RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03316
BRANCH OF SERVICE:  Army	BOARD DATE:  20150701
Separation Date:  20051124 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Quartermaster and Chemical Equipment Repairer) medically separated for posttraumatic arthritis of the right ankle.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS).  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The condition, characterized as “posttraumatic arthritis of the right ankle after open reduction internal fixation (ORIF) of the right ankle fracture dislocation” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “posttraumatic arthritis, right ankle following operative treatment of fracture dislocation” as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  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 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 20051124	VA* - (~6 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Posttraumatic Arthritis, Right Ankle…	5010-5271	10%	Status Post (S/P) Fracture of the Right Ankle with Posttraumatic Degenerative Joint Disease (DJD)	5271	10%	20060523	
			Surgical Scar, Right Ankle …	7804	10%	20060523	
Other x 0 (Not In Scope)	Other x 9 	
RATING:  10%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20060714 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Right Ankle Condition.  The CI sustained a right ankle closed fracture-dislocation in July 2003.  She underwent right ankle ORIF (surgery that realigns the bone fracture with steel rods, screws or plates [hardware] to keep the bone fracture stable to heal) in August 2003.  Surgery involved the tibia and fibula (lower calf bones that make up the sides of the ankle).  Due to continued pain and tenderness the hardware was surgically removed in June 2005.  The month after surgery the CI dropped a large piece of wood on her right foot and had increased pain.  A right ankle X-ray showed post-traumatic and post-surgical changes.  A repeat right ankle X-ray in August 2005 showed healing of the hardware removal area.  The CI continued to report deep aching in her right ankle despite hardware removal.  Magnetic resonance imaging (MRI) performed in September 2005 showed an osteochrondral (bone/cartilage) defect at the tibial surface.  Orthopedic exam noted that there was diffuse right ankle pain anteriorly, laterally and posteriorly and diagnosed osteoarthritis.  The MEB Narrative Summary (NARSUM) exam in September 2005, approximately 2 months prior to separation, documented that the CI complained of constant ankle pain and required both non-steroidal anti-inflammatory and narcotic pain medications.  Pain occurred with walking and “markedly interferes with her activities of daily living.  …  She cannot wear boots.”  The examiner rated the pain according to the American Medical Association (AMA) pain scale at marked and constant.  The profile did not include any military footgear restriction.  The MEB NARSUM physical exam findings and DD Form 2808, Report of Medical Examination, findings are summarized in the chart below.  

The VA Compensation and Pension (C&P) exam approximately 6 months after separation reported that the CI had intermittent right ankle pain walking for distances greater than 50 yards on flat surfaces and would have pain with any type of step climbing running or walking on any type of uneven surface.  She continued with an inability to engage in play activities with her students that involved running and an inability to engage in any activities that required running or activities that required carrying heavy loads.  She rated the daily pain at 4/10 with one flare-up per week that lasted 4 to 6 hours and with swelling and pain rated at 8/10.  When a flare-up occurred, she had to cease all activities and sit until the pain resolved and she required a cane during this time.  She denied any laxity or subluxation.  The right ankle X-ray showed post-traumatic degenerative changes.  The VA C&P physical exam findings are summarized in the chart below.

There were range-of-motion (ROM) evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.  

Right Ankle ROM
(Degrees)	DD 2808 ~2 Mo. Pre-Sep	MEB ~2 Mo. Pre-Sep	VA C&P ~6 Mo. Post-Sep	
Dorsiflexion (20 Normal)	“Full ROM”	0	0-20	
Plantar Flexion (45)		30	0-23	
Comment:  Surgery ~5 Mo. Pre-Sep	Pain with weight bearing; mild inflammation	Moderate effusion (tissue swelling); diffuse tenderness to palpation; drawer testing equivocal (laxity); well healed 13mm scar lateral ankle; subjective numbness 2-3 cm around scar	TTP entire length of scar; no adherence; TTP over lateral malleolus; ROM with pain; Deluca neg	
§4.71a Rating	10%	10%-20%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the right ankle condition as 5010 (arthritis, due to trauma, substantiated by X-ray findings) with 5271 (ankle, limited motion) and rated at 10% (moderate).  The VA coded the right ankle DJD as 5271 and rated at 10%.  The NARSUM ROMs may have supported a “moderately severe” (20%) ankle limitation; however that exam was within approximately three months of surgery and was considered in light of normal ROM documented on the DD Form 2808.  The Board majority adjudged that the VA exam had the highest probative value for rating at separation, especially with consideration of the ROMs portrayed in the remainder of the record.  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.  

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 by a majority vote 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 20140714, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB	0 6 JUL 2016

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, AR20160003081  (PD201403316)

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