RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02937
BRANCH OF SERVICE:  Army	BOARD DATE:  20150415
SEPARATION DATE:  20050722

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Motor Transportation Specialist) medically separated for chronic left ankle pain.  The ankle 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 “chronic left ankle pain secondary to open fracture-dislocation of the left ankle with open reduction, internal fixation with iliac crest bone graft” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal adjudicated “chronic left ankle pain” as unfitting, rated 10% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  Subsequently, a Revised PEB corrected administrative items pertaining to description of the disability.  There was no change to the CI’s disposition or rating.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions”

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:

Admin IPEB – Dated 20050719	VA* - (~2 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Ankle Pain, Status Post Open Reduction with Internal Fixation of Severe Ankle  Fracture/Dislocation	5099-5003	10%	Left Ankle Fracture/Severance with Reattachment	5271	20%	20050907	
Other x 0 (Not In Scope)	Other x 9	
RATING:  10%	RATING:  70%	
*Derived from VA Rating Decision (VARD) dated 20060327 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Chronic Left Ankle Pain Condition.  The treatment record and narrative summary (NARSUM) detailed a left ankle injury (fractured dislocation) in 2004 that required open reduction and internal fixation surgery, followed by bone graft to the left distal fibula.  The NARSUM documented two follow-up surgeries for incision and drainage.  The CI was treated with physical therapy and medication with minimal benefit; and he continued to complain of pain.  At the MEB exam, the CI reported “constant, daily” left ankle pain that he rated at 4/10.  His pain is worse in the morning and with prolonged rest (9/10).  He denied any swelling of the foot.  Computerized tomography (CT) of the left ankle a month prior to separation documented “extensive disuse osteopenia,” and no evidence of loosening of hardware or infection.  Post-surgical defect was noted within the calcaneus, and findings consistent with incomplete healing of the fracture, and there was a small avulsion fracture fragment seen in the posterior to distal medial malleolus.  Focused ankle examination recorded from DD Form 2808, Report of Medical Examination, approximately 3 months prior to separation, recorded dorsiflexion right foot of 10 (normal 10) degrees, left foot 0 degrees; right foot plantar flexion of 60 (normal 45) degrees and left foot of 40 degrees.  Surgical incisions were well healed with decreased sensitivity to light touch distal to the incisions.  Tests for ankle instability were negative.  The examiner wrote, “There is marked decreased range of motion during the exam.”

At the VA Compensation and Pension exam performed approximately 8 weeks after separation, the CI reported he injured his left ankle in a motorcycle accident and that his left foot was hanging on by the Achilles tendon.  The CI indicated there had been multiple surgeries on the left ankle, and he has continued to have constant pain.  The examiner noted there were areas where he essentially had no sensation.  His pain is worse on awakening and he loses sleep due to pain.  The CI used a cane for bearing weight, and was observed walking with his weight bearing primarily on the cane.  Examination of the left ankle recorded significant swelling; however, there was evidence of good blood flow.  Tenderness was noted from the mid-leg down to the ankle with demonstrated decrease in sensitivity to pain, pinprick and light touch and proprioception and vibration.  Range-of-motion (ROM) measurements left ankle recorded dorsiflexion of 0-5 degrees and plantar flexion of 60 degrees.  The examiner opined that if the left ankle had any further loss of motion the joint would be essentially immobile.

The Board directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB rated the ankle (citing all directions of motion are reduced due to mechanical block following surgery) at 10%, coded analogously 5099-5003 for painful motion.  The VA, 2 months after separation, rated the ankle at 20% based on “marked” limited motion, coded 5271.  The higher rating of 20% under the 5003 code requires X-ray evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations.  Board members agreed there was insufficient evidence to support the higher rating under this code.  The Board next considered the evidence to support a rating under the 5271 code.  Limitation of ankle motion IAW VASRD criteria is based on active ROM (Ankle, limited motion) has two rating levels with 10% “moderate” and 20% “marked.”  The NARSUM examiner opined that the decrease in ROM was marked, dorsiflexion was at 0 degrees.  This measurement was taken 4 months after surgery; however, the orthopedic examination 3 months after surgery also recorded 0 degrees of dorsiflexion.  The Board considered the VA examination 9 months after surgery which documented 0-5 degrees of dorsiflexion.  All Board members agreed that the limitation of motion depicted a disability picture closer to the 20% (marked) criteria.  There was no ankylosis or equivalency to 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), the Board recommends a disability rating of 20% for the left 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 left 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 Left Ankle Pain	5271	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140613, 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-00), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

06 JUL. 2016

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXX, AR20150018869 (PD201402937)

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, I accept the Board's recommendation to modify the individual's disability rating to 20% without recharacterization 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