RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04164
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070405

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E1, Human Resources Specialist, medically separated for “bimalleolar fracture left ankle,” with a disability rating of 0%.

CI CONTENTION:  The CI requests that all conditions be considered.  The CI’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 – 20070315	VARD - 20070828	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bimalleolar Fracture Left Ankle	5099-5003	0%	Residuals, Left Ankle Fracture	5003-5271	20%	20070628	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bimalleolar Fracture, Left Ankle.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent left ankle surgery on 15 November 2006 with open reduction and internal fixation of bimalleolar fractures.  Following surgery, further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “left ankle bimalleolar fracture” for PEB adjudication.

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)	NARSUM ~5 Mos. 
Pre-Sep	Ortho ~1 Mos. 
Pre-Sep	VA C&P  general
~3 Mos. Post-Sep	VA C&P joint
~3 Mos.Post-Sep	
Dorsiflexion (20 Normal)	5	5	“Full”	12	
Plantar Flexion (45)	10	25		30	
Comments	Painful Motion
2 days post-op
GONIOMETER	5 days post-op
GONIOMETER	Painful Motion, Abnormal Gait	Painful Motion, Abnormal Gait, Functional Loss
GONIOMETER	
§4.71a Rating	20%	20%	10%	10%	

At the MEB NARSUM examination on 17 November 2006, 2 days after surgery and 5 months prior to separation, the CI reported constant ankle pain rated moderate to severe.  He was taking narcotic pain medications (Percocet and Demerol).  Physical examination found severe swelling, discoloration, and “quite a bit of pain.”  Gait was not able to be observed due to the CI not being able to bear weight on the left foot.  Radiographic studies (X-rays) revealed postsurgical hardware, good fracture alignment, and no evidence of early healing.  Because of recurrent medial wound breakdown, surgery for hardware removal (screws), irrigation, and debridement (removing dead tissue) was performed on 1 March 2007.  At the time of the examination for the MEB addendum, performed by orthopedics on 6 March 2007, 5 days after surgery and 1 month prior to separation, the CI described constant moderate ankle pain.  On examination there was mild swelling with no bony tenderness.  Strength and sensation were normal and the examiner observed intermittent pain.  

At the 26 June 2007 general medical VA Compensation and Pension (C&P) examination, performed 3 months after separation, the CI reported intermittent ankle pain especially associated with physical activity.  He also reported swelling of the left leg.  Physical examination noted “slight limping on the right leg” and a steady gait.  There was mild to moderate swelling of the left ankle and “full range of motion, painful external rotation.”  The 28 June 2007 joint VA C&P examination recorded complaints of pain with walking long distances and an inability to run more than 3 minutes.  Pain was rated 6/10 in severity, and was characterized as sharp and intermittent, with occasional stiffness, redness, and swelling.  Flare-ups of pain (to 8/10 severity) happened 2-3 times per week and lasted 2-3 hours.  These flare-ups were precipitated by walking more than 5 blocks or running more than 2-3 minutes.  During flare-ups the CI indicated he could not take stairs, squat, or stand for 5 minutes.  He also could not wear sneakers during flare-ups due to swelling.  Dislocation and subluxation were denied, and no prosthetics or assistive devices were used.  Physical examination revealed an increase in pain from 0/10 to 4/10 with 5 repetitions of goniometer measured ROM (reported in the chart above).  Tenderness was reported, and “…gait was slightly abnormal with short stance on left, difficulty and short stance on heel walking and toe walking.”  Radiographic studies (X-ray) indicated hardware present, operative and degenerative changes, with healed fracture and no current fracture or dislocation.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 0% coded 5099-5003 (analogous to degenerative arthritis), citing the absence of “significant loss of motion due to mechanical factors of a permanent nature.”  The VA rated the left ankle condition 20% coded 5271 (ankle, limited motion of), citing marked limitation of motion.  There was limitation of dorsiflexion and plantar flexion that supported a rating under the VASRD diagnostic code for limitation of motion (5271).  Additionally, there was evidence of painful motion causing functional loss supporting the 10% rating (based on §4.59, §4.40 and §4.45), as reported at the NARSUM examination as well as both VA C&P examinations.  An abnormal gait was reported at both VA examinations and additional functional loss was reported at the focused VA C&P oints examination on 28 June 2007.  The board assigned little probative value to the MEB NARSUM and orthopedic surgery MEB addendum examinations because they occurred in the immediate postoperative periods following two surgeries.  The board assigned higher probative value to the C&P examinations because they occurred after a period of convalescence.  The Board considered alternative VASRD ankle and analogous codes, but all were less applicable and not advantageous to rating.  The Board considered whether the limitation of motion was moderate or marked when considered under 5271 (limitation of ankle motion).  The Board agreed that the ROM examinations proximate to separation (detailed above) were consistent with a moderate limitation of motion for the 10% rating under this code.  The Board majority agreed the limitation of motion was no more than moderate, therefore supporting the 10% rating adjudicated by the PEB.  A higher rating of 20% was not indicated in the absence of marked limited ROM of the left ankle.  

BOARD FINDINGS:  In the matter of the left ankle condition, the Board majority recommends a disability rating of 10% coded 5271 IAW VASRD §4.71a.  The single voter for dissent recommended a higher modification and did not elect to submit a minority opinion.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Bimalleolar Fracture Left Ankle	5271	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 AR20160013691 (PD201404164)

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, accept the Board’s recommendation to modify the individual’s disability rating to 10% without re-characterization 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