RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01261
BRANCH OF SERVICE:  army	SEPARATION DATE:  20040915

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 pain left ankle” with a disability rating of 10%.

CI CONTENTION:  No specific contention was made.  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 - 20040708	VARD - 20051110	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain 
Left Ankle	5099-5003	10%	Residuals, Status Post Fasciotomy and Revision Fasciotomy Fascial Hernia, Left Lower Extremity	5099-5021	10%	20050707	
			Residual Scars	7804	10%	20050707	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:

Chronic Left Ankle Pain.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left ankle condition began in October 2003 with a painful lump in the distal left leg following running.  On 2 February 2004, the CI underwent an anterolateral left ankle fasciotomy to repair a fascial hernia.  He developed a post-operative infection and was hospitalized for intravenous antibiotics and therapy on 5 March 2004 which resolved.  

The 9 April 2004 physical therapy (PT) appointment, 5 months prior to separation, showed the CI with a near normal gait and a well-healing scab around the incision.  Though the infection was resolved the CI still had difficulty moving the ankle.  Left ankle range of motion (ROM) was dorsiflexion to -10 degrees from a neutral position; plantar flexion was within normal limits.  Electrodiagnostic studies on 27 April 2004 revealed a normal evaluation; no evidence of left leg nerve injury.  During the 11 May 2004 orthopedic clinic appointment, 4 months prior to separation, the CI had a left ankle foot orthosis, or AFO, to provide support and alignment.  Examination showed left ankle dorsiflexion to 20 degrees and plantar flexion was 45 degrees with decreased sensation and strength (3+ to -4/5).  

During the 2 June 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported left foot drop with use of a brace.  Physical examination documented decreased left ankle ROM and a “drop foot abnormal gait.”  There was pitting edema and decreased strength.  

The 2 June 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of left ankle pain, weakness, stiffness, and swelling.  Physical examination showed a well-healed longitudinal scar over the distal anterior lateral leg.  There was sensory numbness over a 4-inch strip at the dorsum on the left foot.  Ankle dorsiflexion, eversion and inversion strength were decreased (4/5) with normal ankle plantar flexion strength.  On examination the left ankle dorsiflexion was -25 degrees and plantar flexion was 45 degrees.  At the 6 August 2004 orthopedic clinic appointment, 1 month prior to separation, the CI continued to complain of left ankle pain with decreased ROM.  On examination the left ankle dorsiflexion was -10 degrees and plantar flexion was 30 degrees.  Gait was decreased with heel-to-toe exercises, there was 4-/5 weakness of the extensor digitorum longus, and decreased sensation.  The CI was to use an articulating AFO and continue PT as tolerated.  

At the time of the orthopedic clinic appointment on 22 March 2005, 6 months after separation, the CI reported a “knot” on the left leg with continued left leg pain and swelling.  The examiner noted the history of left leg surgery in February 2004, the post-operative staph infection, and the left foot drop along with treatment with an AFO.  There was decreased sensation laterally over the scar and tenderness over the anterolateral left leg.  The CI was diagnosed again with fascial hernia.  On 23 March 2005, 6 months after separation and after failing conservative care, surgery was again performed on the left leg for fascial hernia and complete release of the anterolateral compartments.  

At the 7 July 2005 VA Compensation and Pension (C&P) evaluation, 10 months after separation, the CI reported swelling in his left calf and ankle to mid foot.  He experienced a flare-up of ankle pain twice a week, lasting 12 hours, with a pain intensity of 6-7/10.  The CI reported the pain as constant and aggravated by heavy lifting and stated he had numbness over the area of the scars on his left lower leg.  Physical examination showed left ankle ROM dorsiflexion to 20 degrees and plantar flexion was 40 degrees; repetition did not increase pain or cause fatigability.  There was no crepitus with ROM.  Rising on heels or tiptoes did not elicit subjective or objective complaints of pain.  There was no abnormality in alignment of the Achilles tendon.  Sensation was intact.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 10%, analogously coded 5099-5003 (arthritis, degenerative), citing the US Army Physical Disability Agency pain policy.  The VA also rated the left ankle condition 10%, analogously coded 5099-5021 (myositis), based on the C&P examination 10 months after separation, citing the condition was analogous to a disability in which not only the functions are affected, but anatomical localization and symptoms are also closely related.  The VA additionally rated the left leg scar at 10%, coded 7804 (painful scar), citing scar tenderness.  

The VA examination was following a second left ankle surgery and had little probative value for rating at separation (prior to surgery).  The VA-rated tender scar was also following additional surgery, and there was no evidence of a duty-limiting scar proximate to separation.  
The post-separation VA examination was adjudged as post-separation improvement following additional surgery after separation.  The panel determined the MEB, MEB NARSUM and pre-separation evaluations had the highest probative value for rating at separation.  Members agreed the ROM evidence proximate to separation was more reasonably characterized as “marked” limitation of motion consistent with the 20% rating under diagnostic code 5271.  There was no ankylosis of the ankle or foot injury for any higher rating under codes 5270 (ankle, ankylosis) or 5284 (foot injuries, other).  As the CI’s surgery involved the tissues and fascia of the distal tibia and fibula, the panel considered alternative rating analogous to code 5262 (tibia and fibula, impairment) IAW VASRD §4.20 (analogous ratings).  The panel adjudged the CI’s foot drop, use of an AFO, weakness and other symptoms most closely approximated a marked ankle disability that was best rated as 5271-5262 at 30%.  There was no evidence of nerve injury for alternative rating under §4.124a (neurological conditions and convulsive disorders), and alternative rating analogous to lower leg muscle injury IAW VASRD §4.73 (muscle injuries) and §4.56 (evaluation of muscle disabilities) would not provide for any 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 30% for the left ankle condition, coded 5271-5262.

BOARD FINDINGS:  In the matter of the chronic left ankle pain condition, the panel unanimously recommends a disability rating of 30%, coded 5271-5262 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.

The panel recommends the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Left Ankle Pain	5271-5262	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160920, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record  

AR20180000482, XXXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,					      
						      					
Enclosure