RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  pd-2016-00833
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 E1, Signal Support Specialist, medically separated for “chronic left ankle pain” with a disability rating of 0%.  

CI CONTENTION:  “Issues still with ankles and multiple surgeries.  I have at least one more pending surgery.”  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 - 20040601	VARD - 20050104	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Ankle Pain	5009-5003	0%	Residual Left Ankle Achilles Tendonitis with Laxity	5271-5024	10%*	20041026	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	
*A Decision Review Officer Decision VARD changed the left ankle rating to 20%, coded 5024-5271, effective 20040715.  

ANALYSIS SUMMARY:  

Chronic Left Ankle Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic left ankle pain (left ankle) condition began in September 2003 when it reportedly popped during a PT test.  She was taken to sick call the next day and was placed on crutches.  A bone scan in October 2003 showed a small focal area of increased tracer uptake in the mid shaft of the left tibia consistent with a small acute stress fracture.  X-rays in October and November 2003 showed no signs of bony abnormalities or fracture.  

The range of motion (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.  

Left Ankle ROM
(Degrees)	Ortho ~5 Mo. Pre-Sep	Ortho ~4 Mo. Pre-Sep	PT ~4 Mo.
Pre-Sep	MEB ~3 Mo.
Pre-Sep	C&P ~3 Mo.
Post-Sep	
Dorsiflexion (20 Normal)	-10	5	-5	5	-15	
Plantar Flexion (45)	55	50		50	50	
Comments	Limited motion	Painful motion	Antalgic gait	Limited motion	Limited motion	
§4.71a Rating	20%	10%-20%	20%	10%-20%	20%	

At the 11 February 2004 orthopedic clinic examination, 5 months prior to separation, the CI reported increased pain anteriorly in the left ankle as well as the Achilles insertion point.  Physical examination documented use of a cane for ambulation with tightness and tenderness of the Achilles tendon.  Range of motion (ROM) measurements were recorded per chart above.  The 25 March 2004 orthopedic evaluation, 4 months prior to separation, showed painful left ankle motion (ROM’s charted above), and a tender insertion of the Achilles tendon.  The specialist made a diagnosis of left Achilles tendonitis.  A 30 March 2004 Physical Therapy evaluation documented an “antalgic gait, missing dorsiflexion,” and active dorsiflexion “lacking 5 degrees of zero” (-5 degrees) as charted above.  

During the April 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported numbness in the left foot and tingling on the outside of the left leg.  She had used crutches or a cane for about 8 months, suffering from pain in the joint in front of the left ankle.  Physical examination showed no tenderness or swelling over the left tibia, but tenderness was noted over the left Achilles tendon.  Decreased ROM was noted in dorsiflexion.  

The 4 May 2004 MEB NARSUM, 2 months prior to separation, noted complaints of chronic daily pain which required use of a cane in order to ambulate.  The CI said the ankle felt weak and she had difficulty with dorsiflexion secondary to pain at the top of the foot and the ankle.  Physical examination from 15 April 2004, 3 months prior to separation, showed a normal but slow gait with use of a cane.  The CI could walk on her heels and her toes.  There was normal muscle bulk and tone of the lower extremities, and no swelling or redness in the ankle.  There was minimal point tenderness at the anterior joint line.  ROM measurements were recorded per chart above.  

At the 26 October 2004 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI reported stiffness of the left lateral malleolus (side of the ankle) in the morning with throbbing.  Standing more than 15 to 20 minutes caused the ankle to become swollen and numb.  The CI claimed to have an increased tendency for inversion sprain of the left ankle with increased walking more than 20 minutes.  The CI claimed she compensated for her left ankle pain and was in a dorsiflexion stance (on tippy toes) during normal ambulation.  Physical examination showed the CI had a normal gait.  There was mild swelling of the left lateral malleolus with mild tenderness to palpation of the left Achilles tendon with no palpable abnormality of the Achilles tendon itself.  There was good strength on plantar flexion.  ROM measurements were recorded per chart above.  The examiner noted the CI held the left ankle at 15 degrees of plantar flexion and could not dorsiflex the ankle back to 0 degrees.  No pain, fatigue, weakness, lack of endurance or incoordination were noted.  There was a left sided plantar flexion deformity of 15 degrees.  There was no inversion or eversion deformity and there was no ankylosis.  Later VA records indicated the CI underwent left ankle surgical correction in April 2006 (2 years after separation).  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 0%, analogously coded 5099-5003 (arthritis degenerative), citing U.S. Army Physical Disability Agency pain policy.  The VA initially rated the left ankle condition 10%, coded 5271-5024 (ankle limited motion-tenosynovitis), based on the C&P examination 3 months after separation, citing painful or limited motion of a major joint or group of minor joints.  A Decision Review Officer Decision retroactively changed the left ankle rating to 20%, coded 5024-5271 indicating the C&P examination supported marked limited motion of the ankle.  

The panel considered rating under the diagnostic code 5271, limited ankle motion.  The panel deliberated the probative value of the examinations and evidence in record.  Both the February 2004 orthopedic and post-separation C&P examinations documented inability of any left ankle dorsiflexion (less than 0 degrees), while the March 2004 orthopedic and NARSUM examinations showed dorsiflexion to 5 degrees.  The panel noted that other findings in the examinations such as gait, use of a cane, and heel walking did not always align with the formal ROM measurements, and that only the C&P examination considered repetition.  

The panel majority adjudged that the documented ROM limitations of dorsiflexion were consistent with a marked limitation of motion, supporting the 20% rating under this code.  Because there was no ankylosis of the ankle with plantar flexion less than 30 degrees, no nonunion or malunion, and insufficient evidence of a severe foot injury (5284), VASRD §4.71a offers no applicable joint code which would yield a higher rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 20% for the left ankle condition, coded 5024-5271.  

BOARD FINDINGS:  In the matter of the left ankle condition, the panel majority recommends a disability rating of 20%, coded 5024-5271 IAW VASRD §4.71a.  The single voter for dissent recommended modification to 10% and did not elect to submit a minority opinion.  There are no other conditions within the panel’s scope of review for consideration.  

The panel 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	
Chronic Left Ankle Pain	5024-5271	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160911, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170018014, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	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