RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-00868
BRANCH OF SERVICE:  Army	 SEPARATION DATE:  20080917

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Light Wheel Vehicle Mechanic) medically separated for left ankle pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  “Left ankle pain status post resection of talocalcanel coalition” [sic] was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded 2 other medically acceptable conditions (obesity and nicotine dependence) for PEB adjudication.  The Informal PEB adjudicated “limitation of motion, left ankle” as unfitting, rated 10%, citing application of Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.  

CI CONTENTION:  His condition continues to worsen and negatively impacts his daily activities.  Additionally, he was not evaluated for his PTSD, lower back or right shoulder conditions.  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 20080606	VA* - (~3 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Limited Motion, Left Ankle	5271	10%	Residuals, Excision of Subtalar Cyst, Left Ankle	5271	20%	20081208	
Other MEB/PEB Conditions x 2 (Not In Scope)	Other x 7	
RATING:  10%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20090320 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Limited Motion, Left Ankle.  The CI was evaluated in orthopedics on 4 August 2006 for a year-long history of left ankle pain.  It was aggravated by activity, but the CI denied a history of trauma.  The examination was remarkable for tenderness over part of one of the ankle bones (sustentaculum tali).  The gait was normal and the ankle stable.  X-rays were unremarkable.  An MRI of the ankle was read as normal by the radiologist, but thought to show a cyst and a soft tissue coalition (a fibrous bridge) by the orthopedic surgeon.  He was also noted to have flat feet (pes planus) and given orthotics.  He was also treated with physical therapy (PT), duty restrictions, and medications, but his symptoms persisted.  He underwent surgery on 6 July 2007.  Following surgery, he was casted for several weeks and then placed partial weight bearing during rehabilitation.  Apparently, the profile was not followed completely by the commander and the CI began weight bearing earlier than directed by the treating orthopedic surgeon.  It was also noted that the CI was overweight and continued to smoke cigarettes, both of which can hinder and delay full healing.  On 2 August 2007, the incision was noted to be healing and the range-of-motion (ROM) was good.  He continued rehabilitation, but rolled his ankle several times during the recovery period.  On 5 September 2007, 2 months after surgery, the ROM was limited in both dorsi-flexion (toes up) and plantar flexion (toes down) at 5 and 20 degrees, respectively.  Three weeks later, he showed improvement in plantar flexion, but his gait remained abnormal secondary to pain (antalgic).  In orthopedics on 16 October 2007, he was unable to put his full weight on the left foot.  His ROM was noted to be pain free.  One week later in PT, almost 4 months after surgery, dorsiflexion was limited to 0 degrees, but plantar flexion was near normal at 40 degrees.  On 8 November 2007, X-rays showed good bony alignment, but a slight haziness (of the soft tissue) on one view.  A weight bearing film showed a possible fracture of a different bone in the ankle.  The narrative summary (NARSUM) was dated 19 December 2007, 9 months prior to separation and 5 months after surgery.  The CI still used a brace and cane as needed for support.  Dorsiflexion and plantar flexion were reduced and painful as charted below.  However the unaffected right ankle was limited to 10 degrees dorsi-flexion with full plantar flexion (5-10 degrees greater than the VA normal value of 45 degrees).  

At the VA Compensation and Pension (C&P) examination performed on 8 December 2008, 3 months after separation, the CI reported that he could walk 15-20 minutes before he developed pain and that he was limited to carrying 35 pounds.  He used a brace, but denied incapacitation.  He was unemployed and receiving social security disability for his ankle, back, and shoulder.  On examination, he had a slight antalgic gait, but did not use an assistive device.  The ROM was reduced bilaterally with dorsi-flexion 5 degrees left and 15 degrees right.  Plantar flexion was 40 degrees left and right.  He did not meet the VA normal values of 20 degrees dorsiflexion and 45 degrees plantar flexion on either side.  An x-ray accomplished 2 months previously was noted to show some spurring (a sign of degeneration), but the previously cited hairline fracture was not apparent.  Three weeks later, the CI was seen in primary care.  He was noted to have full ROM albeit with pain.  The goniometric 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.  

Left Ankle ROM
(Degrees)	PT ~11 Mo. Pre-Sep	PT ~10 Mo. Pre-Sep	VA C&P ~3 Mo. Post-Sep	
Dorsiflexion (20 Normal)	0/0/0	0/0/0	5	
Plantar Flexion (45)	40/40/35	35/40/40	40	
Comment	3 months post op; right ankle 10 degrees dorsiflexion	Painful motion; 4 months post op; right ankle 10 degrees dorsiflexion	Painful motion; R ankle 15 degrees dorsiflexion and 40 degrees plantar flexion	
§4.71a Rating	10%	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB both coded the left ankle 5271, limitation of motion of the ankle, but rated it 10% and 20%, respectively, for moderate and marked limitation.  The Board noted that the dorsiflexion was typically measured at 0 or 5 degrees which supports a 20% rating.  However, the dorsiflexion of the unaffected right ankle was also limited to 10-15 degrees of motion, less than the VA normal value of 20 degrees.  The Board considered the evidence.  Although the CI showed a loss of dorsiflexion to 0 degrees, the loss was 10 degrees compared to the non-affected side.  A post-separation primary care note documented full ROM.  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 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 20140216, 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 XXXXXXXXXXXXXXXXXXXXXXXXX, AR20160002400 (PD201400868)

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