RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00955
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030414

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

CI CONTENTION:  The CI requests review all conditions.  His 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 -20330210	VARD - 20030314	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Ankle Pain	5099-5003	10%	Left Ankle Instability, Post Brostrom Reconstruction	5299-5271	10%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Left Ankle Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent surgical reconstruction of the left ankle secondary to instability in July 2002.  Despite surgery and post-operative rehabilitation, his pain continued.  The CI’s condition could not be adequately rehabilitated to meet the physical requirements of his military specialty and the CI was referred for MEB.  The MEB forwarded “left ankle pain of unclear etiology,” for PEB adjudication.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated November 2002, 3 months prior to separation, the CI reported pain on standing for prolonged periods of time.  His Physical examination (PE) revealed tenderness about the left ankle.  The MEB NARSUM examination on 25 November 2002, 3 months prior to separation, noted complaints of 3 -7/10 pain on the left ankle related to activity and prolonged weight bearing.  His PE revealed tenderness over the outside of the left ankle.  There was no joint instability or abnormal sensory/motor actions.  Left ankle range of motion (ROM) was recorded at 10 degrees dorsiflexion (normal 20) and normal plantar flexion.  There was no VA Compensation and Pension (C&P) examination contained in the case file.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 10%, coded 5099-5003 (arthritis, degenerative), citing the US Army Physical Disability Agency (USAPDA) pain policy, rating pain.  The VA also rated the left ankle condition 10% analogously coded 5299-5271 (ankle, limited motion), based on the STR citing full ROM with tenderness.  Absent joint ankylosis or evidence of a deformity from malunion, the 10 degree limitation of ankle dorsiflexion did not support a higher rating under code 5271 at moderate (10%) impairment.  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’s 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 modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150605, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander

08 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170000894 (PD201500955)

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