RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01466
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20040805

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E6, Bridge Crewmember, medically separated for “post traumatic degenerative changes, left ankle, following open tibial fracture” and “chronic pain left foot” rated 20% and 0%, respectively, with a combined disability rating of 20%.  

CI CONTENTION:  “Amputation of left leg. Also not rated for his PTSD, depression, anxiety, loss of hearing, or right foot injury.”  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 conditions at the time of separation.  The panel has neither the role nor the authority to compensate for progression or complications of service-connected conditions after separation.  That role and authority is granted by Congress to the Department of Veterans Affairs (VA), 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 - 20040622	VARD - 20040816	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Post Traumatic Degenerative Changes, Left Ankle	5271	20%	Degenerative Joint Disease, Left Ankle, Post Open Reduction Internal Fixation	5010-5271	20%	STR	
Chronic Pain Left Foot	5099-5003	0%	Fracture, Metatarsal of Toe 2, Left Foot	5299-5284	0%		
			Fracture, Metatarsal of Toe 3, Left Foot	5299-5284	0%		
			Fracture, Metatarsal of Toe 4, Left Foot	5299-5284	0%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Post Traumatic Degenerative Changes, Left Ankle.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left ankle condition began in April 2003 after a motor vehicle accident in Iraq.  The 5 May 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of left ankle pain and stiffness.  Physical examination showed left tibial fracture site non-tender to palpation and healed soft tissue.  There was evidence of slight erythema (redness).  Dorsiflexion to neutral (normal 20) and plantar flexion to 5 degrees (normal 45).  Ankle dorsiflexion and plantar flexion strength was 3/5 secondary to pain

At the 8 April 2005 VA Compensation and Pension (C&P) evaluation, 8 months after separation, the CI reported left below the knee amputation on 2 November 2004 (3 months after separation) due to osteomyelitis (bone infection).  He reported daily phantom pain which was alleviated by rest.  He reported use of a prosthesis.  Physical examination showed steady gait with a slight left limp and a well healed stump.  There was no left thigh muscle atrophy.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 20%, coded 5271 (limited motion of the ankle), citing dorsiflexion to neutral and plantar flexion 5 degrees rated as marked limitation of motion.  The VA rated the left ankle condition 20%, coded 5010-5271, (limited motion of the ankle due to traumatic arthritis), based on the STR, citing marked limited motion of the ankle.  There was no evidence of ankle ankylosis for a higher than 20% rating as 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 left ankle condition.  

Chronic Pain Left Foot.  According to the STR and the MEB NARSUM, the CI’s left foot condition began in April 2003 after a motor vehicle accident in Iraq.  The CI underwent closed reduction, percutaneous pinning, and a fasciotomy.  The 5 May 2004 MEB NARSUM physical examination showed site of the metatarsal fractures was non-tender to palpation.  The left foot was neurovascularly intact.  The examiner noted the CI was able to move his toes spontaneously, but did not address limitation of, or painful motion.  The 18 June 2004 physical therapy range of motion was noted as limited motion in the distal interphalangeal and proximal interphalangeal joints in all toes.  

The physical findings from the 8 April 2005 VA C&P evaluation were noted above.  Radiographic evaluation of the left foot 3 weeks after separation noted a partial collapse of the talar dome and infection/inflammation of the talar bone.  Multiple VA treatment notes documented reports of pain in the mid-foot and physical findings of pain with motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left foot condition 0%, coded 5099-5003 (analogous to arthritis, degenerative), citing minimal/occasional pain rated IAW the US Army Physical Disability Agency pain policy.  The VA rated the left foot condition by providing three separate ratings for fractures of the metatarsal in toes 2, 3, and 4 of the left foot, all rated 0% and coded 5299-5284, (analogous to foot injuries, other), based on the STR.  The VA cited full range of motion of the toes with no clinical findings of pain, sensitivity, or functional limitation, and indicated the 0% ratings resulted from an absence of moderate symptoms associated with foot injury.  

The panel noted that the CI underwent a left below the knee amputation 2 months after separation for osteomyelitis of the left leg and foot.  The panel noted evidence of left lower extremity cellulitis prior to separation.  The panel also noted that service and VA treatment notes documented metatarsal limitation of motion and mid-foot painful motion.  Panel members agreed that the evidence supports a 10% rating for metatarsalgia (5279) or moderate impairment due to foot injury (5284).  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 foot condition, coded 5284.  

BOARD FINDINGS:  In the matter of the left ankle condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the left foot condition, the panel unanimously recommends a disability rating of 10%, coded 5284 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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Post Traumatic Degenerative Changes, Left Ankle	5271	20%	
Chronic Left Foot Pain 	5284	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160923, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180001438, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

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.

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

Sincerely,					      
Enclosure