RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD1300871
BRANCH OF SERVICE:  Army	BOARD DATE:  20140318
SEPARATION DATE:  20031205

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SFC/E-7 (96H/Common Ground Station Operator) medically separated for bilateral Achilles tendonitis.  The CI suffered from chronic heel pain.  She underwent surgical correction in 2003, but despite continued conservative treatment post-surgery, her condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The bilateral Achilles condition, characterized as “bilateral achilles tendinitis” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two other conditions: status post (s/p) Haglund’s resection of the left posterior heel, left foot and Haglund’s deformity (exostosis) right posterior calcaneus for PEB adjudication.  The PEB adjudicated “bilateral achilles tendonitis, status post Haglund’s resection left foot with Haglund's deformity right foot, without limitation of motion” as unfitting, rated 0%.  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI wrote a lengthy contention in blocks 3 and 12 of the application, which described a bilateral condition affecting both feet, in addition to her achilles tendons.  She also cited a “nerve pain” condition as associated with her contended conditions.

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 bilateral Achilles tendonitis is addressed below.  In addition, the CI’s contended left and right foot conditions are within the purview of the board and will be addressed.  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 20030925 | VA - ~4 Mos. Post-Separation
Condition | Code | Rating | Condition | Code | Rating | Exam
Bilateral Achilles Tendonitis, Status Post Haglund’s Resection Left Foot With Haglund's Deformity Right Foot. | 5024 | 0% | Osteoarthritis, Left Ankle | 5271-5010 | 10% | 20040415
| | | Osteoarthritis, Right Ankle | 5271-5010 | 10% | 20040415
No Additional MEB/PEB Entries | Other x 7 | 20040526
Combined:  0% | Combined:  80%
Derived from VA Rating Decision (VARD) dated 20040726* 
* NOTE:  VARD 20040511, which was actual VARD closest to separation, rated DC 5271-5010 as a bilateral condition at 10% combined.  The VARD cited above re-rated the DC 5271-5010 as separate service connected conditions, rating each at 10%, as reflected in the chart above.  

ANALYSIS SUMMARY:  The Board acknowledges the CI’s information regarding the significant impairment with which her service-connected condition continues to burden her; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board considers VA evidence proximate to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12-month interval for special consideration to post-separation evidence.  Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation.

Bilateral Achilles Tendinitis Status Post Haglund’s Resection Left Foot with Haglund’s Deformity Right Foot: The first entry in the service treatment record is from 27 January 1997 troop medical clinic, when the CI presented with a 3-day history of pain on the outside of her right ankle down to heel during and after running PT and with walking.  She had continuing pain and an X-ray of the right ankle for pain was normal.  She had a right ankle sprain injury on 1 May 1998 while in field and ignored pain for a week; she was seen in the emergency room.  On a 27 July 1998 visit, she had right ankle pain after a near fall down stairs the day before.  On 16 December 2002, the CI was seen for heel pain left worse than right since August 2000.  She reported a history of heel spurs since 2000 and normally got relief from wearing civilian shoes.  X-rays revealed old trauma of the left metatarsal-phalangeal joints and benign bilateral first metatarsal head exostoses.  She was seen by civilian podiatry on 16 January 2003 and found to have prominent exostoses and pain over the prominent area of the posterior heels.  She was diagnosed with Haglund’s deformity and the area was injected with Marcaine.  Right and left ankle X-rays showed minimal degenerative charges of the feet and ankles, magnetic resonance imaging (MRI) revealed no definite pathology of the right or left ankles.  On 30 January 3003, the civilian podiatry consult remarked that the MRI showed thickening of the insertion of the Achilles tendon, increased inflammation at the insertion laterally of the Achilles tendon and bilateral irregular borders of the calcaneus, and the right posterior lateral aspect of the Achilles insertion appeared to be larger on the right.  The diagnosis was Haglund’s deformity bilaterally with tendinosis, and spur and surgery was recommended.  She underwent surgery of the left ankle with Haglund’s resection and Achilles tendon debridement on 24 February 2003 and was followed-up a week later on 4 March 2003, without complications.  She underwent physical therapy.  On 8 May 2003, upon follow-up, her foot was reported as doing very well, better in the morning than the other foot, pain was much more diminished on the left foot and she was getting ready for possible surgery on the right foot, she was returned to full duty by the civilian podiatrist and to follow-up as needed for the right heel surgery if podiatry agreed.  On 23 July 2003 she was seen by podiatry and reported no improvement, she was diagnosed with s/p left Haglund’s resection and left Achilles tendinitis, and the MEB was initiated.  Left calcaneus X-ray showed an orthopedic interosseus screw, no other findings.  A bone scan showed an area of increased uptake on the left heel, which may represent postoperative changes and the right first metatarsal-phalangeal joint which may represent mild osteoarthritis were noted.  On 28 August 2003, 4 months prior to separation, the MEB narrative summary (NARSUM) noted the complaint of bilateral posterior heel pain.  She had surgical correction for Haglund’s deformity on 24 February 2003 in the civilian sector.  Since then the patient had chronic pain.  There was no response to conservative treatment consisting of inserts, night splints, post galvanic stimulation, physical therapy, stretching, icing, and pain medications.  She had a difficult time running, wearing boots, standing for prolonged periods of time and unable to participate in regular Army duties.  She had extreme difficulty wearing military shoe gear and showed minimal progress.  Physical examination revealed intact neurovascular status; scar along the left posterior heel region, no edema, no erythema, skin was of normal temperature, turgor and texture.  There was tenderness to palpation along bilateral posterior heels, tenderness along the bilateral Achilles tendon insertion sites, full range of ankle motion; muscle strength was approximately 3/5 on the left, and 4/5 on the right.  The final diagnoses were (1) bilateral Achilles tendinitis, (2) status post Haglund’s resection of the left posterior heel, left foot, and (3) Haglund’s deformity of the right posterior calcaneus.  At the VA Compensation and Pension exam performed 4 months after separation, the CI reported the bilateral Achilles tendinitis since 1999, occurring insidiously.  She had pain, weakness, stiffness, swelling and fatigue.  She had a Haglund’s procedure on the left with residuals of pain.  Physical examination revealed normal posture and gait, no evidence of abnormal weight bearing at the feet.  Right ankle was normal in appearance; left ankle had a surgical scar, posterior lateral calcaneus, non-tender.  No deformities of the ankles.  No limitations with standing and walking.  Range-of-motion of right and left ankle joints were dorsiflexion 20 degrees (normal) and plantar flexion 45 degrees (normal), without additional limitations by pain, fatigue, weakness, lack of endurance or incoordination.  X-rays of the ankles revealed degenerative arthritic changes of the right, and degenerative arthritic changes on the left, status-post surgical procedure.

The Board directs attention to its rating recommendation based on the above evidence.  The Board, IAW VASRD §4.7 (higher of two evaluations), must consider separate ratings for PEB bilateral joint adjudications; although, separate fitness assessments must justify each disability rating.  The commander’s statement, on 6 August 2003, indicated the CI’s performance of duty in garrison has been outstanding within the limitations of her physical profile, but in a tactical unit she was unable to fulfill a large portion of her duty.  The profile on 11 August 2003, was for the right Haglund’s deformity, and left s/p Haglund’s resection and left Achilles tendinitis, lower extremity level three permanent profile, with additional limitations to walk at own pace and distance, no running, no jumping, no prolonged standing, unlimited bicycling, unlimited swimming and no backpack.  Since the disability attendant to either joint could not be isolated by the clinical evidence, or extricated from the fitness implications of the bilateral limitations; in this case, both ankles were considered to fail retention standards; both were implicated by the NARSUM, and in the commander’s statement; and, both were profiled.  Members agreed therefore that each ankle should be conceded as separately unfitting; and, that coding and rating features were logically identical.

The Board first considered VASRD diagnostic code 5024 (tenosynovitis) used by the PEB for a 0% rating.  The VASRD specifies code 5024 will be rated on limitation of motion of affected parts, as arthritis, degenerative (5003).  The Board considered the VASRD principle of §4.10 (functional impairment), §4.40 (functional loss) for this rating recommendation.  The Board determined that the functional impairment of: not running, no prolonged standing at work or in formation, or carrying a backpack, were sufficiently limiting to apply separate 10% ratings for each ankle.  Rating the tenosynovitis and the degenerative arthritis at the ankles separately, did not overcome the §4.14 avoidance of pyramiding instruction.  There was no evidence of any neurological impairment in the record for an alternate §4.124a (neurological conditions) coding or rating.  The pain component was subsumed under the 5024 rating.  The Board then considered VASRD codes 5271 (ankle, limited motion of) -5010 (arthritis, due to trauma, substantiated by X-ray findings) used by the VA for right ankle rated 10% and left ankle also rated 10%.  The Board did not find any evidence of limited ankle motion for a higher rating.  The Board did not find evidence of trauma associated with what was described in the record as insidious onset of foot pain.  The VASRD further instructs 5010 be rated as 5003 (degenerative arthritis) as already discussed above.  Thus, there was no avenue for a higher rating in the CI’s favor using these alternate codes.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left s/p Haglund’s resection, Achilles tendinitis condition, and 10% for the right Achilles tendinitis with Haglund’s deformity condition.

BOARD FINDINGS:  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 left s/p Haglund’s resection, Achilles tendinitis condition, the Board unanimously recommends a disability rating of 10%, coded 5024 IAW VASRD §4.71a.  In the matter of the right Achilles tendinitis with Haglund’s deformity condition, the Board unanimously recommends a disability rating of 10%, coded 5024 IAW VASRD §4.71a.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:

UNFITTING CONDITION | VASRD CODE | RATING
Left Status-Post Haglund’s resection, Achilles Tendinitis Condition | 5024 | 10%
Right Achilles Tendinitis with Haglund’s Deformity Condition | 5024 | 10%
COMBINED (w/ BLF) | 20%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130616, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			
XXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXXXXX, AR20140019339 (PD201300871)

1.  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 to modify the individual’s disability rating 20% without recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     XXXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary
						         (Army Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA