RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX						             CASE:  PD-2013-01926
BRANCH OF SERVICE:  AIR FORCE  	SEPARATION DATE:  20050222

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Aircraft Armament Systems Journeyman) medically separated for a left ankle condition.  The left ankle condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty (AFS).  He was issued a temporary L4 profile and referred for a Medical Evaluation Board (MEB).  “Chronic left ankle pain” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “chronic left ankle pain” as unfitting, rated 10%, citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.  

CI CONTENTION:  His condition continues to negatively impact his activities.  His complete submission is at Exhibit A.

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 20041201	VA* - (~13 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Ankle Pain	5271	10%	Residuals of Fracture of the Left Ankle, Status Post
Arthroscopic Surgery (claimed as Chronic Left Ankle Pain)	5271	20%	20060315	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 7 	
RATING:  10%	COMBINED RATING:  70%	
*Derived from VA Rating Decision (VARD) dated 20060330 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Left Ankle Condition.  The Service treatment record (STR) documents that the CI initially sustained a left ankle inversion injury during a pick-up basketball game in 2001.  A left ankle X-ray showed degenerative changes in the tarsal region and an os subfibulare (small accessory bone at the distal tip of the fibula) or chronic avulsion (forcible separation/detachment of a bodily structure/part) injury.  A subsequent left ankle X-ray showed avulsion fractures around the distal fibula and lateral talus.  The left ankle CT showed ankle/hindfoot degenerative changes and an inferior lateral malleolus (ankle rounded bony prominence) avulsion chip fracture.  At the orthopedic surgery preoperative exam, the CI complained of chronic anterior left ankle pain.  Residual pain and recurrent (six or seven) ankle sprains prevented him from doing activities.  The diagnosis listed left ankle post-traumatic pain.  Having failed conservative therapy (activity modification, medications, splints, air cast and physical therapy [PT]), the CI elected to have surgical intervention.  The CI underwent diagnostic operative arthroscopy.  The arthroscopy revealed hypertrophic (tissue/organ enlargement from size increase of constituent cells) soft tissue in the lateral medial gutter and synovitis (synovial membrane inflammation).  Debridement was performed on the affected tissues.  At the orthopedic surgery follow-up, the CI had no real complaints as his pain was “just about gone.”  The left ankle exam revealed well healed portals, no swelling and excellent strength.  The range-of-motion (ROM) was plantar flexion of 30 (normal 0-45) degrees and dorsiflexion of just past neutral (normal 0-20).  At a PT encounter the CI reported no complaints of pain with activity or at rest.  He reported no problems with exercise but might get up to 3/10 pain with prolonged weight bearing or ambulation.  The physical exam revealed no gait abnormalities and the CI was able to perform a full squat.  Left ankle active ROM was plantar flexion of 45 degrees and dorsiflexion of 5 degrees.  Left ankle strength was 5/5 for plantar flexion, 5/5 for dorsiflexion, 4+/5 for inversion, and 4+/5 for eversion.  The narrative summary (NARSUM), 8 months before separation, recounted the history and interventions.  The CI complained that his left ankle was intermittently extremely painful, and that he had no pain-free days.  Symptoms were exacerbated by weather changes and he experienced mixed effectiveness with medication (Naprosyn).  Pain restricted his ability to run, jump, and perform his primary duties, etc.  The left ankle exam revealed well healed surgical scars and no edema (swelling from excess tissue fluid).  There was tenderness over the distal tibia and fibula, lateral malleolus, and talonavicular areas.  The ROM was documented as “The left ankle does have passive full ROM, not without discomfort.  Discomfort is appreciated at the extremes of plantar flexion and dorsiflexion.”  The diagnosis listed persistent ankle pain.  At an orthopedic surgery follow-up, 6 months before separation, the CI stated “… his ankle really hasn't had any changes in it over the last 10 months.”  The left ankle exam revealed well healed portals and there was no instability.  The ROM was plantar flexion of 35 degrees, dorsiflexion of 5 degrees.  The X-rays showed no significant arthritic changes.  The surgeon opined that the CI would have some pain with the pounding of running but he would be able to do non-impact aerobic activity without any restriction.  A left ankle MRI showed talonavicular and tarsal degenerative arthritis and a multiloculated cyst (1.5 x 1.5 cm.) posterior to the flexor digitorum longus.  At an orthopedic surgery encounter, 11 months after separation, the CI complained of anteromedial, posteromedial and posterolateral left ankle pain.  He reported difficulty with walking without shoes and going up stairs.  Pain was exacerbated by exercise and he had associated stiffness.  The left ankle exam revealed a cystic mass over the flexor tendons posterior to the medial malleolus.  Tendons (Achilles, peroneals, and posterior tibials) and sensation were intact.  There was no evidence of lateral instability and the drawer test (assesses anterior talofibular ligament) was negative.  The ROM was plantar flexion of 45 degrees and dorsiflexion of 0 degrees.  There was pain with forced dorsiflexion.  The MRI showed a cystic mass in the sheath of the flexor hallucis.  The impression listed left ankle pain, etiology unclear.  The compensation and pension (C&P) exam, 13 months after separation, recounted the history and interventions.  The CI denied symptom improvement following the arthroscopic surgery.  He complained of constant 7/10 left ankle pain with associated swelling and stiffness.  Pain was exacerbated by standing, excess walking, exercise, and prolonged sitting and relieved by medications (etodolac [Lodine]), ice, and heat.  The physical exam documented the CI walked with a cane and had a significant limp (worse barefoot).  He was unable to toe walk or heel walk.  The left ankle exam revealed mild puffiness over the lateral malleolar area.  There was tenderness over the lateral and medial malleolar areas.  The ROM was plantar flexion of 40 degrees and dorsiflexion of 5-10 degrees.  There was pain with forced dorsiflexion.  Joint function was additionally limited by pain, fatigue, and weakness secondary to repetitive use.  The neurological exam was essentially normal.  The diagnosis listed chronic left ankle pain, status post injury, fracture, and arthroscopy.  The examiner listed chronic functional impairment as moderate to moderately severe and moderately severe to severe with repetitive use and flare-ups.

The Board directed its attention to its rating recommendation based on the above evidence.  The Informal PEB rated the left ankle condition 10%, coded 5271 (ankle, limited motion of:  moderate).  The PEB cited chronic left ankle pain.  The VA rating decision, citing the C&P exam 13 months after separation, rated the left ankle condition 20%, coded 5271 (ankle, limited motion of:  marked).  The VARD cited ankle fracture, arthroscopy, chronic pain, tenderness, swelling, a significant limp, using a cane, ROM limited by pain, repetitive ROM limited by pain, fatigue, and weakness, moderate to moderately severe functional impairment, X-ray findings,  and MRI findings.  Board members agreed that the ankle limitations in motion (5271) in the proximate exams more closely approximated the moderate (10%) than the marked (20%) rating.  There was no deformity for consideration under 5270 (ankle, ankylosis), 5272 (subastragalar or tarsal joint, ankylosis of), or 5273 (os calcis or astragalus, malunion of).  There was no excision of the astragalus for consideration under 5274 (astragalectomy).  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 adjudication for the left 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 left 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 20131024, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX
XXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2013-01926.

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 appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Attachment:
Record of Proceedings