RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01616
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080731

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Fire Support Specialist) medically separated for right ankle and left foot disabilities.  These conditions 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 MEB forwarded “right ankle pain status post Brostom reconstruction” and “left foot pain” to the Physical Evaluation Board (PEB) as medically unacceptable IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “right ankle pain…” and “left foot pain…” as unfitting, rated 10% and 10% respectively, citing application of Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.  

CI CONTENTION:  The CI contended for both of his ankles.  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 20080407	VA* - (~1 Mos. Post-Separation)    	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Ankle Pain…	5099-5003	10%	S/P Brostom Reconstruction, Right Ankle	5271	10%	20080828	
Left Foot Pain…	5099-5003	10%	No VA Entry	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 7	
RATING:  20%	RATING:  50%	
*Derived from VA Rating Decision (VARD) dated 20080925 (most proximate to date of separation [DOS]). 

ANALYSIS SUMMARY:  

Right Ankle Condition.  The service treatment record (STR) documented that the CI rolled his right ankle in 2006 while deployed to Iraq.  He subsequently experienced recurrent right ankle inversion sprains.  A right ankle X-ray showed a possible fracture of the distal lateral malleolus (ankle rounded bony prominence).  A right ankle MRI showed evidence of a previous lateral avulsion fracture at the anterior talofibular ligament with mild degenerative changes of the anterior tibiotalar joint.  A right ankle inversion stress X-ray showed significant anterior and greater lateral, instability.  The CI failed conservative management which included activity modification, casts, braces, medications, and physical therapy (PT).  The CI underwent an open surgical reconstruction (Brostrom) of the right lateral ankle ligaments to correct lateral instability.  The history and physical (H&P) exam for the MEB documented the right ankle range-of-motion (ROM) was within normal limits (WNL).  In a VA Compensation and Pension (C&P) exam, 7 months before separation, the right ankle ROM was dorsiflexion (20 normal) of 0 and plantar flexion (45 normal) of 45 degrees.  Repetitive right ankle active ROM, measured by PT with a goniometer, was dorsiflexion (20) of 15/20/19 and plantar flexion (45) of 56/57/56 degrees.  The narrative summary (NARSUM) completed 4 months before separation, recounted the history and interventions.  The CI complained of right ankle pain associated with activity (walking on uneven ground, running, and stairs) but denied taking pain medication.  The physical exam recorded a normal gait.  The right ankle exam revealed mild tenderness over the lateral malleolar scar.  There was no swelling, warmth, or erythema (redness) and ROM was WNL with very mild limitation due to pain.  Motor function, sensation, and circulation were WNL.  The diagnosis listed right ankle pain status post Brostrom reconstruction.  The subsequent C&P exam, a month after separation, recounted the history and interventions.  The CI complained of right ankle 4/10 pain, weakness, and stiffness.  He stated it was now stable but it would “lock up” about five times a year.  He complained of flare-ups about once a week when he “turns it” or “steps wrong.”  Flare-ups lasted 5-6 hours and were relieved by elevation and medication (ibuprofen or Tylenol).  The CI denied episodes of dislocation or subluxation (incomplete or partial dislocation) or use of an assistive device.  The physical exam recorded a normal gait.  The right ankle exam revealed a well healed, nontender, anterior scar.  There was no heat, erythema, or effusion (fluid collection).  There was no instability and the drawer test (assesses anterior talofibular ligament) was negative.  The goniometer measured active ROM was dorsiflexion (20) of 0 and plantar flexion (45) of 50 degrees.  There was no objective evidence of pain, loss of motion, fatigue, weakness, lack of endurance, or incoordination after repetitive motion.  Strength (5/5), reflexes (2+), and sensation were normal.  The diagnosis listed status post open Brostrom reconstruction with residual pain and loss of motion.

The Board directed attention to its rating recommendation based on the above evidence.  The informal PEB rated the right ankle condition 10% (VA code 5099-5003; rating by analogy-degenerative arthritis).  The PEB cited right ankle pain, status post Brostrom surgery, ankle ROM, painful motion, and no neurologic abnormality.  The VARD citing the C&P exam a month after separation rated the right ankle condition at 10% (5271; ankle, limited motion of:  moderate).  The VARD cited right ankle pain, weakness, stiffness, status post Brostrom surgery, flare-ups, ROM, pain free motion, no deficits after repetitive motion, and a normal gait with no instability, dislocation, subluxation, heat, effusion, or erythema.  Board members agreed that the ankle limitation of motion (5271) in the proximate exams more closely approximated the moderate (10%) than the marked (20%) rating.  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).  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).  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 condition.  

Left Foot Condition.  The STR documented the CI complaint of left lower extremity pain following a hard parachute landing.  The CI complained of pain in the left lower leg, anterior malleoli, and midfoot.  The left lower leg and foot X-rays were normal.  A left ankle X-ray showed talus (ankle bone that articulates with tibia, calcaneum, and navicular) degenerative changes.  The H&P exam for the MEB recorded that while sky diving, the CI landed wrong and injured his left foot.  He complained of left foot pain “on and off” for a few years but was not taking any pain medications.  The CI noted increasing left foot pain after right ankle surgery.  The left foot exam revealed no tenderness over the location of the pain (area of talus bone).  There was no swelling, erythema, or warmth.  Motor function, sensation, and ROM were WNL.  The assessment listed foot pain (soft tissue).  The first C&P exam, 7 months before separation, documented no left foot complaints or exam findings.  In the NARSUM the CI complained of intermittent left foot pain that occurred only with activity.  The severity of the activity related pain was characterized as “light” and he denied taking pain medication.  The physical exam recorded a normal gait.  The left lower extremity exam revealed no tenderness over the area of the talar bone or ankle.  There was no swelling, warmth, or erythema.  Motor function, sensation, and circulation were WNL.  The ROM was WNL with very mild limitation due to pain.  The diagnosis listed left foot pain.  At the subsequent C&P exam, a month after separation, the CI reported he strained his left ankle while sky diving.  He did not remember any other specific injury and noted it would be painful at times.  The exam documented no left foot complaints.  The physical exam recorded a normal gait.  The left lower extremity exam revealed no foot pain but mild tenderness of the medial maleolus.  There was no heat, erythema, effusion, or instability.  Strength, reflexes, and sensation were normal.  The diagnosis listed left ankle sprain.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left foot condition 10% (5099-5003).  The PEB cited left foot pain status post injury when he landed wrong while skydiving, ankle ROM, painful motion, and no neurologic abnormality.  While left foot pain was implicated in the profile, MEB, and PEB, the majority of subjective complaints, objective imaging and exam findings, measurements, and treatments were related to the left ankle.  The VARD, citing the C&P exam a month after separation, did not rate the left foot condition.  The proximate exams consistently documented that gait, motor function, sensation, and ROM were normal.  There was no weakness for consideration under 5277 (weak foot).  There was no evidence of sensory pathology for consideration under 5279 (metatarsalgia).  There was no deformity for consideration under 5276 (flatfoot), 5278 (claw foot), 5280 (hallux valgus), 5281 (hallux rigidus), 5282 (hammer toe), or 5283 (metatarsal bones malunion/nonunion of).  Board members agreed that the intermittent foot symptoms more closely approximated the moderate (10%) than the moderately severe (20%) rating under 5284 (foot injuries, other).  Board members agreed that there was sufficient evidence of pain with use prior to separation to support a 10% rating considering painful motion (§4.59).  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 foot 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.  In the matter of the left foot 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 20140401, 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, AR20160003231 (PD201401616)

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