RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00747
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090421

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E3, Petroleum Supply Specialist, medically separated for “chronic left ankle pain…” and “medial tibial stress injury…,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI made no specific contention.  Her 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 on 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 - 20090403	VARD - 20100322	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Ankle Pain…	5099-5003	10%	Recurrent Left Ankle Strain	5271	10%	20090707	
Medial Tibial Stress Injury…	5299-5262	10%	Residual Left Medial Tibial Plateau Stress Injury…	5257	0%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Left Ankle Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI injured her left ankle during basic training in August 2008 after falling and fracturing her ankle.  This was repaired surgically on 12 August 2008.  X-rays on 27 October 2008 showed a healed fracture.  Despite rehabilitation in physical therapy, she was not able to return to training and was entered into the MEB process.  The MEB NARSUM was dated 11 March 2009, 1 month prior to separation, and recorded complaints of constant pain in both ankles with the left being worse.  Flare-ups lasted one hour after prolonged periods of walking.  She was unable to run or march.  She was no longer under treatment and took Tramadol “only rarely” for pain.  The physical examination showed a normal gait and stance.  The CI was able to get on and off the examination table without difficulty.  The examiner noted 20 degrees of dorsiflexion and 40 degrees of plantar flexion for the left ankle with no weakness or incoordination.  The ankle was mildly tender.  The strength was normal and the ankle was stable.  At the 7 July 2009 VA Compensation and Pension (C&P) evaluation, performed 3 months after separation, the CI reported falling from a tower during basic training.  The line of duty recorded that she tripped jumping over a log en route to the chow hall.  She took Motrin twice a day for pain, but did not use an assistive device.  The physical examination showed evidence of painful motion, edema, tenderness and abnormal movement.  She had a limp; though on the same day she was examined for her knee condition by another physician, she was noted to have a normal gait.  The ankle was stable.  An X-ray showed a healed ankle status-post surgery.  The range of motion (ROM) examinations 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)	PT ~1 Mos. Pre-Sep	MEB ~1 Mos. Pre-Sep	VA C&P ~2 Mos. Post-Sep	
Dorsiflexion (20 Normal)	20	20	16	
Plantar Flexion (45)	40	40	33	
Comments	Painful motion	Motion pain free	Painful motion; Abn gait on one examination.  Nml on another	
§4.71a Rating	10%	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic left ankle pain condition 10%, coded 5099-5003 (arthritis, degenerative), citing painful motion, fatigability, incoordination and weakness.  The VA also rated the left chronic ankle pain condition 10%, coded 5271 (ankle, limited motion of), based on the VA C&P examination 2 months after separation, citing limitation due to pain.  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 left ankle condition.  

Medial Tibial Stress Injury.  According to the STRs and the MEB NARSUM, the CI’s tibial stress injury condition began in August 2008 while running and prior to the ankle fracture.  There was no specific injury or trauma noted.  There was one clinical note in evidence for the knee condition dated 1 August 2008.  At the March 2009 MEB examination (recorded on DD Forms 2807 and 2808), 1 month prior to separation, the CI had left knee pain over the tibia (shin bone).  The MEB NARSUM examination on 11 March 2009, 1 month prior to separation, noted complaints of knee pain with activity.  The physical examination showed no edema or effusion and negative testing for instability.  The gait and stance were normal and she was able to get on and off the examination table without difficulty as noted above.  Tenderness was present at the knee.  The ROM was slightly reduced as charted below.  A bone scan 2 weeks earlier had showed a stress injury to the left medial tibial plateau (the part of the knee made by the top of the shin).  It was noted that the ROM of both knees was normal.  At the 7 July 2009 VA C&P evaluation, performed 2 months after separation, the CI reported pain in both knees.  The CI reported no dislocations or recurrent subluxations.  The physical examination showed tenderness and crepitus (an audible or tactile sensation of grinding).  The knee was stable other than mediolateral laxity when stressed.  This was not otherwise recorded.  The gait was normal (but noted as abnormal the same day during the ankle examination as noted above).  Stiffness was noted, but painful motion was not.  The ROM examinations 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 Knee ROM
(Degrees)	PT ~1 Mos. Pre-Sep	MEB ~1 Mos. Pre-Sep	VA C&P ~2 Mos. Post-Sep	
Flexion (140 Normal)	128	128	0-125	
Extension (0 Normal)	3	0	0	
Comment	Painful motion	Neg Lachman’s 	Tenderness/Mild crepitus	
§4.71a Rating	10%	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the medial tibial stress fracture condition 10%, coded 5299-5262 (tibia and fibula impairment of), citing painful motion, fatigability, incoordination and weakness.  The VA rated the medial tibial stress fracture condition 0%, coded 5257 (knee, other impairment of), based on the C&P examination 2 months after separation, citing normal extension and flexion.  The Board found no route to a rating higher than the 10% 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 left knee condition.  

BOARD FINDINGS:  In the matter of the chronic left ankle pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic left medial tibial stress injury condition 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 20150601, w/atchs
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

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX, AR20170000787 (PD201500747)

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