aspect of the right ankle.  Physical findings at the time of the exam were minimal edema over the anteromedial aspect, and TTP along the scar, an ace wrap was applied.  The CI returned later in the day to the Medical Clinic for a reevaluation with physical exam findings of a slight decrease in ankle edema however, the toes were still slightly edematous.  The CI was seen by orthopedics in November 2001 for ongoing complaints of persistent pain and swelling and was noted to have mild erythema and edema.  The Medical Clinician noted keloid formation and pain over the scar area.  The orthopedist indicated that in February 2002, the CI still had pain, the right foot still turned purple, and the scar area was very painful with hyperesthesias and large keloid 6 cm x 5 cm along the tibial anterior ankle.  The CI was given a permanent L3 profile for post-operative right foot pain syndrome with restrictions of no running, no jumping, and no prolonged standing greater than thirty minutes.  The commander’s statement indicated that the CI had made limited progress and the persistent pain prevented him from performing his MOS duties.

The MEB narrative summary (NARSUM) exam approximately 2 months prior to separation documented chronic pain and discomfort due to the chronically hypertrophied surgical scar on the medial aspect of the right foot and ankle; frequent changes in coloration of the scar and surrounding skin; frequent pain in the scar area which would occur at night, during sleep and at rest; pain that radiated from the scar proximally and distally; and pain that was worsened by increased activities such as prolonged standing, walking, and running.  The CI was not able to run distances because of the pain nor could he wear boots to perform long road marches.  The examiner noted that the pain had been refractory to multiple treatments which included a transcutaneous electrical nerve stimulation (TENS) unit, ultrasound and various other forms of physical therapy (PT).  The physical exam findings were a hypertrophied keloid longitudinal scar approximately 10 cm long and 1 cm wide at the medial and dorsal aspect of the right ankle and foot.  There were changes in the color of the scar during the exam which indicated changes in vascular blood flow to the area; the skin on and about the scar was sensitive to touch and caused dysesthesias; Tinel’s testing was positive over the scar with pain that radiated to the great toe; and ankle motion caused pain and discomfort in and about the scar.  However, there was a normal neurologic exam with active normal ankle dorsiflexion and plantar flexion, mid and forefoot pronation and supination, and toe flexion and extension.  The examiner discussed the findings from a Bone scan as showing an abnormal uptake of the right medial malleolus.  No VA Compensation and Pension (C&P) examination was completed at the time of separation.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB coded the right ankle pain secondary to a hypertrophic keloid scar condition as 7804 scar(s), unstable or painful rated 10% (One or two scars that are unstable or painful).  The VA coded the residuals of right ankle injury s/p surgery condition as 7804 with 5271 ankle, limited motion of rated at 10% (Moderate) based on the service treatment records (STRs).  More than 5 years after separation, the VA increased this rating to 20% based on marked limitation of ROM of the right ankle.  More than 7 years after separation from service, after a follow-up VA C&P examination, the VA assigned separate disability ratings for the painful scar and the ankle joint.  All exams proximate to separation showed painful, but not limited, right ankle motion.  The Board considered rating under 5271; however, this rating schema would not result in rating greater than 10%.  The Board also considered rating the condition as a neuritis 8627 or neuralgia 8727 of the saphenous nerve; however, the maximum permissible rating IAW §4.123 would have been 10%.  The Board also considered separate ratings for 7804 and 5271; however, the record at the time of separation does not support a finding of two separate disabilities with one related to the scar and another, separate, disability related to the joint or nerve.  Therefore, assigning two separate ratings would be pyramiding.  While the coding chosen by the VA more accurately reflects the disability, it does not affect the rating.  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 ankle pain secondary to a hypertrophic keloid scar condition.

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 ankle pain secondary to a hypertrophic keloid scar condition and IAW VASRD §4.118, 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 Ankle Pain secondary to a Hypertrophic Keloid Scar status post Ganglion Excision | 7804 | 10%
COMBINED | 10%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20120607, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

Physical Disability Board of Review

SFMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(TAPD-ZB),

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for AR20130010955 (PD201200637)

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						
						         (Army Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA