RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2013-01631
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040720

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard member ordered to active duty E-1 (Basic Trainee) medically separated for a right ankle condition.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards. She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The ankle condition, characterized as “right ankle pain s/p medial malleolus fracture,” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The Informal PEB adjudicated “right ankle pain s/p medial malleolus fracture” as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “R foot is not strong, fall a lot and it hurts a lot.  Balancing is a problem.  1st review was pregnant in 2007”

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:

Service IPEB – Dated 20040512	VA - (2 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Ankle Pain	5099-5003	10%	S/P ORIF of FX of Medial Malleolus, R Ankle	5271	20%	20040910	
Other x 0 (Not in Scope)	Other x 0		
Combined:  10%	Combined:  20	
Derived from VA Rating Decision (VARD) dated 20041213 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Right Ankle Pain.  The narrative summary (NARSUM) notes the CI fractured her right ankle in basic training on 30 October 2003 and underwent surgery for open reduction and internal fixation the next day.  Following the surgery the CI continued with pain with weight bearing activities.  Ankle X-rays noted a healed fracture with two screws in place in good position, without degenerative joint changes.  The NARSUM examiner noted that the CI would likely improve, but could not predict whether she would be able to run in the future without pain.

At the MEB examination on 4 March 2004, 5 months prior to separation, the CI reported ankle pain.  The MEB physical exam noted a mild antalgic gait favoring the right.  Range-of-motion (ROM) was dorsiflexion of 10 degrees (normal 20) and plantar flexion of 30 degrees (normal 45) and there was no evidence of instability.

At the VA Compensation and Pension (C&P) examination on 10 September 2004, 2 months after separation, the CI reported right ankle pain, stiffness, and daily pain with weight bearing activities, without flare-ups, or dislocations.  The CI reported that her daily activities were limited by ankle pain, especially driving or prolonged walking or standing.  Ankle ROM was noted as dorsiflexion (DF) of 0 degrees and plantar fasciitis (PF) of 45 degrees without pain, and there was no additional decreased ROM after multiple ROM repetitions.  There was no swelling, tenderness, instability, or guarding of movement.  The examiner noted “there was essentially no pain on movement of the hips or ankles, except in repetitive movement of the right hip, there was a very low grade pain complaint of 1.  This was basically complaint by the Veteran.  The veteran was able to complete the goal of repetitions on both the ankles and the hips.”  At a VA orthopedic outpatient treatment visit on 11 March 2005, 8 months after separation, the CI reported ankle pain at the site of the fracture without any other problems including “twisting or giving way.”  The exam noted the full ankle ROM with normal exam except for TTP of the site of the fracture, thought to be related to the retained hardware and surgery to remove the hardware was scheduled.  Right ankle X-rays on 18 July 2005 noted soft tissue swelling with early degenerative joint changes and noted the hardware had been removed.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right ankle condition 10%, coded 5099-5003 for moderate and occasional pain.  The VA rated the ankle condition 20%, coded 5271 (limited ankle motion).  The Board noted the discrepancy between the ankle ROM noted at the MEB and C&P exams and deliberated how to reconcile them.  The C&P exam of the ankle was otherwise normal and provided no explanation of the 0 degrees DF finding, leading the Board to question if it was a typographical or dictation error.  There was no apparent way to account for the loss of DF, since there was no pain of the ankle with ROM, even after several repetitions, and the CI still had the hardware in place when full ROM was noted 6 months later (hardware movement could limit joint ROM).  The Board considered that if the CI could not DF her foot, essential for ambulation, she would have greater gait disturbance than the mild antalgic gait noted at the MEB exam (no mention of abnormal gait at the C&P exam) and possibly difficulties as well, such as with stairs.  The C&P examiner indicated that the CI’s main issue that day was related to the hip as opposed to the ankle.  The Board agreed that the totality of the evidence supports that the C&P DF value was not consistent with all the other information in record at the time of separation.  The Board therefore provided the greater probative weight to ROM at the MEB exam and the VA orthopedic evaluation 8 months after separation.  Rating criteria for limited ankle motion coded as 5271 are subjective and described as moderate for 10% and marked for 20% and members agreed that the disability due to the ankle limited motion was best described as moderate.  Thus, the Board concluded that there was insufficient evidence to recommend a rating greater than 10% based on ROM and there was no evidence of malunion or ankylosis of the foot or ankle to provide for higher rating.  The Board noted that the PEB’s reliance on the USAPDA pain policy for rating was not detrimental to arriving at the highest rating and that coding with 5003 criteria and rating 10% is VASRD compliant for degenerative changes of one joint on X-ray with limited motion.  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 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 condition and IAW VASRD §4.71a, 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 re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130925, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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, AR20150018462 (PD201301631)

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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA