RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX  	CASE:  PD-2016-01033
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20040629

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 “chronic left ankle pain post left ankle surgery” with a disability rating of 0%.  

CI CONTENTION:  “My ankle and foot have only gotten worse…”  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 - 20040405	VARD - 20040715	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Ankle Pain…	5099-5003	0%	Posttraumatic Arthritis…	5271	10%	20040513	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Left Ankle Pain Post Left Ankle Surgery.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI injured his left ankle prior to service.  This was treated surgically and followed by a successful rehabilitation.  This was reported and was cleared at accession.  He re-injured his left ankle condition in February 2003 after hyper-dorsiflexion (toes up).  An MRI was suspicious for a tear of one of the ankle ligaments.  The CI underwent an arthroscopy of the left ankle on 14 October 2003; these records are not in evidence.  However, despite the surgery and rehabilitation, he was not able to return to full duty and entered into the MEB process.  The MEB NARSUM dated 14 January 2004, 5 months prior to separation, noted continued left ankle pain.  The physical examination noted minimal tenderness without edema.  There was increased discomfort with valgus and varus stress and with resisted dorsiflexion.  Instability was not recorded.  The Podiatry MEB addendum, 5 days later, noted a well-healed 16 cm scar without evidence of hypertrophy or focal edema.  Dorsiflexion was limited to 10 degrees (20 is normal) and plantar flexion (toes down) to 20 degrees (45 is normal).  Tenderness was present as was abnormal sensation about the scars.  Instability was not documented on the examination although it was listed under the diagnoses.  

At the VA Compensation and Pension (C&P) examination performed on 13 May 2004, 1 month before separation, the CI reported that he had difficulty climbing stairs.  The physical examination recorded a normal gait and strength.  Scars were noted to be present, but the examination was otherwise only remarkable for a limitation in motion to 15 degrees dorsiflexion and 30 degrees plantar flexion.  Painful motion was not recorded.  He was thought to have residual fibrosis (scarring).  X-rays showed expected post-surgical changes.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 0%, coded analogously 5099-5003 (degenerative arthritis), citing that the condition existed prior to service (EPTS), was permanently service aggravated and was rated for pain.  A formal EPTS deduction was not specified.  The panel did not find evidence to support a determination that the ankle would have been rated at 10% or higher at accession; accordingly, no deduction is recommended for the EPTS component.  The VA rated the left ankle condition 10%, coded 5271 (limited motion of the ankle), citing moderate limitation of motion of the left ankle.  The panel considered if the limitation of motion was “moderate” or “marked” when considered under 5271.  All panel members agreed the limitation of motion was no more than “moderate,” therefore supporting the 10% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left ankle condition, coded 5271.  

BOARD FINDINGS:  In the matter of the left ankle condition, the panel unanimously recommends a disability rating of 10%, coded 5271 IAW VASRD §4.71a.  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…	5271	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160922, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170018587, 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