RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00855
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040601

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Wheel Vehicle Mechanic, medically separated for “ankle pain” with a disability rating of 10%.  

CI CONTENTION:  “Review all conditions.”  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 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 - 20040402	VARD - 20060510	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Ankle Pain	5099-5003	10%	Residual Right Ankle Pain, Fracture of Tibia and Fibula Right	5262-5271	0%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Right Ankle Pain Diagnosis.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s underwent surgical repair right a right tibia-fibula fracture in February 1999.  Status post-surgery, the CI developed ankle pain and swelling resulting in orthopedic limitations.  Despite treatment, the right ankle pain condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for a MEB.  The MEB forwarded “right ankle pain, status post open reduction internal fixation” for PEB adjudication.  

During the December 2003 MEB examination (recorded on DD Forms 2807 and 2808) 5 months prior to separation, the CI reported constant right ankle pain.  The physical examination showed decreased range of motion in all planes, mild tenderness to palpation over the lateral scar, and increased pain over the lateral ankle.  The 9 March 2004 MEB NARSUM examination, 2 months prior to separation, noted complaints of pain above the right lateral malleolus, inability to walk fast or for long periods, and ankle and knee pain occurring with “road marches”.  The physical examination showed dorsiflexion on the right at 85 degrees, plantar flexion at 30 degrees, internal rotation at 10 degrees, and external rotation at 5 degrees.  There was no VA Compensation and Pension examination in evidence proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the ankle condition 10%, coded 5099-5003 (analogous to arthritis, degenerative), citing painful motion.  The VA rated the ankle condition 0% coded 5262-5271 (tibia and fibula impairment/ankle, limitation of motion), based on the STR, citing chronic pain without objective findings.  The panel noted the underlying cause for the ankle impairment was residuals of a fracture of the tibia and considered rating using the VASRD diagnostic code 5262 (impairment of the tibia, fibula and ankle), however there was no malunion or nonunion to assign a rating.  There was no limitation of dorsiflexion or plantar flexion that supported a rating under the VASRD diagnostic code for limitation of motion (5271).  However there was evidence of painful motion causing functional loss supporting the 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right ankle condition.  

BOARD FINDINGS:  In the matter of the right ankle condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There were no other conditions within the panel’s scope of review for consideration.  The panel, 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

AR20170006563, XXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					       
						      					
Enclosure