RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01510
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080618

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Abrams System Tank Maintainer) medically separated for a right ankle.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The forwarded “chronic synovitis of the right ankle with RSD [reflex sympathetic dystrophy] of the right ankle status post  right ankle surgery repair,” “possible chondral fracture of the talus of the right ankle,” and “anterolateral impingement of the right ankle” to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “right ankle loss of motion” as unfitting, rated 20% with application of Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.  

CI CONTENTION:  The CI contended that he received a higher rating form the VA and that his condition continues to hinder his daily activities.  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 20080415	VA* - (~1 Mo. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Ankle Loss of Motion	5271	20%	Chronic Tenosynovitis, Right Ankle Status Post Ligament Tear, with Non-tender Scar	5024-5271	20%	20080602	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 3	
RATING:  20%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20080926 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY: 

Right Ankle Condition.  The service treatment record documented that the CI sustained a right inversion ankle sprain on 13 January 2007.  The 30 January 2007 right ankle magnetic resonance imaging study showed tears involving the lateral ligaments, tenosynovitis (inflammation of fluid-filled sheath around tendon), lateral soft tissue swelling, and joint fluid.  The 4 April 2007 nuclear medicine bone scan showed increased uptake of tracer material in the right ankle and metatarsal bones suggestive of osteomyelitis (inflammation/infection of bone or bone marrow).  At the 14 May 2007 physical therapy (PT) encounter the CI complained of right ankle joint pain but denied hypersensitivity to touch and skin color or temperature changes.  The ankle exam revealed joint tenderness and swelling without ecchymosis (bruising), hypertrophic changes, hypersensitivity to touch, or sensory exam abnormalities.  The diagnoses listed ankle sprain and RSD (chronic extremity pain, swelling, limited range-of-motion [ROM], vasomotor instability, skin changes, and patchy bone demineralization following injury).  The plan was for desensitization for RSD symptoms.  The 5 July 2007 right lower extremity electrodiagnostic testing did not reveal any electrophysiologic evidence of peripheral nerve entrapment and showed a decreased likelihood of underlying peripheral neuropathy (injury or irritation of a peripheral nerve).  On 13 November 2007 the CI underwent a right ankle arthroscopic surgical procedure.  At the 18 February 2008 orthopedic surgery evaluation the CI reported he injured his right ankle on 17 February 2008 while running down a hill with weights.  He complained of pain, tenderness, stiffness, swelling, and weakness of the right ankle.  The CI reported limited ROM and was unable to run or walk without pain.  The right ankle physical exam revealed a well healed scar.  The lateral aspect was severely swollen and bruised, while the medial aspect was normal.  The tendons were intact but there was some laxity over the lateral side.  There was limited and painful ROM with 10 (normal 45) degrees of plantar flexion and 10 (normal 20) degrees of dorsiflexion.  The diagnosis listed right ankle ligament tear with loose bodies.  

The narrative summary (NARSUM), 3 months before separation, recounted the history and interventions to date.  It recorded that a bone scan in June 2007 showed increased uptake consistent with RSD of the right lateral ankle.  The CI reported that postoperatively the pain was back to the baseline, constant, sharp, throbbing, 6-7/10 pain.  The pain involved the right lateral ankle and dorsal, proximal foot.  Pain was exacerbated by walking, prolonged standing (> 15 minutes), and ankle movement (especially plantar flexion and dorsiflexion).  The physical exam revealed a gait that was not antalgic (assuming a posture or gait to lessen pain).  The right lower extremity exam showed well healed ankle surgical scars and mild swelling to the lateral malleolus (ankle bony prominence) area.  There was tenderness at the lateral malleolus and dorsum of the foot.  The anterior drawer test (assesses integrity of anterior talofibular ligament) was negative.  Measurement of right ankle ROM was limited by pain with 10 degrees of plantar flexion and 10 degrees of dorsiflexion.  The diagnoses listed right ankle chronic synovitis (synovial membrane inflammation), RSD status post surgery, possible fracture of the talus (ankle bone that articulates with navicular, calcaneum, and tibia), and anterolateral impingement.  The examiner reported that the pain remained at its pre-surgical level and there were no indications for surgery.  

The VA Compensation and Pension (C&P) exam, a month before separation, recounted the history and interventions to date.  The CI reported he had RSD of the right lower extremity related to his ankle injury.  The exam reported that the course of PT included desensitization and treatment for hyperesthesia (abnormal increased sensitivity to stimulation) of the right ankle and foot.  The CI complained of chronic, 6/10, lateral, right ankle pain.  He had associated weakness, stiffness, swelling, instability, fatigue, lack of endurance, and locking but denied dislocation.  He complained of up to daily flares, which could last to all day.  He was unable to run and pain was exacerbated by prolonged standing, prolonged walking, and driving.  Pain was relieved by rest and/or medication.  The CI reported using a cane and a right ankle Velcro brace (except with boots).  The physical exam revealed the CI using a straight cane, unloading the right lower extremity, and an antalgic gait.  The right ankle exam showed a tender lateral scar and a nontender anterior scar.  The scars were otherwise nonadherent, nondepressed, and nondisfiguring, and revealed no ulceration, keloid, or loss of function.  There was a mild effusion (fluid collection) and hyperesthesia to light touch over the lateral ankle.  The anterior drawer test was negative and the examiner was unable to perform the talar tilt test (assesses integrity of lateral ankle ligaments) due to pain and guarding.  The right ankle ROM was 30 degrees of plantar flexion and -15 degrees of dorsiflexion.  The impression listed right ankle arthroscopy and the examiner would not provide a diagnosis without requested medical records and studies.

The Board directed attention to its rating recommendation based on the above evidence.  The informal PEB rated the right ankle condition 20% using VASRD code 5271 (ankle, limited motion of:  marked).  The PEB cited the arthroscopic debridement, persistent stiffness, pain, localized joint tenderness, and restricted ROM with a normal gait, skin color, and skin temperature.  The PEB reported normal current imaging and electrodiagnostic testing and a bone scan verifying RSD.  The PEB indicated that RSD could not be separately rated due to pyramiding.  The VARD, citing the C&P exam a month before separation, rated the right ankle condition 20% (5024-5271; tenosynovitis-ankle, limited motion of:  marked).  The VARD cited the arthroscopic procedure, chronic pain, guarding, weakness, stiffness, swelling, instability, locking, fatigue, lack of endurance, and restricted ROM with an antalgic gait and hyperesthesia over the lateral right ankle.  Board members agreed that there was sufficient evidence of pain with use prior to separation, as well objective exam and imaging findings, to support a 10% rating considering functional loss and painful motion (§4.40, §4.59).  Board members agreed that the ankle limitations in motion (5271) in the proximate exams more closely approximated the marked (20%) than the moderate (10%) rating.  The marked (20%) rating is the highest evaluation the law allows for this disability.  There was no deformity for consideration under 5270 (ankle, ankylosis), 5272 (subastragalar or tarsal joint, ankylosis of), or 5273 (os calcis or astragalus, malunion of).  There was no excision of the astragalus for consideration under 5274 (astragalectomy).  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination 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 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 20140327, 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, AR20160003131 (PD201401510)

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