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AF | PDBR | CY2014 | PD-2014-00149
Original file (PD-2014-00149.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX       CASE: PD-2014-00149
BRANCH OF SERVICE: Army  BOARD DATE: 20150529
SEPARATION DATE: 20050622


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty O-3 (Aviation Officer) medically separated for right ankle pain and a right foot nerve lesion. These conditions could not be adequately rehabilitated to meet the physical requirements of his Area of Concentration. The profile allows for an alternate aerobic event to satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The “ankle pain secondary to sequelae of osteochondritis dissecans and surgery” and “nerve lesion right foot dorsum, secondary to arthroscopic insertion and surgery” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other condition was submitted by the MEB. The Informal PEB adjudicated the right ankle pain as unfitting, rated 0%, 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 a MEB dismissal from the service as my injury and subsequent surgery made flying helicopters not possible. Since the original evaluation and discharge from the service, I have had another operation to correct damage from the initial injury and subsequent surgery. Following rehab, I have been dependent upon pain medication to manage pain. I have been unable to run and properly exercise as a result of the injury. Between the pain medication and existing pain and damage to my right ankle, I would remain unfit for military duty. In addition left ulnar nerve damage to left elbow from injury in military service in 1999 left fingers numb. VA evaluations in 2013 most current but records exist from date of injury.”


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 20050316
 VA* - (~2 Mos. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Right Ankle Pain… 5010 0% Right Ankle Surgery Residuals 5299-5271 10% 20050421
Right Foot Nerve Lesion … 8599-8521 10% 20050421
Other x 0 (Not In Scope)
 Other x 5
RATING: 0%
 RATING: 20%
* Derived from VA Rating Decision (VA RD ) dated 200 50810 (most proximate to date of separation [ DOS ] ) .


ANALYSIS SUMMARY:

Right Ankle and Foot Conditions. The CI sustained a severe right ankle sprain while running in January 2003. Pain persisted, and radiologic studies later confirmed a diagnosis of osteochondritis dissecans (OCD, damage to a piece of cartilage and underlying bone) in the area of the talar dome of the ankle. After arthroscopic surgical intervention in December 2003, the CI experienced surgical complications of nerve damage manifested by extensor weakness of the four lateral toes and numbness. These symptoms improved somewhat, but ongoing ankle pain worsened and led to medical evacuation from his deployment to Iraq. Imaging studies showed persistence of the OCD lesion; further surgery was considered but not performed.

At the MEB exam on 8 December 2004 (6 months prior to separation) the CI reported continued pain of the right ankle; although numbness in some fingers was reported, numbness or weakness of his foot was not. The commander’s statement on 15 December mentioned the history of ankle injury and pain, and the history of nerve damage. The limits of the profile were acknowledged, and some duty impairments such as mounting or dismounting aircraft and prolonged operation of flight pedals were specified.

The narrative summary (NARSUM) on 29 December 2004 (6 months prior to separation) noted a chief complaint of right ankle pain and loss of motion. The pain was present 75-100% of the time during waking hours, and interfered with physical activities and activities of daily living. Examination showed an antalgic gait due to right ankle pain. Decreased sensation of the dorsal aspect of the right foot at the lateral four toes (i.e. all toes except the great toe) was present, in addition to weakness of extension of those four toes. The examiner concluded that the ankle pain was medically unacceptable, but the right foot nerve lesion was medically acceptable.

At the VA Compensation and Pension exam on 21 April 2005 (2 months prior to separation), the CI complained of continued ankle pain. He planned to have additional surgery after separation. Examination showed a normal gait. An inability to extend toes two through five was noted; and those toes maintained a flexed position. Sensation was intact.

At a pre-operative evaluation on 17 October 2005 (4 months after separation) the CI complained of right ankle pain and also noted numbness and tingling of the distal foot. Examination showed ankle tenderness, “excellent motion” of the ankle, and decreased sensation in a poorly described location (likely distal foot and/or toes). Strength examination was reportedly normal. On 1 November 2005 (4 months after separation) the CI underwent additional arthroscopic and open surgical treatment of an OCD lesion of the right ankle. During the procedure, the superficial peroneal nerve was freed from scar tissue at the site of the previous arthroscopy. The 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 ~6 Mo s . Pre-Sep PT ~6 Mo s . Pre-Sep VA C&P ~2 Mo s . Pre-Sep
Dorsiflexion (20 Normal) “Relative f ull ” 8 “ Significant d ecrease ”
Plantar Flexion (45) “Relative f ull ” 35 Not Reported
Comment +Painful motion +Tenderness, painful motion
§4.71a Rating 0 % or 10% 10 % 10% or 20%

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the ankle at 0% under the 5010 code (post-traumatic arthritis), citing single joint involvement of arthritis as the rationale. The VA rated the ankle analogously to code 5271 (ankle; limited motion) at 10% for moderate limitation of ankle motion. After a temporary increase to 100% following the after separation surgery, the VA maintained a 10% rating. Board members agreed that the evidence at hand justified a 10% rating for “moderate” limitation of ankle motion, or IAW VASRD §4.40 (functional loss) or §4.59 (painful motion). The Board concluded that there was no pathway under other ankle codes to a rating higher than 10%.

The Board also deliberated if additional disability was justified for peripheral nerve impairment, which the PEB referred to as “non-ratable decreased sensation on the dorsal aspect and lateral four toes.” The VA rated this separately at 10% under an analogous code 8521 (paralysis of external popliteal nerve). The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting. The arthroscopy led to nerve compromise manifested by loss of sensation and extensor weakness in toes two through five. The Board considered that all profiles identified only ankle pain as the limiting medical condition. The commander’s statement reported a history of nerve impairment, but on the MEB physical the CI did not document issues related to such impairment. Finally, although the MEB form listed the right foot nerve lesion as medically unacceptable, the NARSUM orthopedist deemed the condition was medically acceptable. The Board majority concluded there is insufficient evidence in this case of functional impairment attributable to foot neuropathy, and therefore concluded that additional disability was not justified on this basis. 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 right ankle 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 condition, the Board unanimously recommends a disability rating of 10%, coded 5010 IAW VASRD §4.71a. In the matter of the right foot nerve condition, the Board by a majority vote agrees that it cannot recommend it for additional disability rating. 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:

CONDITION VASRD CODE RATING
Right Ankle Pain 5010 10%
COMBINED 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131205, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record



XXXXXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXXXXX AR20150014181 (PD201400149)


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 to 10% 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                                                  XXXXXXXXXXXXXXXXXXXX
                                                       Deputy Assistant Secretary of the Army
                                                      (Review Boards)








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