RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01490
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150407
SEPARATION DATE:  20091226

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Aircraft Loadmaster Journeyman) medically separated for chronic right ankle pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty or satisfy physical fitness standards.  He was issued a duty and mobility restriction and referred for a Medical Evaluation Board (MEB).  The “chronic right ankle pain due to post-traumatic osteoarthritis” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated “chronic right ankle pain…” as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI appealed to the Formal PEB (FPEB), which affirmed the PEB finding and rating but changed the VASRD code from 5003 to 5271 and was medically separated.

CI CONTENTION:  “I believe that an increase in the benefit is appropriate because since being medically separated from the Air Force on 12/26/09 my alinements [sic] that caused my medical separation have worsened.  The major problem I had was with my right ankle.  During the time in the service I received two surgeries in attempts to repair this ankle, but all were unsuccessful resulting in a final suggestion by the Base Doctors that I have ankled [sic] fused.  At the time being a 29 year old father of three I choose to live with the pain, which becomes extreme at times, rather than have a surgery done on my ankle that would exponentially limit my range of motion more than it already was at that point.  Over the past 4 and half years since separating my ankle pain has limited my ability to participate in everyday activities such as walking, exercising, driving, even playing with my children, and many more activities.  I am experiencing pain in my back, knees, neck, and shoulders due to manner in which my body is trying to compensate for the right ankle pain.  Just in the past two years I have had to get pain medication for my back, neck, and shoulder due in largely to my inability to use my right ankle normally.  I am consistently trying to improve the condition of my right ankle through medications offered through the VA and over-the-counter along with attempts at physical therapy, which all I have been unsuccessful.  The physical therapy I participated in during the service and within the past year did nothing but aggravate my ankle and cause more pain.  In addition to my ankle pain, I am still, experiencing hearing issues, headaches, and acid reflux/heartburn, which developed from my time in the service.  I was expecting those later aliments to decrease if not disappear altogether after being out of the service for an extended period of time, but that has not happen and in some instances, especially the hearing, they have gotten worse.  With all of these problems continuing it has been very difficult for me to dealing with my anxiety, insomnia, and depression.  Being a father is something I am very proud of and consider a honor, but nothing pains me more when I have to tell my children that I can't do what most people call normal activities (play football with my son in the back yard, walk the dog with my daughters, play their favorite game 'chase', and so on). I feel like I am letting them down if I don't do these things, so sometimes I try and end up paying for it later with intense pain.  It only makes sense that if I was rated at 40% in 12/09 and my aliments [sic] have gotten worse.”

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:

FPEB – Dated 20091026	VA* - (~10 Days Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Ankle Pain due to Post-Traumatic Osteoarthritis	5271	10%	Right Ankle Sprain and Microfracture With Surgical Repair	5271	20%	20091216	
			Scars Right Ankle	5271-7804	0%	20091216	
Other x 0 (Not In Scope)	Other x 12	
RATING:  10%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20100308 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Chronic Right Ankle Pain due to Post-Traumatic Osteoarthritis Condition.  The narrative summary noted persistent right ankle pain and recurrent sprains following an injury in 2005.  Magnetic resonance imaging documented post-traumatic arthritis and conservative management did not return the ankle to full function.  The CI underwent arthroscopic surgery and microfracture (for bony resurfacing) in September 2007 and following multiple Synvisc injections, had a second surgery in March 2008.  Physical therapy (PT) and rehabilitation were not effective.  Further surgery of an ankle fusion was declined.

At the MEB exam, (approximately 9 months prior to separation) the CI reported pain in the right ankle with walking, weight bearing, or dorsiflexion.  The MEB physical exam noted decreased range-of-motion (ROM) of the ankle and referenced the PT ROMs charted below.  There was mild contracture of the gastrocnemius (shortened calf muscle) with no neurosensory deficits noted.  The PT evaluation also documented a mild antalgic gait with stiffness and pain on motion.  A clinical treatment note, dated 5 August 2009 (approximately 4 months prior to separation), was referenced by the FPEB and made an assessment of “moderate” limitation of motion, without measured ROMs.

At the VA Compensation and Pension exam, performed 10 days prior to separation, the CI reported weakness, stiffness, swelling, giving way, lack of endurance, locking, fatigability, tenderness, effusion, and intense pain.  He had flares of pain up to 10/10 multiple times a day with activities and was taking anti-inflammatory and narcotic medication.  He did not use an assistive device and gait was normal.  There was no tenderness, instability, weakness or neurovascular deficit noted.  Ankle movement was abnormal (limited as charted below), no pain on motion was documented and “the joint function is not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use.”  The surgical scars were irregular, superficial, and not painful on examination.

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.

Right Ankle ROM
(Degrees)	PT ~9 Mo. Pre-Sep	VA C&P ~10 Days Pre-Sep	
Dorsiflexion (20 Normal)	5,5,7	5	
Plantar Flexion (45)	30,32,35	30	
Comment	Antalgic gait, with pain (passive w/in 2 degrees of active ROM	Gait normal	
§4.71a Rating	20% (FPEB 10%)	20% (VA 20%)	

The Board directed its attention to its rating recommendation based on the above evidence.  The key rating criteria in this case is if the CI’s limited right ankle ROMs were “marked” (20% under disability code 5271) or “moderate” (10% under 5271, or other arthritis codes).  The Service exam and record supported painful motion, an antalgic gait and gastrocnemius contracture.  The clinic note referenced by the FPEB did not provide any ROM measurements.  In conjunction with the 5-degree limitation of dorsiflexion and limited plantar flexion, the Board considered that the CI’s disability picture more nearly approximated the VA disability picture for “marked” limitation.  Although there was no antalgic gait or painful motion noted at the VA exam (which was closest to separation), there were additional symptoms described including flares and weakness with a similar limitation of motion of the ankle.  There was no muscle or nerve injury, and painful motion is included in the 5271 limited motion coding.  The ankle scars were not tender, were not noted as interfering with duty performance and did not require military footgear restriction.  The Board concluded, therefore, that the scars could not be recommended for additional disability rating.  There was no ankylosis of the ankle (frozen joint) and insufficient evidence that the CI’s ankle disability approached equivalency to actual loss of use of the foot for any rating higher than 20%.

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), §4.7 (higher of two evaluations), and §4.40 (functional loss); the Board recommends a disability rating of 20% for the right 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 right ankle condition, the Board unanimously recommends a disability rating of 20%, coded 5271 IAW VASRD §4.71a.  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 his prior medical separation:

CONDITION	VASRD CODE	RATING	
Chronic Right Ankle Pain due to Post-Traumatic Osteoarthritis	5271	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140328, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-01490.

	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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay. 

	I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  The office responsible for making the correction will inform you when your records have been changed.

Sincerely,

XXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
1.  Directive
2.  Record of Proceedings

cc:
SAF/MRBR