RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03112
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090817

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Motor Transport Operator, medically separated for “left ankle instability,” with a disability rating of 20%.

CI CONTENTION:  The applicant contends that many of his medical conditions were not addressed by the military.  Additionally, he indicates that his left ankle condition continues to worsen.  The applicant’s 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 - 20090511	VARD - 20091005	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Ankle Instability…	5271	20%	Left Ankle, Status Post Brostrum and Arthroscopic Surgery…	5271	20%	20090622	
			Residual Scar, Status Post Left Ankle Surgery	7802	0%	20090622	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Left Ankle Condition.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had a left ankle fracture and injury during Airborne Operations in March 2007.  He underwent left ankle surgery in March 2008 for torn ligaments and again in November 2008 for ligament reconstruction and synovial debridement.  Despite treatment, the CI’s left ankle condition of pain and instability could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and was referred for an MEB.  

The range-of-motion (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.  

Left Ankle ROM
(Degrees)	PT ~7 Mo. Pre-Sep	VA C&P ~2 Mo. Pre-Sep	VA C&P ~5 Mo. Post-Sep	
Dorsiflexion (20 Normal)	5	10	15	
Plantar Flexion (45)	20	35	30	
Other impairments:  	Painful motion; abnormal gait; complaint of interference with standing, walking and other weight bearing activities	Painful motion; normal gait; complaint of weakness, giving way, lack of endurance, fatigability, and numbness	Painful motion; abnormal gait; complaint of weakness, giving way, instability, episodes of dislocation or subluxation	
§4.71a Rating	20%	20%	20%	

At the MEB examination (recorded on DD Forms 2807 and 2808) dated September 2008, 11 months prior to separation, the CI reported that his ankle went “numb after standing 10, 15 minutes.”  The CI also reported that the “limited movement in ankle and toes caused knee problems.”  Physical examination was non-contributory.  At the MEB NARSUM examination on 21 October 2008, the CI reported a history of “left foot paresthesia secondary to his fracture.”  He also reported that he had “limited mobility and walked with some pain and discomfort” and “no longer had the ability to run or put significant stress on his left ankle.”  Physical examination was non-contributory.  

At the time of the physical therapy examination for MEB ROM study on 23 January 2009, 7 months before separation, the examination showed limitation of motion as indicated in the chart above with painful motion.  He also limped and had stiffness and swelling of the left ankle joint.  Pain appeared to interfere with standing, walking, and other weight bearing activities.  The examiner also indicated that the CI had “additional functional loss secondary to pain and joint stiffness, when the joint [was] used repeatedly over a period of time.”  However, the examiner did not quantify the functional loss.  

At the VA Compensation and Pension (C&P) examination on 22 June 2009, 2 months before separation, the CI reported symptoms of weakness, stiffness, swelling, giving way, lack of endurance, locking, fatigability and pain.  His pain was elicited by physical activity and associated with numbness.  “I can’t stand for long, limited on everything.”  Physical examination showed normal gait without assistive device.  “A well-healed surgical scar in the lateral aspect of the left ankle associated with a mild decrease in the range of motion of the left ankle.”  There was no edema, effusion, weakness, tenderness, redness, heat, or abnormal movement noted by the examiner.  His ROM was limited as indicated in the chart above.  

At the VA Compensation and Pension (C&P) examination on 19 January 2010, 5 months after separation, the CI reported symptoms of weakness, stiffness, swelling, giving way, decreased joint speed, episodes of dislocation, weekly flare-ups, repeated effusions, and pain.  Prolonged walking and standing caused his ankle symptoms to flare.  He reported that he was able to stand for 15-30 minutes and walk for almost a mile.  “He had to wear [a] shoe on his left foot at night to stop muscle spasms.”  Physical examination showed an antalgic gait that required the use of a cane on a frequent basis.  He had decreased motion as indicated in the chart above along with painful motion.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 20% (coded 5271, limited motion of ankle), citing marked limitation of motion and functional loss due to factors such as pain, including pain on repeated use and painful motion; fatigability; incoordination; weakness with repetitive use; and flare-ups IAW VASRD 4.10; 4.40; 4.45; and 4.59.  The VA rated the left ankle condition 20% (coded 5271), citing limitation of motion on dorsiflexion.  

The Board agreed that the ROM examinations proximate to separation detailed above were consistent with a marked limitation of motion for the maximum 20% rating under this code.  The Board also considered whether a higher rating was supported under other diagnostic code options.  Because there was no ankylosis, nonunion or malunion, VASRD §4.71a offers no applicable joint code which would yield a rating higher than the 20% rating adjudicated by the PEB.  The Board also considered whether ratings under the VASRD code for other foot injuries (5284) provided for a higher rating (§4.7); however, all Board members agreed that the severe level (30%) was not supported.  

The VA also assigned a separate 0% rating for ankle scar.  The Board does not recommend separation ratings for scars unless their presence imposes a direct limitation on fitness.  The Board reviewed service treatment records and did not find evidence that a tender or painful scar separately interfered with duty, and therefore a separate rating was not recommended.  

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 ankle condition.  

BOARD FINDINGS:  In the matter of the left 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.  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 20140413, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

XXXXXXXXXXXXXXXXX

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, AR20160007961 (PD201403112)

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