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AF | PDBR | CY2013 | PD-2013-01352
Original file (PD-2013-01352.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX  CASE: PD-2013-01352
BRANCH OF SERVICE: Army  BOARD DATE: 20141015
SEPARATION DATE: 20040508


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard SFC/E-7 (88M/Motor Transport Operator) medically separated for right ankle pain. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The ankle condition, characterized as “chronic right ankle instability, status-post lateral reconstruction” and “chronic right ankle pain” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded six other conditions for PEB adjudication. The Informal PEB adjudicated “chronic right ankle pain, status post lateral reconstruction with tarsal tunnel syndrome” as unfitting, rated 10% citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy. T he remaining conditions were determined to be not unfitting . The CI made no appeals and was medically separated.


CI CONTENTION: The CI attached a 2-page statement to his application which was reviewed by the Board and considered in its recommendations.


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; the requested obstructive sleep apnea (OSA), anxiety disorder (contended as posttraumatic stress disorder), gastroesophageal reflux disease (GERD), seasonal allergies, right knee chondromalacia patella and hypertension, which were determined to be not unfitting by the PEB, are likewise addressed below. The requested lumbar strain, neurological deficiency lower extremity and Guyons canal, finger and ulnar nerve left elbow conditions were not identified by the PEB; and, are not 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 20040319
 VA - (~1 to 4 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Right Ankle Pain… 5099-5003 10% Residual Right Ankle Pain 5271-5272 20% 20040901
Obstructive Sleep Apnea Not unfitting Sleep Apnea 6847 50% 20040603
Anxiety Disorder, NOS Not Unfitting Generalized Anxiety Disorder 9413 30% 20040617
GERD Not unfitting GERD 7399-7305 10% 20040603
Seasonal Allergies Not unfitting Allergic Rhinitis 6522 0% 20040603
Right Knee Chondromalacia Patella Not Unfitting Torn Meniscus Right Knee… 5299-5257 NSC 20040605
Hypertension Not Unfitting Hypertension 7101 NSC 20040603
Other x 0 (Not in Scope)
 Other x 1 (Not in Scope) 20040603
Combined: 10%
 Combined: 80%
* Derived from VA Rating Decision (VA RD ) dated 200 40901 (most proximate to date of separation ( DOS ))


ANALYSIS SUMMARY:

Chronic Right Ankle Pain Condition. The CI had a long history of right ankle pain and instability. Surgical intervention in 2002 by a civilian orthopedist did not result in adequate relief of his symptoms, and in October 2003 the CI was medically evacuated from Iraq because of right ankle pain. In November 2003 (6 months prior to separation), he underwent lateral reconstruction and revision of the previous tarsal tunnel release surgery. The narrative summary (NARSUM) evaluation performed on 20 January 2004 (2 months after surgery and 3.5 months prior to separation) noted that although symptoms of instability improved after the recent surgery, residual pain persisted. Examination showed a mild antalgic (limping) gait with a protective post-surgical boot worn on the right lower extremity. Surgical incisions were well healed and ligaments were stable. A positive Tinel’s sign was present over the tarsal tunnel area (tenderness suggesting nerve related pain at the inner ankle). In March 2004, the CI was issued an L3 physical profile where he could bike, swim, walk or run in pool at his own pace.

At the VA Compensation and Pension (C&P) exam performed a month after separation, the CI reported wearing an air cast on his right ankle on a daily basis. He complained of occasional burning pain, numbness and tenderness on the inside portion of his right foot. Exam showed stable ligaments. There was no hypersensitivity and strength was normal in both plantar flexion and dorsiflexion. A general medical C&P examiner 2 days later observed a narrow-based gait with a brace on the right ankle. At a C&P exam on 6 November 2004 (6 months after separation) the CI reported that his right ankle was somewhat painful and he continued to wear an aircast. He was “able to walk and deliver mail for the postal service with the aircast on.” He could walk approximately 30 minutes or two miles without significantly increased pain.

The range-of-motion (ROM) evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

“
“
Right Ankle ROM
(Degrees)		 MEB DD2808 ~ 4.5 Mos. Pre-Sep NARSUM 4 Mos. Pre-Sep VA C&P ~1 Mo. Post-Sep VA C&P ~6 Mos. Post-Sep
Dorsiflexion (20 Normal) 10 05 or 10” 20
Plantar Flexion (45) 30 35Approximately 30” 45
§4.71a Rating 10% 10% or 20% ( PEB 10% ) 10% or 20% ( VA 20% ) 0% ( VA 2 0 % )

The Board directs attention to its rating recommendation based on the above evidence. The PEB relied on an analogous 5003 code (degenerative arthritis) for a 10% rating while the VA assigned a 20% rating under a combination 5271-5272 code (limitation of motion; tarsal joint ankylosis). Since there was no ankylosis present, rating under the 5270 or 5272 codes was not supported. The Board considered the ROM in evidence. A 10% rating is warranted for “moderate” and a 20% rating for “marked” limitation of motion. The NARSUM examination showed a mild antalgic gait with a protective post-surgical boot and his ankle ligaments were stable. His profile allowed him to walk and bike at own distance. Three VA examinations, within 6 months of separation, noted the resolution of the antalgic gait and use of a support brace. He then transitioned to an aircast for use in his postal service job where he could walk approximately 30 minutes or two miles without significantly increased pain. The Board consensus was that “moderate” limitation of ankle motion was reflected in the evidence. 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 chronic right ankle pain condition.

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that OSA, anxiety disorder NOS (not otherwise specified), GERD, seasonal allergies, right knee chondromalacia patella and hypertension were not unfitting. The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

Obstructive Sleep Apnea. This condition was diagnosed by a sleep study in March 2004. He was prescribed night time continuous positive airway pressure (CPAP) which relieved his sleep-related symptoms. Routinely OSA is not considered unfitting solely on the basis of field and operational impediments to the use of CPAP. There is no evidence in this case that OSA was associated with any functional impairment that was not corrected by CPAP. The condition was not profiled and was determined by the MEB to be medically acceptable. Accordingly, members concurred that the PEB’s fitness determination was reasonable; and, after due deliberation, the Board finds insufficient cause to recommend a change in the PEB adjudication of the OSA condition.

Anxiety Disorder, Not Otherwise Specified. This disorder was listed by the NARSUM examiner as a current diagnosis, who noted that symptoms began after returning from Operation Iraqi Freedom. On the MEB separation exam, the CI marked “No” for “Nervous trouble of any sort” and “Depression or excessive worry.” The commander’s statement indicated that physical limitations interfered with performance of duties. The MEB DD Form 3947, which was signed by a psychiatrist, identified anxiety disorder as medically acceptable.

Right Knee Chondromalacia Patella. Right knee issues began after an injury in 1997 that required arthroscopic surgery. Ongoing knee pain (along with ankle pain) led to medical evacuation from Iraq in October 2003. Magnetic resonance imaging showed only mild chondromalacia patella of the medial patellar facet (inflammation and softening of the knee cap cartilage). The MEB separation examiner indicated that the CI could not run the fitness test, but could walk it. The NARSUM examiner noted a trace amount of knee swelling and a positive (painful) patellar grind test; and intact knee ligaments. The right knee chondromalacia condition was listed on the permanent profile dated 3 March 2004, along with the right ankle condition. At the C&P exams a month after separation, the CI reported occasional episodes of giving way, instability and locking. Knee pain was noted to be sporadic.

With the exception noted above of profiled knee chondromalacia patella, none of the other conditions, to include GERD, seasonal allergies and hypertension, were profiled and none were judged to fail retention standards. All were reviewed by the action officer and considered by the Board. There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the any of the contended conditions and so no additional disability ratings are recommended.
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. As discussed above, PEB reliance on the USAPDA pain policy for rating chronic right ankle pain was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the chronic right ankle pain condition and IAW VASRD §4.71a, the Board by a vote of 2:1 recommends no change in the PEB adjudication. In the matter of the contended obstructive sleep apnea, anxiety disorder not otherwise specified, right knee chondromalacia, gastroesophageal reflux disease, seasonal allergies and hypertension conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting. There were no other conditions within the Board’s scope of review for consideration.


RECOMMENDATION: The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130912, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




                 
XXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXX, AR20150003733 (PD201301352)

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                                                  XXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)
                                                     
CF:
( ) DoD PDBR
( ) DVA

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