RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01486
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050803

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Basic Trainee, medically separated for “left ankle pain,” with a disability rating of 10%.

CI CONTENTION:  The CI made no specific contention.  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 - 20050615	VARD – N/A	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Ankle Pain	5271	10%	No VA examination in evidence	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Left Ankle Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent left ankle surgery 24 February 2005 for open reduction and internal fixation (ORIF) of a bi-malleolar ankle fracture during basic training.  At the time of the orthopedic clinic appointment on 11 April 2005, 4 months before separation, the examiner recorded minimal edema of the left ankle with well healed incisions.  Ankle X-rays that same day revealed normal alignment, normal reduction of the fracture and no hardware complication.  An orthopedic visit on 9 May 2005 indicated the CI did not want to complete basic training and requested a MEB.  The MEB forwarded “left ankle pain status-post open reduction, internal fixation “for PEB adjudication.

At the MEB examination (recorded on DD Forms 2807 and 2808) dated May 2005, 3 months prior to separation, the CI reported continued swelling and deformity of the ankle.  Physical exam showed swelling at the surgical site and lateral and medial ankle scarring.  The MEB NARSUM examination on 9 May 2005, 6 months prior to separation, noted complaints of left ankle pain and swelling and inability to stand for prolonged periods and inability to ambulate without pain and/or limping.  Physical examination showed a well healed incision over both the medial and lateral aspects of the ankle.  The CI had range of motion (ROM) of 25 degrees of plantar flexion (PF-45 normal) and 15 degrees of dorsiflexion (DF-30 normal) with pain at extreme ROMs which was the same as the unaffected right ankle.  Pulses and sensation were intact over the entire foot.  The CI had intact posterior tibial muscle/tendon function.  The MEB NARSUM examiner noted left ankle X-rays showed a well healed bi-malleolar ankle fracture with no evidence of hardware complication, no evidence of non-union and a well maintained joint space.  A physical therapy appointment a few days later noted difficulty walking with stiffness, pain, and swelling of the ankle joint.  The measured active range of motion (ROM) for the left ankle (after three repetitions) showed PF of 20 degrees (45 normal) and DF of 0 degrees (30 normal) although a second copy of the same form revealed a strike-through of the active ROMs.  

There was no VA claim, evaluation, or treatment; and, no other post-separation evidence in this case.
The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle pain condition 10%, coded 5271 (ankle, limited motion of), citing 87% retained ROM and there was no VA examination in evidence for comparison.  The Board considered if the limitation of motion was best characterized as “moderate” or “marked” when considered under 5271 (limitation of ankle motion).  The Board noted that the conflict in the documentation of the physical therapy MEB ROM measurements on 13 May 2005 caused uncertainty as to their validity and also considered the experience of the orthopedic physician who performed the surgery and was the MEB NARSUM examiner, and concluded that the MEB NARSUM ROM examination detailed above was the most probative exam for the Board’s rating recommendation.  Additionally, at the time of both of these evaluations the Board noted that the CI was approximately 3 months from surgery, and accepted medical principles dictate full recuperation from this injury takes significantly longer.  The ankle pain, swelling, and ROM following ORIF of a bi-malleolar fracture were reasonably anticipated to improve further.  The ankle ROM at the MEB NARSUM exam was consistent with a moderate limitation of motion for the 10% rating under 5271.  The Board 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 of the fracture to warrant rating with this code.  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 pain condition.  

BOARD FINDINGS:  In the matter of the left ankle pain 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 20150606, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170006604, XXXXXXXXXXXXXXXXXX

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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