RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00402
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041203

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

CI CONTENTION:  The CI requests the Board consider all conditions.  The CI made no specific contention.  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 - 20041109	VARD - 20041216	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Ankle Pain	5271	20%	Right Ankle Instability, Post Operative Ligament Repair	5271	20%	20041119	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:

Right Ankle Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent right ankle surgery in April 2004 for modified Brostrom-Gould lateral right ankle reconstruction.  Following surgery, further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “right ankle instability” for PEB adjudication.  

At the MEB examination (recorded on DD Form 2807 Report of Medical History and DD Form 2808 Report of Medical Examination) dated 23 September 2004, 3 months prior to separation, the CI reported “right ankle rolling/dislocating.”  Physical examination showed swelling above the lateral malleolus, full range of motion (ROM) and 5/5 strength. 

The MEB NARSUM examination on 13 October 2004, 2 months prior to separation, noted complaints of right ankle instability while walking on uneven surfaces or performing routine military duties.  Physical examination of the right ankle showed intact light touch and proprioceptive senses and eversion without tenderness.  Anterior drawer test noted an “audible clunk”.  ROM was 5 degrees plantar flexion (45 normal) and 5 degrees dorsiflexion (20 normal) with 5/5 muscle strength.  X-rays of the right ankle revealed no talar tilt bilaterally and a February 2004 MRI study revealed a thickened inferior anterior talofibular ligament consistent with old trauma, but no acute or osteochondral lesions about the talus.  At the 19 November 2004 VA Compensation and Pension (C&P) evaluation, performed 2 weeks before separation, the CI reported right ankle pain and instability prevented walking on uneven ground, running or participating in sports.  Physical examination showed antalgic gait to the right secondary to right ankle pain.  ROM was 45 degrees plantar flexion (45 normal) and 10 degrees dorsiflexion (20 normal) with no crepitus.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right ankle pain 20%, coded 5271 (ankle, limited motion of), citing marked limited right ankle motion.  The VA also rated the right ankle pain 20% coded 5271 (ankle, limited motion of), based on the VA C&P examination 2 weeks before separation, citing evidence of marked limited motion with instability of the right ankle.  The Board agreed that the ROM examinations proximate to separation detailed above were consistent with a marked limitation of motion.  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.  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 pain.  

BOARD FINDINGS:  In the matter of the right ankle pain 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 20150602, 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

07 Feb 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160019838 (PD201500402)

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