RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03891
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20080519

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Munitions Systems Journeyman, medically separated for “chronic right ankle pain status post fracture dislocation with open reduction and internal fixation (ORIF),” with a disability rating of 10%.

CI CONTENTION:  The CI contends for review of all conditions.  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 based upon a 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 - 20080403	VARD - 20090122	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Ankle Pain S/P Fracture Dislocation with ORIF	5099-5003	10%	Right Ankle Medial Malleolar and Talar Fractures, S/P ORIF with Degenerative Changes; Left Ankle Medial Malleolar and Talar Fractures, S/P ORIF with Degenerative Changes; and Degenerative Arthritis of the Right Hip	5010	10%*	20080902	
			Right Ankle Scar	7805	0%	20080902	
Right Femur Fracture S/P ORIF of Condyle Fracture	Category II 
Not Unfitting	S/P Right Patella Lateral Facet Fracture and Closed Comminuted Segmental Right Femur Shaft Fracture	5260	0%	20080902	
Left Index Finger Fracture S/P ORIF with Tendon and Nerve Repair	Category II 
Not Unfitting	Left Index Neuropathy, S/P Fracture with Surgery	5229-8516	10%	20080902	
S/P Liver Laceration, Healed	Category II 
Not Unfitting	Right Lobe Liver Laceration	7399-7345	Not Service Connected	
S/P Right Kidney Laceration, Healed	Category II 
Not Unfitting	Right Renal Laceration	7599-7533	Not Service Connected	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	
*VARD 20100910 rated right ankle 10% coded 5271-5010 effective to date of separation, separate from left ankle, right hip.

ANALYSIS SUMMARY:

Chronic Right Ankle Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right ankle condition began in April 2007 after a motorcycle accident.  Dislocation and fracture of the ankle required emergent surgical ORIF.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “limited function due to multiple fractures” for PEB adjudication.

Right ankle range of motion (ROM) measurements performed by physical therapy (PT) on 20 November 2007, 6 months prior to separation, showed dorsiflexion of 15, 15, and 18 degrees (normal 20 degrees) and plantar flexion of 42, 48 and 49 degrees (normal 45 degrees).  

The MEB NARSUM examination on 30 November 2007, 6 months prior to separation, the CI reported being able to walk 100-150 feet before activity-limiting ankle pain occurred.  Physical examination, previously performed on 20 November 2007, showed ambulation “with a bit of a limp” favoring the right ankle.  Post-surgical scars were healing well.  There was tenderness of the medial malleolus, midfoot and right foot.  Right ankle range of motion (ROM) was “limited in the extremes of flexion and extension.”

Re-evaluation by PT on 17 December 2007 showed right ankle dorsiflexion of 0 degrees and plantar flexion of 45 degrees.  At the time of an orthopedic clinic appointment on 30 April 2008, three weeks prior to separation, the CI reported pain around his ankle primarily located along the anterolateral joint line and over the tip of the medial malleolus.  The pain was aggravated by prolonged walking, which could cause subsequent limping.  The pain was relieved by rest.  On examination his gait was normal and surgical scars were well-healed.  There was no swelling, and ligaments were stable.  There was mild tenderness over the tip of the medial malleolus and the anterolateral joint.  Passive ankle dorsiflexion was 5 degrees and plantar flexion was 20 degrees.  Radiographic studies showed healed fractures and intact surgical hardware.
At the 2 September 2008 VA Compensation and Pension (C&P) evaluation, performed 3 months after separation, the CI reported throbbing right ankle pain after walking more than 100 yards.  The pain was also aggravated by sitting for prolonged periods.  The pain was located in the medial malleolus and lateral forefoot region.  Assistive devices were not required, but the condition imposed moderate restrictions on exercise and sports participation.  He was not allowed to run, but exercised on an elliptical trainer 3 days per week for 20 minutes.  The condition did not interfere with his occupation as a student.  He experienced a flare-up of pain every 2 weeks lasting 30 minutes.  Physical examination showed a normal gait and there was no painful motion, tenderness, crepitus or ligamentous instability.  Right ankle dorsiflexion was 15 degrees and plantar flexion was 40 degrees.  There was no additional limitation of motion after repetition.  Right ankle X-rays did not report arthritic changes.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right ankle condition 10% coded analogously to 5003 (arthritis, degenerative).  The VA initially combined the right ankle condition with left ankle and right hip conditions and rated at 10%.  Acknowledging a “clear and unmistakable error” the VA later amended their decision to specify separate ratings for each condition; a 10% rating for the right ankle was effective the day after separation.  Under a combination 5271-5010 code (ankle limitation of motion; traumatic arthritis) the rating was assigned for limitation of motion in a joint with arthritis, effective the day after separation.

The Board considered if the limitation of motion in evidence was moderate (10% rating) or marked (20% rating) under the 5271 code.  Although the orthopedic examination, 3 weeks before separation, recorded a marked degree of limited ROM, the measurements were of passive (not active) motion and therefore did not adequately reflect functional impairment.  While one PT evaluation on 17 December 2007, 5 months prior to separation, documented absent dorsiflexion (and normal plantar flexion), the two other ROM assessments in evidence (PT 6 months prior to separation and VA C&P 3 months after separation) recorded near normal ROM.  The Board concluded that the evidence was most accurately described by the “moderate” stipulation.  Therefore, a 10% rating was warranted via this pathway.  It was noted that one possible underlying cause for the ankle impairment was residuals of a fracture of the medial malleolus (distal tibia), so a rating using the VASRD diagnostic code 5262 (impairment of the tibia, fibula and ankle) was considered; however, there was no malunion or nonunion to assign this rating.  There was likewise no ankylosis of the ankle or subastragalar (sub-tarsal) joints, no malunion of the oscalcis (calcaneus) or astragalus (talus) or astragalectomy for consideration under the respective diagnostic codes (5270, 5272, 5273 or 5274).  The Board also considered whether ratings under the VASRD code for other foot injuries (5284) provided for a higher rating (§4.7), however all members agreed that the impairment did not approach the level of moderately severe to support a higher (20%) rating.  

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.

Contended PEB Conditions:  Right femur fracture, left index finger fracture, liver laceration and right kidney laceration.  As the CI was entering the MEB process for his right ankle condition, he was involved in a motorcycle accident on 12 October 2007 which caused injuries to his right femur, left index finger, liver and right kidney.  The NARSUM examiner, approximately 1 month after the accident, discussed the aforementioned injuries and included “multiple severe skeletal injuries” in the final diagnosis.  The MEB forwarded “limited function due to multiple fractures” for PEB adjudication.

Right Femur and Condyle Fracture.  On 13 October 2007, the CI underwent intramedullary nailing (placement of a rod) of a distal third femur fracture, ORIF of the lateral femoral condyle (aspect of femur that forms the top of the knee joint) and excision of a small lateral fracture fragment of the patella.  By 20 November 2007 the CI returned to light duty, and walking was limited due to the right ankle.  At the VA C&P examination, 3 months after separation (7 months after injury), the CI reported right knee pain (at the site of the ORIF of femoral condyle) when walking more than 500 yards or with running.  The distal third right femur fracture treated with rod placement caused no symptoms or functional limitations.  The CI exercised on an elliptical trainer 3 days per week for 20 minutes each session.  His hobbies included weight-lifting, which he performed 3 days per week.

Left Index Finger Fracture.  The right-handed CI required ORIF of the proximal phalanx of the left index finger on 16 October 2007.  Repair of the extensor tendon and ulnar digital nerve was also accomplished.  Orthopedic follow-up on 12 December 2007, 5 months prior to separation, found the fracture to be well-healed.  Some decreased finger sensation was present, but ROM was nearly full.  At the VA C&P examination, 3 months after separation, the CI denied any functional limitations due to the finger.

Status Post Liver and Right Kidney Lacerations.  The CI was hospitalized under close observation.  Surgery was not indicated and the CI was released from the hospital after one week.  The C&P examiner, 3 months after separation, stated that there was no abdominal pain and no functional limitations as a consequence of these conditions.

The commander’s statement on 13 December 2007 recommended the CI be returned to duty.  The Duty Limiting Condition Report on 30 January 2008, 3 months after the aforementioned injuries and 4 months prior to separation, specified no running, marching or climbing and no walking greater than 100 yards.  The right and left foot were the only anatomic body parts that were specifically mentioned.  An orthopedic evaluation was requested by the CI on 30 April 2008, three weeks prior to separation, as a “final checkup.”  The orthopedist indicated that other injuries (besides the right ankle) had “healed uneventfully.”  The right femur injuries were not implicated as a source of concern or disability by the CI.  On the DD form 2807, Report of Medical Assessment, dated 12 May 2008, 1 week prior to separation, the CI indicated that none of the aforementioned conditions limited his ability to work in his primary specialty.  The right femur and condyle fractures, left index finger fracture, liver laceration and right kidney laceration were reviewed and considered by the Board.  There was no performance-based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  

After due deliberation, and 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 any of the contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  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 contended right femur fracture and condyle fracture, left index finger fracture, liver laceration and right kidney laceration conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 20140825, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR

1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-03891.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings