RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00397
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070309

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Field Artillery Automation Specialist, medically separated for “right ankle pain,” with a disability rating of 0%.

CI CONTENTION:  “The CI’s conditions continue to worsen and negatively affect daily activities.  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 - 20070214	VARD - 20070711	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Ankle Pain Status Post Arthroscopic Chondroplasty	5099-5003	0%	Status Post Osteochondritis Dissecans, Right Ankle	5271-5024	10%	20070504	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Right Ankle Pain Status Post Arthroscopic Chondroplasty.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent right ankle surgery in October 2006 for the osteochondritis dissecans ankle condition.  Following surgery, further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “osteochondritis dissecans” for PEB adjudication.  The MEB NARSUM examination on 8 Feb 2007, 1 month prior to separation, noted complaints of the inability to walk without a cane and go up and down stairs due to the pain.  The CI reported constant pain; rated 2/10 while at rest, 4/10 with normal daylily activities, and 8/10 when attempting to walk without his cane, climb stairs, or ambulate on uneven ground.  Physical examination showed painful right ankle motion of dorsiflexion to 4 degrees (normal 20) and plantar flexion to 35 degrees (normal 40).  There was normal strength.  There was right ankle swelling.  At the 4 May 2007 VA Compensation and Pension (C&P) evaluation, performed 2 months after separation, the CI reported right ankle weakness, stiffness and intermittent locking with pain of 1/10 at rest.  Physical examination showed antalgic gait with poor balance.  The CI had tenderness over the lateral collateral ligaments of the right ankle (the site of his sprain).  Range of motion of the right ankle was normal.  X-Ray evaluation of the ankle on 4 May 2007 revealed no acute fracture, dislocation, or bony destructive lesion.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the ankle condition 0%, coded 5099-5003 (degenerative arthritis), citing range of motion limited by pain.  The VA rated the ankle condition 10% coded 5271-5024 (ankle limited motion of-tenosynovitis), based on the VA C&P examination 2 months after separation, citing tenderness and painful motion.  The Board noted evidence of painful motion at the MEB and VA examinations which met criteria for a 10% rating IAW VASRD §4.59 (Painful motion).  The Board also noted the limitation of dorsiflexion to 4 which also met criteria for a 10% rating for moderate ankle limitation of motion.  The Board determined that the evidence did not support a 20% rating for marked ankle limitation of motion.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the ankle condition, coded 5271.  

BOARD FINDINGS:  In the matter of the ankle condition, the Board unanimously recommends a disability rating of 10%, coded 5271 IAW VASRD §4.71a.  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	
Right Ankle Pain Status Post Arthroscopic Chondroplasty	5271	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150531, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB										

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

03 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170002068 (PD201500397)

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