RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01383
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040327

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Cavalry Scout, medically separated for “left ankle pain with a history of an injury in Iraq and subsequent surgery,”  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 - 20040114	VARD – 20040329	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Ankle Pain…	5271	10%	Left Fibular Fracture Status Post (S/P) Surgical Repair with Residual Scars 	5271	20%	Service Treatment Record (STR)	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Left Ankle Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left ankle condition began in June 2003 after he sustained a fracture with fragmentation.  The CI underwent surgical fixation of his left ankle fracture on 24 June 2003.  The MEB forwarded “left ankle pain with decreased range of motion (ROM), status post open ankle fracture secondary to war fragmentation …” for PEB adjudication.
	
The 10 October 2003 MEB NARSUM examination, approximately 6 months prior to separation, noted complaints of left ankle pain with any motion and/or prolonged standing.  The physical examination (PE) revealed decreased ROM of the left ankle noting plantar flexion of 15 degrees (normal 45) and dorsiflexion of 10 degrees (normal 20).  The 15 December 2003 MEB addendum, 3 months prior to separation, documented left ankle ROM as normal plantar flexion and 0 degrees of dorsiflexion.  At the 09 April 2004 VA Compensation and Pension (C&P) evaluation,  13 days after separation, the CI reported that his ankle was not as flexible and had occasional pain if he played basketball.  His PE revealed decreased and non-painful ROM of his left ankle noting plantar flexion of 15 degrees and dorsiflexion of 10 degrees.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 10%, coded 5271 (ankle, limited motion).  The VA rated the left ankle condition 20% coded 5271, based on the C&P examination 13 days after separation, citing marked limitation of motion.  Absent evidence of joint ankylosis or deformity due to malunion on the more probative VA examination, the Board concurred that a ROM rating was most 
of ankle dorsiflexion would support an impairment level above that of moderate at 10%.  Additionally, the Board considered whether a rating under the VASRD code for other foot injuries (5284) provided for a higher rating (§4.7); noting rating levels of ‘moderate’ at 10%, ‘moderately severe’ at 20% and ‘severe’ at 30%.  All Board members agreed that the severity of the left ankle motion was well above a ‘moderate’ and just below that of a severely impaired condition; equating to a 20% impairment as ‘moderately severe’.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the left ankle pain condition, coded 5271.

BOARD FINDINGS:  In the matter of the left ankle condition, the Board unanimously recommends a disability rating of 20%, coded 5271 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Ankle Pain	5271	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150617, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170006003, XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure