RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01133
BRANCH OF SERVICE:  Army 	 Separation Date:  20080502

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E-1 (Basic Trainee) medically separated for left ankle pain.  The condition could not be adequately rehabilitated to meet the physical requirements of basic training.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic left ankle pain secondary to residual scarring from previous open reduction internal fixation” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated the left ankle pain as unfitting, rated 10%, with application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals, and was medically separated.  

CI CONTENTION:  “Her condition continues to worsen and negatively impact her daily activities.  Her 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:  

Service IPEB – Dated 20080312	VA* - (~5 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pain in Area of Prior Open Reduction Internal Fixation for Ankle Fracture…	5099-5010	10%	Residuals, Fracture, Left Ankle	5010-5271	10%	20081002	
			Scar, Residuals Left Ankle Fracture	7804	10%	20081002	
Other x 0 (Not in Scope)	Other x 0	
RATING:  10%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20081110 (most proximate to date of separation (DOS))

ANALYSIS SUMMARY:  

Pain [Left] ORIF Ankle Fracture Condition.  The CI sustained a left ankle (medial malleolus) fracture during Basic Training on 12 July 2007.  She underwent an ORIF with surgical band wire and a surgical screw on 17 July 2007.  The CI was treated by physical therapy (PT) and required medication for pain control.  The surgeon noted that the CI had some pain from the hardware prominence over the surgical site.  She underwent a second surgery for hardware removal on 16 October 2007.  The MEB Narrative Summary (NARSUM) exam approximately 3 months prior to separation documented that since the surgery for hardware removal the CI reported continuous throbbing, aching pain which was 100% of the day, around the scar over the left ankle.  She further reported that the pain was only partially relieved with medications and PT.  She underwent a prolonged course of PT which included iontophoresis and scar desensitization which failed.  The examiner noted that the CI had full ROM and there was no painful motion.  The CI had functional impairments of an inability to run, jump, march and an inability to wear military boots due to hyperesthesia over the scar.  The CI was given a permanent L3 profile for “chronic left ankle pain due to residual scarring from surgery.”  The commander’s statement noted that the CI had not lost her motivation due to the ankle injury; however, despite numerous treatments; the CI had not adequately recovered to perform her MOS.  The MEB NARSUM physical exam findings are summarized in the chart below.  The PT approximately three months prior to separation performed a range-of-motion (ROM) evaluation for the MEB.  The PT physical exam findings are summarized in the chart below.  

The VA Compensation and Pension (C&P) exam approximately 5 months after separation documented that the CI had hyperesthesia over the scar area and was unable to wear a brace due to this pain and hyperesthesia.  She was unable to work as a restaurant manager due to the prolonged standing on her feet.  A left ankle X-ray was normal.  The VA C&P physical exam findings are summarized in the chart below.  

There were 3 exams in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.  

Left Ankle ROM
(Degrees)	NARSUM ~3 Mo. Pre-Sep	PT ~3 Mo. Pre-Sep	VA C&P ~5 Mo. Post-Sep	
Dorsiflexion (20 Normal)	20	10 (11/11/10)	10	
Plantar Flexion (45)	45	30 (33/35/30)	40	
Comment:  Surgery ~7 Mo. Pre-Sep	No painful motion; scar 2 ½ inches over medial malleolus, hyper esthetic to even superficial palpation; normal gait	Painful motion; DeLuca	Hypersensitive hypertrophic scar over medial malleolus-hypersensitive to touch over 3 cm area; mild limp	
§4.71a Rating	0% (PEB 10%)	10% (PEB 10%)	10%	
§4.118 (7804-Scar)	10%	Not evaluated	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the left ankle condition analogous to 5010 (Arthritis, due to trauma, substantiated by X-ray findings) and rated at 10%.  The VA coded Residuals, Fracture, Left Ankle condition as 5010 with 5271 (Ankle, limited motion of) and rated at 10% (“moderate”), and also rated the left ankle surgical scar at 10% coded 7804 (scars, superficial, painful on examination).  

At the time of the MEB exam, the CI had full ROM; however, the PT exam documented pain-limited ROM and the VA exam documented limited (compensable) ankle ROM.  The Board agreed that the PT exam was closest to the date of separation, more precise and thorough for ROM evaluation, included consideration of repetition and used a goniometer and therefore had a higher probative value for rating based on ROMs.  Rating and coding the ankle at 10% analogous to 5010 or to 5271 was reasonable given the CI’s history and functional loss.  There was no ankylosis, instability or more limited ROM for any limitation of motion rating higher than 10%.  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 pain condition.  

The Board then deliberated if the scar were separately unfitting and ratable.  The Board’s threshold for adding unfitting associated/residual conditions for rating is reasonably unfit as the condition was combined in the PEB unfit condition, and remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The Board deliberated the probative values of the exams and the potential overlap between painful/limited ankle motion (ROM) and the painful scar to determine if the scar was separately unfitting and ratable, or if dual coding would be inappropriate pyramiding (IAW §4.14 - avoidance of pyramiding).  The painful scar was a major aspect of the CI’s disability picture and the bulk of exams documented painful ankle motion (IAW VASRD §4.59).  The scar had disability elements that went beyond any limited or painful motion of the ankle and it was not possible to delineate if the painful ankle motion was due to only the scar, or from other residuals of the repaired ankle fracture.  The MEB examiner specifically noted that the CI was unable to wear military boots due to hyperesthesia over the ankle scar (equivalent to painful scar).  The CI was given a permanent L3 profile for chronic left ankle pain due to residual scarring from surgery.  The VA examiner documented that the CI had a painful scar.  After due deliberation in consideration of the evidence, the Board concluded that there was sufficient evidence to recommend that the painful scar (residual of left ankle fracture) condition be added as an additional unfitting condition.  The Board recommends a 10% rating for the painful scar coded 7804.  

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 “Pain in Area of Prior Left Ankle ORIF for Ankle Fracture” including “Residual Scarring” from the MEB diagnosis, and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB ankle adjudication; however, the Board unanimously recommends an additionally unfitting painful scar condition with a disability rating of 10%, coded 7804 IAW VASRD §4.118.  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 her prior medical separation:  

UNFITTING CONDITION	VASRD CODE	RATING	
Pain in Area of Prior Left Ankle ORIF for Ankle Fracture … (… Residual Scarring)	Left Ankle	5099-5010	10%	
	Painful Scar	7804	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140219 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 XXXXXXXXXXXXXXXXXX, AR20160003621 (PD201401133)

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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization 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:

CF: 
(  ) DoD PDBR
(  ) DVA