RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01086
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20041008

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 right ankle pain” with a disability rating of 0%.

CI CONTENTION:  The CI made no specific contention.  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 - 20040604	VARD - 20060511	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Ankle Pain	5010	0%	No VA Placement	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NSC*	
*Not service connected

ANALYSIS SUMMARY:

Right Ankle.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI complained of right ankle pain in January 2003.  X-rays on 30 January 2003 revealed no acute fracture, dislocation or bony lesion.  Prior to service (July 1999) the CI broke his right ankle and underwent an open reduction internal fixation with hardware which was removed a year later.  The CI had no problems with his ankle during basic training or advanced individual training.  At the 2 February 2003 orthopedic clinic appointment, the CI reported “every day-all day” throbbing pain in his right ankle after rolling his ankle a couple dozen times in the previous 6 months.  The examiner noted a positive anterior impingement sign.  The 22 February 2003 diagnostic imagining (MRI) revealed findings consistent with surgical repair.  There was degenerative changes within the anterior ankle joint.  At the 6 March 2003 follow-up orthopedic evaluation, the CI denied pain.  Physical examination revealed “full” range of motion (ROM) and no tenderness to palpation.  During the 9 February 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months prior to separation, the CI reported increasing right ankle pain.  Physical examination showed “full” ROM without pain and no tenderness to palpation.  The CI was able to heel, toe and duck walk without problems or pain.  The 19 February 2004 MEB NARSUM examination, 8 months prior to separation, noted complaints of constant throbbing aggravated with prolonged walking, jogging or driving long distances.  Physical examination showed well healed surgical scars above the medial malleolus.  There was “full” ROM without pain and no tenderness to palpation.  The CI was able to heel, toe and duck walk without problem or pain.  The 2 March 2004 physical therapy examination, 7 months prior to separation, repetitive ROM showed right ankle dorsiflexion to 5 degrees (20 normal) and plantar flexion to 30 degrees (45 normal); painful motion was addressed.  The 9 April 2004 orthopedic evaluation, 6 months prior to separation, recorded dorsiflexion to 10 degrees and plantar flexion to 25 degrees; painful motion was not addressed.  There was no instability with anterior drawer or lateral talar tilt testing.  Strength testing was normal.  There was no VA examination in evidence proximate to separation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right ankle condition 0%, coded 5010 (degenerative arthritis, due to trauma) citing full ROM without ligamentous laxity or neurological deficit.The panel agreed that the physical therapy and orthopedic ROM examinations proximate to separation were consistent with a “moderate” limitation of motion to support a 10% rating under code 5271 (ankle, limitation of motion).  Because there was no ankylosis, nonunion or malunion, 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 recommends a disability rating of 10% for the right ankle condition, coded 5271.

BOARD FINDINGS:  In the matter of the chronic right ankle pain 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 Right Ankle Pain	5271	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160924, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170018121, 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