RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00857
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070530

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Wheeled Vehicle Mechanic, medically separated for “left ankle pain,” with a disability rating of 20%.

CI CONTENTION:  “I was reviewed and didn’t get anything…”  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 - 20070507	VARD - 20110111	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Ankle Pain	5099-5003	20%	Residuals of Left Ankle Surgery	5271	NSC	STR	
			Scars due to Left Ankle Surgery	7804	NSC	STR	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:

Left Ankle.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left ankle condition began in March 2006 during physical training.  Diagnostic imaging (MRI) showed torn ligaments consistent with the reported sprain.  The CI underwent an open left ankle ligament reconstruction in June 2006, but did not have improvement sufficient to allow unrestricted duty.

On 31 August 2006, the CI was seen in orthopedics and reported persistent pain.  However, he had normal gait and posture and the range of motion (ROM) was full but painful.  He continued to have normal findings when again evaluated on 25 September 2006 and testing for instability was normal as well.  These findings were stable on the next two orthopedic evaluations and in primary care on 20 December 2006, which revealed full ROM with painful motion.  He did have sensory impairment of the sural nerve though.

At the MEB NARSUM on 27 April 2007, 1 month prior to separation, the CI noted constant ankle pain with daily activities.  The examination noted neuropathy on the left side and an effusion.  No comment was made on either the gait or stability.  The ROM was dorsiflexion 5 degrees (normal 20) and plantar flexion 40 degrees (normal 45).  The MEB forwarded “joint pain localized in the ankle after surgery” and “joint instability ankle/foot (status post-surgical repair)” for PEB adjudication.

The CI did not report for the scheduled VA Compensation and Pension examination.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 20%, coded analogously 5099-5003 (degenerative arthritis), citing the US Army Physical Disability Agency pain policy.  The VA did not service connect the left ankle condition, citing failure to report for a scheduled VA examination.

The Board agreed that the NARSUM ROM examination most proximate to separation detailed above was consistent with a marked limitation of motion for the maximum 20% rating under this code.  It also noted that these values were outliers from the other ROM assessments which were typically normal.  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 left ankle condition.

BOARD FINDINGS:  In the matter of the left ankle 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 20150604, 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, AR20160019327 (PD201500857)

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