RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00215
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040714

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Petroleum Supply Specialist, medically separated for “post-traumatic degenerative arthritis right ankle” with a disability rating of 10%.

CI CONTENTION:  “Review all conditions.”  The 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 - 20040427	VARD - 20050404	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Post-Traumatic Degenerative Arthritis Right Ankle	5010	10%	Residuals, Right Ankle Ligament Reconstruction with Osteoarthritis	5010-5271	10%	20050110	
RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

Right Ankle Arthritis.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right ankle was severely sprained in 2000 and again in April 2003 while deployed to Iraq where he stepped in a deep hole during a sand storm.  In October 2003 he received surgical reconstruction of the right ankle lateral collateral ligaments.  The 23 February 2004 MEB examination (recorded on DD Forms 2807 and 2808), 5 months prior to separation, revealed right ankle lateral aspect edema and tenderness to palpation and decreased range of motion (ROM) for eversion, inversion, pronation, and supination due to pain.  Dorsiflexion and plantar flexion were intact. 

The 30 March 2004 MEB NARSUM examination, 4 months prior to separation, noted complaints of constant right ankle pain with occasional “giving-way”.  He reported only being able to walk for 2 minutes or 100 yards before he had to stop due to pain.
Physical examination showed a negative drawer test (ligament instability), and inversion motion to approximately 45 degrees.  The ROM was dorsiflexion 5 degrees (normal 20) and plantar flexion 30 degrees.  Gait and painful motion were not addressed. 

At the 10 January 2006 VA Compensation and Pension (C&P) general evaluation, performed 6 months after separation, the CI walked with a noticeable limp and wore a right-ankle brace.  On this same date, during the VA Compensation and Pension (C&P) joint evaluation, the CI reported having some right ankle pain, weakness, stiffness, swelling and give-way.  He also reported being able to work involving standing, walking and physical mechanic and driver work.  Repetitive ankle use and weather irritated his ankle.  Physical examination showed the CI was able to raise from toes and heels and squat, and was able to walk and stay in standing position without restrictions.  There was right ankle lateral tenderness to palpation, stable lateral and anterior/posterior stability testing without ankle or foot swelling or deformity.  ROM was plantarflexion to 45 degrees with painful motion. 
 
The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right ankle condition 10%, coded 5010 (degenerative arthritis due to trauma).  The VA also rated the right ankle condition 10% analogously coded 5010-5271 (degenerative arthritis due to trauma-ankle, limitation of motion), based on the C&P examination 6 months after separation, citing moderate limited motion.

Panel members agreed the limitation of motion was no more than moderate, supporting the 10% rating under code 5271.  A higher rating of 20% was not indicated in the absence of marked limited ROM of the ankle.  There was no ankylosis, nonunion or malunion, VASRD §4.71a offers no applicable joint code which would yield a rating higher than the 10% rating adjudicated by the PEB.  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 post-traumatic degenerative arthritis 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 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 20160415, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170014108, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	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