RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX			CASE:  PD-2014-01401
BRANCH OF SERVICE:  Army	 SEPARATION DATE:  20090302

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E4, Unit Supply Specialist, medically separated for “right talus fracture with painful motion” and “painful linear superficial 5cm scar over the medial malleolus of the right ankle,” with a combined disability rating of 20%.

CI CONTENTION:  “I am in me in constant right ankle pain limited range of motion.  This injury limits my ability to exercise, run, do prolonged activity with my daughter, or drive.  I have back pain as a result of my ankle injury.”  His complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 Veterans Affairs Schedule for Rating Disabilities (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 PEB - 20090113	VARD- 20080320	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Talus Fracture	5271	10%	Residuals, Status-Post Surgery, Lucency Fracture at the Base of Trigonum, Right ankle	5271	10%	20071008	
Painful Linear Scar…Right Ankle	7805	10%	Surgical Scar, Right Ankle	7804	10%	20071008	
Combined RATING:  20%	COMBINED RATING FOR ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:

Right Ankle (Painful Scar).  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right ankle condition began in February 2006 when she stepped off a curb awkwardly during a training exercise and hyper-dorsiflexed her right ankle.  Radiographic studies showed a right posterior tendon tear and a nondisplaced right talar (ankle bone) fracture, while an orthopedic surgeon also noted a dorsal chip fracture of the tarsal navicular.  The CI underwent a right posterior tibial tendon exploration with debridement of inflammatory changes of the tendon sheath and a primary repair on 8 June 2006.  Postoperatively, the CI used a walker boot and bore weight as tolerated.  At 2 months postoperatively range of motion (ROM) was dorsiflexion was 0 degrees (20 normal) and plantar flexion was 30 (45 normal) and increased to 10 degrees dorsiflexion and 40 degrees plantar flexion at 3 months postoperatively.  Scar tenderness to palpation was present and there was tenderness to light touch.  Despite treatment by physical therapy, the CI continued to have constant right ankle pain.  At an examination on 19 September 2006 there was swelling, tenderness and allodynia (pain from a non-painful stimulation such as light touch) and hyperpathia (exaggerated level of pain).  ROMs were normal.  The examiner opined the CI definitely had more pain than could be explained objectively and that would be consistent with a complex regional pain syndrome and a probable os trigonum syndrome (pain in the posterior ankle and reduced plantar flexion caused by “the nutcracker phenomenon,” when the accessory bone becomes wedged between the tibia, talus and calcaneus).  A bone scan revealed no increase activity in the region of the right ankle, but there was mild to moderate increased activity noted in the region of the midfoot/forefoot articulations on the right.  Approximately once a month the CI had an inversion type of buckling of the right ankle, which was treated with a lace-up brace to prevent an ankle sprain and Ultram (Tramadol, an opioid-like narcotic) for pain relief.  X-rays of the right ankle in October 2007 were normal without an evidence of fracture or other structural abnormalities.

A permanent L3 profile was issued on 2 March 2007 for symptomatic right ankle pain with limitations of all physical fitness testing and all functional military activities except wearing a protective mask and all chemical defense equipment.  The commander’s performance statement dated 20 May 2007 noted the MOS/Medical Retention Board’s determination that the CI’s permanent profile prohibited retraining and reclassification and her ability to satisfactorily perform her military occupational specialty (MOS).

The CI’s ankle condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty and she was referred for an MEB.  At the MEB examination dated 8 October 2008 the CI reported on DD Form 2807-1, a right ankle fracture and repair of the right tibial tendon and that she used a brace on the right ankle.  The medical examiner annotated the right ankle dorsiflexion 8 degrees and plantar flexion 31 degrees with tenderness to palpation.  The examiner was unable to perform the “drawers” tests (to determine laxity) secondary to pain, however, muscle strength of the lower extremities was normal.

At the MEB NARUM examination dated 14 October 2008, 5 months prior to separation, the CI had a right antalgic gait.  There was no swelling, but a 5cm surgical scar was noted along the right medial malleolar area, which was exquisitely tender to palpation.  ROM measurements, which were limited by pain and were the same as noted during the MEB examination above.  Right ankle anterior and posterior drawer tests (for laxity) could not be performed due to exquisite pain.  The NARSUM diagnosed chronic right ankle pain and instability.  The commander in a memorandum for the record dated 4 December 2008 noted the CI’s medical condition prevented her from being deployed; however, her skills as a Human Resource Specialist could be utilized in-garrison.

At the VA Compensation and Pension (C&P) examination on 8 October 2007, performed 17 months before separation, the CI reported right ankle weakness, stiffness, swelling, giving way, lack of endurance and a constant ripping that traveled up her inner calf or knee.  The pain increased with physical activity and was helped by Tramadol and Percocet.  Her pain prevented driving with her right foot, running, jumping or squatting, and difficulty with prolonged walking, standing, climbing up and down stairs and lifting.  On examination there was weakness and tenderness without edema or redness, with an abnormal gait.  ROM was dorsiflexion 10 degrees and plantar flexion 25 with pain, fatigue, weakness, lack of endurance and incoordination with an additional 5 degrees limitation of motion.  There were no signs of calluses, but there was some wearing out of the shoes.  X-rays of the right ankle showed no significant findings.  There was a scar on the medial aspect of the right ankle, which was crescent shaped and measured 5.5cm long by 0.3cm wide.  The scar was level with tenderness, disfigurement, hyperpigmentation and an abnormal texture and measured less than 6 square inches without any ulceration, adherence, instability, inflammation, edema, tissue loss, keloid or hypopigmentation.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating coded 5271 (ankle limited motion) and 10% rating coded 7805 (other scars).  The VA assigned a 10% rating coded 5271 and 10% rating coded 7804 (unstable or painful scar).  The Board first sought a route to a higher rating for the right ankle injury.  In the absence of ankylosis, malunion of the os calcis (heel bone) or astragalus (talus) with a marked deformity, or having undergone an astragalectomy (removal of the talus bone, the Board was unable to find a route to a higher rating.  The Board members then discussed whether ankle ROM limitation was more marked than moderate and noted dorsiflexion was approximately 40 percent of normal and plantar flexion was approximately 75 percent of normal at an examination most proximate to separation.  The Board then discussed whether a route to a higher rating was possible for the scar of the right ankle.  Code 7805 used by the PEB is rated using code 7804.  There was only one scar that was painful postoperatively, which was rated 10%.  An additional 10% rating requires the scar be painful and unstable, while a higher rating at 20% requires there be three or four scars that are unstable or painful.  Finally, the scar was surgically induced, was less than six square inches, and was neither deep nor nonlinear.  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 status post healed fracture condition or the right ankle painful scar condition.

BOARD FINDINGS:  In the matter of the right ankle status post healed fracture condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the right ankle painful scar condition and IAW VASRD §4.118, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.

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 20140219, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB 

JUL 2 8 2016

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, AR20160007284 (PD201401401)

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 1 O, 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