RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  pd-2015-01516
BRANCH OF SERVICE:  army	SEPARATION DATE:  20020926

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

CI CONTENTION:  “Review all conditions.”  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination 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(s) at the time of separation.  The panel 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 panel 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 - 20020729	VARD - 20030127	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Ankle Pain Secondary to Degenerative Joint Disease	5003	10%	Right Ankle Arthrosis and Impingement	5271	10%	20030109	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Right Ankle.  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI initially injured his right ankle while in the US Marine Corps (USMC) in November 1996.  He sustained an avulsion fracture and underwent arthroscopic surgery in January 1998.  This was subsequently revised in January 1999.  He was medically discharged from the USMC on 31 August 1999 for the right ankle condition.  One year later, the CI sought entry into the US Army.  On the accession history dated 6 November 2000, he disclosed the prior medical separation from the USMC and was referred for an orthopedic evaluation which was accomplished on 1 December 2000.  The CI reported no problems with his right ankle including no pain or swelling.  X-rays were normal and muscle atrophy was absent.  The ankle was stable without ligamentous laxity.  The right ankle range of motion (ROM) was diminished compared to the left as charted below, but both ankle ROMs were less than VA normal values.  On 11 April 2001, the CI reported a right ankle sprain after stepping on the person in front of him in a group run.  He was treated with duty restrictions and crutches.  He was returned to duty, but had continued pain with running.  In primary care on 5 June 2001, he was noted to have full ROM and strength, but bruising and swelling.  An MRI on 11 September 2001 showed ligamentous tears and effusion.  In physical therapy on 3 October 2001, the CI continued to report ankle pain aggravated by activity.  Plantar flexion (toes down) was 50 degrees (normal 45) and dorsiflexion (toes up) 10 degrees (normal 20).  An X-ray the next day (per the NARSUM) showed a small bony spur.  The ROM findings were unchanged at a physical therapy appointment 1 month later.  On examination in orthopedics on 5 February 2002, the CI was noted to have DJD (degenerative joint disease) of the ankle.  It was stable.  An MEB was recommended.  

The 26 June 2002 MEB NARSUM, 3 months prior to separation, noted constant right ankle pain.  It recorded that the CI had received 2 steroid injections without benefit.  On examination, there was tenderness, but no swelling.  The CI could walk on his heels and toes without difficulty.  The ROM from physical therapy was decreased as charted below.  

At the 9 January 2003 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported chronic pain and stiffness and intermittent swelling of the right ankle.  He did not use an assistive device or brace.  He reported that he was able to run a short distance.  The physical examination showed he walked without an antalgic gait.  Severe pes planus was present.  There was no effusion, discoloration or increased warmth of the right ankle.  He had well-healed ankle scars.  The ROM was painful and limited as charted below.  There was no evidence of instability.  It was noted that there were arthritic changes on the X-rays, although these were labeled as the left ankle.  It is not clear if this was a typographical error or actually of the left ankle.  The ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Right Ankle ROM
(Degrees)	MEPS Orthopedic Evaluation 	MEB ~3 Mos. Pre-Sep	VA C&P ~3 Mos. Post-Sep	
Dorsiflexion (20 Normal)	5 (Left 10)	0	0	
Plantar Flexion (45)	40 (Left 40)	45 (60)	40	
Comments	Pain free		Painful motion	
§4.71a Rating	10%	10%/20%	10%/20%	

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right ankle condition 10%, coded 5003 (arthritis, degenerative).  The VA rated the right ankle condition 10%, coded 5271, (limited motion of the ankle), citing moderate limited motion of the ankle.  The panel considered if the limitation of motion was moderate or marked when considered under 5271, limitation of ankle motion.  It noted that dorsiflexion was limited to 0 degrees on the MEB and VA examinations proximate to separation.  This would typically be consistent with a marked limitation in motion and support a higher 20% rating.  However, the gait was normal.  At accession, dorsiflexion was 5 degrees and the uninjured left side was limited to 10 degrees.  The CI also reported to the VA examiner that he could still run, albeit short distances.  All panel members agreed that the totality of the evidence supported a moderate limitation of motion and the 10% rating adjudicated by the PEB.  

The panel considered alternative VASRD coding options, but none were more applicable or advantageous to the CI.  There was no ankylosis of the ankle or subastragalar (sub-tarsal) joints, no malunion of the os calcis (calcaneus) or astragalus (talus) or astragalectomy for consideration under the respective diagnostic codes (5270, 5272, 5273 or 5274).  The panel also considered whether ratings under the VASRD code for other foot injuries (5284) provided for a higher rating (§4.7), however all Board members agreed that the impairment did not more nearly approximate moderately severe to support a higher rating.  The panel did not find evidence that a tender or painful scar separately interfered with duty and therefore a separate rating was not recommended for unfitting scar.  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 are no other conditions within the panel’s scope of review for consideration.  The panel, 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 20150620, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record  

AR20170009558, 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