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AF | PDBR | CY2013 | PD-2013-02349
Original file (PD-2013-02349.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX                  CASE: pd-2013-02349
BRANCH OF SERVICE: AIR FORCE              BOARD DATE: 20150429
SEPARATION DATE: 20090219


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Munitions System Craftsman) medically separated for right ankle and foot pain. The condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty (AFS) or satisfy physical fitness standards. He was issued a L4 profile, placed on light duty and referred for a Medical Evaluation Board (MEB). The “chronic right ankle and foot pain” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123. No other conditions were submitted by the MEB. The Informal PEB adjudicated “chronic right ankle and foot pain” as unfitting, rated 10%, c iting application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION: “I received 10% disability severance condition rating for only one condition. The VA found that I am a combined disability rating of 70%.” [sic]


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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting. Any conditions outside the Board’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/Naval Records. Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate. The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation. The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions. That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws. The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.


RATING COMPARISON :

IPEB – Dated 20081020
 VA* - (~4 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Right Ankle and Foot Pain 8722 10% Right Ankle Instability 5271 10% 20090630
Scars, right foot 5271-7804 10% 20090630
Other MEB/PEB Conditions x 0 (Not In Scope)
 Other x 12
RATING: 10%
 COMBINED RATING: 70%
* Derived from VA Rating Decision (VA RD ) dated 200 91030 (most proximate to date of separation ( DOS ) ) .




ANALYSIS SUMMARY:

Chronic Right Ankle and Foot Pain. Service treatment records (STR) noted the CI had a work related 40 foot fall from a tractor trailer in 1998, resulting in a dislocated ankle. There were torn ligaments and instability resulting in right lateral ankle reconstruction in September 1999. He had extensive physical therapy and could run and perform physical training, but he developed increasing pain in the right lateral ankle. In August 2004 an electromyelogram (EMG) was consistent with entrapment of the sensory nerve along the lateral aspect of the ankle and dorsolateral right foot. In March 2006 superficial peroneal nerve neuralgia (stabbing, burning, and pain along a nerve) was diagnosed. He had abnormal sensations and recurrent instability with running. Multiple neurosurgeons and orthopedists were consulted and he had a second surgery in July 2008 (after the narrative summary [NARSUM]) to release the entrapped nerve and tighten the ligaments. He developed a wound problem that resolved with wound care.

The NARSUM dated 29 July 2008 performed 7 months prior to separation, noted the CI had difficulty running and could not perform his physical training run test. The foot pain was associated with numbness and tingling but he did participate in the fitness program, work out on the elliptical machine, and walk on the treadmill for short periods at his own pace. Physical exam revealed healed surgical incision sites, tenderness to palpation, “full range of motion” with dorsiflexion to 5 degrees (normal 20) and plantar flexion to 30 degrees (normal 45), and a positive Tinel’s sign (lightly banging on a nerve elicits tingling). Motor activity was intact and strength was 5/5. Sensory was intact with significant pain along the superficial peroneal nerve. The examiner noted the CI’s condition was chronic but not disabling and he should be allowed to continue active duty. There were no job limitations since duties were purely administrative. The outpatient orthopedics note, performed 2 months prior to separation, noted the CI had done well after the second reconstruction surgery but still had some lateral pain and trouble running. He was able to dorsiflexion to 50 degrees, plantar flex to about 30 degrees, and his peroneal tendons were about 3.5-4.5 in strength. He wore a brace when active and remained in rehabilitation.

The VA Compensation and Pension (C&P) exam performed 4 months after separation, noted the CI was status-post his second surgical repair and since then was reporting sensitivity to post-surgical scars with a numbness and tingling sensation over the dorsolateral foot and anterolateral ankle. Without his medications, the daily pain was 10/10 but with medications, the pain was 4-5/10. It was a burning sensation that shot up his legs and into his toes and occurred in the same distribution as the numbness and tingling. The pain increased with changes in the weather. He had occasional painful clicking and popping in the lateral ankle, occasional swelling, but there was no longer giving out in the right ankle. Icing and elevating the ankle reduced the pain and swelling. He took two pain medications to help control the pain. He wore an ankle brace with increased activities. He could not participate in sports and had trouble playing with his 4-year-old son. His active duty job was affected. He had to decrease physical training. He had no incapacitating flare-ups. Neurological exam revealed slight weakness of dorsiflexion of the foot and ankle and plantar flexion of the foot and ankle secondary to repeated ankle surgeries. Strength was 4/5. There was slight decreased sharp sensation on the right fifth toe and lateral side of the right foot. Physical exam revealed a normal gait, and well healed ankle scars that did not adhere to underlying tissues or restrict joint motion. Palpation of the anterolateral and lateral ankle scars caused pain and tingling sensation. There was spotty decreased sensation over the dorsolateral foot and lateral ankle. The range-of-motion of the right ankle was full. He could hold the foot in 90 degrees neutral, dorsiflexion was to 20 degrees with pain at 20 degrees and plantar flexion was to 45 degrees without pain. There was no increased fatigue, weakness, or lack of endurance on repetitive motion. The ankle was stable to eversion and inversion. A diagnosis of right ankle instability was rendered.
The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 10% rating coded 8722 code (superficial peroneal nerve neuralgia), while the VA assigned a 10% rating under the 5271 code (for moderate ankle limited motion) and 10% coded 5271-7804 for painful scars of the right foot. The NARSUM exam preceded the CI’s second surgery (nerve release) and had a lowered probative value for rating. The orthopedic exam documented was closest to separation and documented pain with limited ankle motion and motor weakness as well as the need for an ankle brace. The exam did not assess sensory testing. The VA exam completed after separation documented both painful motion of the ankle, weakness, and a slight sensory loss over the foot. There was no profile limitation or restriction for use of military foot gear although the CI was prescribed an ankle brace; therefore, the Board adjudged that there was not sufficient justification for a separately unfitting scar rating. The Board considered if there were sufficient symptoms for both a joint rating (10%) and a peripheral nerve rating (10%), or if considering all of the CI’s ankle and foot disability under disability code 5284 (Foot injuries, other) was predominate.

The Board considered that the CI’s two types of surgery (joint stabilization and nerve entrapment) as well as multiple symptoms and findings including sensory loss and pain in the distribution of the superficial peroneal nerve, tenderness, painful (or limited) ankle joint motion, muscle weakness, and the prescription of an ankle brace would have supported both a peripheral nerve rating and a joint rating. However, apportioning the various parts of the CI’s disability was problematic and the CI’s disability level at the time of separation was best described as being moderately severe (20%) analogous to code 8722-5284 encompassing his peripheral nerve and joint disabilities of the ankle and foot. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) and §4.7 (higher of two evaluations), the Board recommends a disability rating of 20% for the chronic right ankle and foot pain 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 chronic right ankle and foot pain condition, the Board unanimously recommends a disability rating of 20%, coded 8722-5284 IAW VASRD §4.71a. There were no other conditions within the Board’s scope of review for consideration.


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

UNFITTING CONDITION
 VASRD CODE RATING
Chronic Right Ankle and Foot Pain … 8722-5284 20%
COMBINED
 20%










The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131113, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record









XXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review


 SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762
XXXXXXXXXXXXXXXXX


Dear XXXXXXX :

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2013-02349 .

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities. Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay.

I have carefully reviewed the evidence of record and the recommendation of the Board. I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force. The office responsible for making the correction will inform you when your records have been changed.

Sincerely,



XXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

cc:
SAF/MRBR

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