RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01003
BRANCH OF SERVICE:  Army 	BOARD DATE:  20141112
SEPARATION DATE:  20080615

SUMMARY OF CASE:  The evidence of record indicates this covered individual (CI) was an active duty SPC/E-4 (92W/Water Treatment Specialist) medically separated for right ankle pain.  This condition could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty or physical fitness standards, so he was issued an L3 profile and referred for a Medical Evaluation Board (MEB).  The ankle condition, characterized as “chronic right ankle pain/right ankle lateral instability/peroneal tendon instability” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “chronic right ankle pain following multiple sprain” as unfitting, rated at 0%, referencing the US Army Physical Disability Agency (USAPDA) pain policy.  An administrative correction was made to the IPEB proceedings upholding the VARSD code 5099-5003, but changing the rating to 10% from 0%, thus compliant with of National Defense Authorization Act, Fiscal Year 2008 guidance.  The CI made no appeals and was medically separated.

CI CONTENTION:  “My right ankle has not gotten any better.  It still sprains (roll to the outside) and snaps back into position.  Constantly have limp due to pain and arthritis in the right ankle.”   

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 those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting right ankle condition is addressed below; no additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application or otherwise outside the Board’s defined scope of review remain eligible for future consideration by the Board for Correction of Military Records. 

RATING COMPARISON:  

Service PDA Admin Corr – Dated 20080317	VA - (2 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Ankle Pain…	5099-5003	10%	S/P R Ankle Reconstruction of Torn Ligament	5271-5010	0%	20080923	
			Surgical Scar, Right Ankle	7805	0%	20080923	
Other x 0	Other x 0		
Rating:  10%	Combined:  0%	
*Derived from VA Rating Decision (VARD) dated 20090217

ANALYSIS SUMMARY:  

Right Ankle Condition.  The service treatment records indicated the CI twisted his right ankle in July 2006 while stepping off a curb at home; also noted CI re-injured the right ankle on two separate occasions within a month of the initial injury.  The CI’s injury was initially diagnosed as right ankle sprain and he did experience improvement with conservative treatment but after re-injuring the ankle, CI’s pain persisted without notice improvement.  A diagnostic magnetic resonance imaging (MRI) study obtained on 5 October 2006 revealed soft tissue edema (swelling), ankle joint effusion (fluids) and signs of tenosynovitis (inflammation of tendon) without underlying tendon pathology and intact ligaments.  In October 2006, the CI was diagnosed with tenosynovitis and was assessed to have joint instability [of] ankle/foot and developed deformity of left and right big toe.  He had bilateral ankle full range-of-motion (ROM).  During a primary care appointment on 16 November 2007, the CI reported his ankle was unstable, that it frequently rolled and had continuous pain.  Physical examination noted edema (swelling) of the ankle, pain and tenderness of the supporting ligaments; however, did have full ROM.  Radiographs images were unremarkable.  However, repeat MRI demonstrated chronic complete ligament tear (anterior talofibular) and split tear of the tendon (peroneus brevis).  The CI was recommended for and underwent, a right ankle debridement and repair/reconstruction surgery, without complication in August 2007.  The wound demonstrated good healing; however, after removal of the cast in October 2007, the CI presented to the emergency room (ER) after noticing fluid drainage from the surgical scar.  Physical examination noted a well-healed scar warm to touch and tender, but without induration (hardness of tissues).  The CI underwent a wound irrigation and debridement and was discharged with antibiotics.

The CI continued to experience pain, therefore he was issued a permanent P3 profile restricting running, road marching, rucksacking or constructing an individual fighting position and was referred for MEB.  The commander’s statement dated 27 November 2007 noted the CI’s surgical wound had not completely closed; [the CI] was still on crutches and had continued to wear the prescribed boot. 

Orthopedic MEB addendum dated 25 October 2007 (8 months prior to separation), recorded dorsiflexion of 10 degrees, inversion was 10 degrees compared to 20 degrees on the left, and eversion was 5 degrees bilaterally.  Drawer test was negative (test of anterior cruciate ligament stability) and strength was normal.  The CI could heel/toe walk, but his gait was antalgic (avoidance of putting full weight on leg due to pain) on the right side.  There was tenderness over the peroneal tendons and over the anterolateral ankle joint.  The physician diagnosed right ankle instability status post-surgical procedure and peroneal tendinopathy.  

The MEB NARSUM evaluation was dated 29 November 2007 (approximately 7 months prior to separation).  The physician recorded the CI was hospitalized for 3 days secondary to wound infection (this is not consistent with ER records; ER indicated discharged to home with outpatient follow-up).  Physical examination of the right ankle noted minimal edema (swelling) and a healed surgical scar.  There was no discharge from the wound and it was not opened.  Tenderness was noted over the right lateral malleolus and the ankle was stable.  ROM recorded by physical therapy evaluation dated 4 December 2007, revealed dorsiflexion average of 0 degrees (20 degrees) with three trials and plantar flexion to 45 degrees (45 degrees) on three trials.  Pain was recorded with motion.

At the VA Compensation and Pension (C&P) evaluation dated 23 September 2008, (approximately 3 months after separation), physical examination noted the scar over the right ankle was well healed without any complications or disfigurement.  There was no evidence of inflammation of the right ankle and no muscle atrophy.  Gait was normal; neurovascular and neurological examinations were normal.  ROM of the right ankle recorded dorsiflexion of 20 degrees, plantar flexion at 45 degrees without pain and no evidence of weakness, fatigue or incoordination with repetitive movement of the right ankle.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB initially rated 0%, but an administrative correction increased the rating of the right ankle condition to 10% coded analogously 5099-5003 (painful motion).  The VA assigned a rating of 0% coded 5271-5010 (increased to 10% 2 years later).  The Board noted the higher rating of 20% under the 5003 code was not supported by the evidence (involvement of 2 or more joints, with incapacitating exacerbations).  The higher rating of 20% under code 5271 requires evidence of marked limitation of the ankle and code 5270 requires evidence of ankylosis (immobility and consolidation of joint), also not supported by the evidence of record, although the ROM recorded 6 months prior to separation, recorded dorsiflexion of 0 degrees.  The Board considered the ROM recorded in the examination most proximal to separation had the greatest probative value (C&P examination). There was no evidence of marked ankle disability to support the use code 5262 (tibia and fibula, impairment).  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 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 surmised from the record or PEB ruling in this case that no prerogatives outside the VASRD were exercised.  In the matter of the chronic right ankle pain 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 no recharacterization of the disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140222, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			

SAMR-RB									

MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXX AR20150006612 (PD201401003)

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:

Encl						     
						         
CF: 
(  ) DoD PDBR
(  ) DVA