RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01582
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20040430

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Indirect Fire Infantryman, medically separated for “chronic left ankle pain following tibia-fibula fracture” with a disability rating of 0%. 

CI CONTENTION:  His ankle condition negatively impacts daily activities and now affects his back.  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 MEB, but determined by the PEB 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 – 20040406	VARD – 20040723	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Ankle Pain…	5099-5003	0%	Status Post Open Reduction Internal Fixation of Left Ankle… 	5271	20%	20040619	

ANALYSIS SUMMARY:  

Chronic Left Ankle Pain.  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI fractured his fibula (lateral ankle) on 11 February 2003 during airborne operations and underwent an open reduction with internal fixation the following day.  Due to continued ankle pain, the hardware was removed on 22 October 2003, but did not result in sufficient pain relief.  At a 12 January 2004 orthopedic clinic appointment, 3 months after surgery and 5 months prior to separation, range of motion (ROM) was dorsiflexion to 10 degrees (normal 20) and plantar flexion to 25 degrees (normal 45).  

During the 3 February 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported continued ankle pain after two surgeries.  Physical examination revealed tenderness with decreased flexion and extension.  Physical therapy ROM measurements on 4 February 2004 were dorsiflexion to 10 degrees and plantar flexion to 50 degrees.  The 4 March 2004 MEB NARSUM examination, 2 months prior to separation, noted constant pain with exacerbations despite hardware removal.  The CI also complained of ankle popping and crepitus.  Physical examination showed a normal gait, tenderness along the lateral scar, and no erythema or effusion.  ROM was recorded as dorsiflexion to 13 degrees and plantar flexion to 42 degrees.  At the 19 June 2004 Joints VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported pain related to activities like going up or down stairs and hills and carrying heavy objects.  Physical examination showed no effusion, swelling or tenderness.  Left ankle ROM was dorsiflexion to 5 degrees and plantarflexion to 35 degrees.  

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 no significant loss of motion.  The VA rated the left ankle condition 20%, coded 5271 (limited motion of the ankle), based on the C&P examination 2 months after separation, citing marked limitation of motion.  The panel agreed that the ROM examinations proximate to separation were consistent with the “moderate” limitation of motion required for the 10% rating under code 5271, but failed to rise to the level of “marked’ for the next higher rating.  There was no evidence of nonunion or malunion of the tibia and/or fibula to validate a rating using code 5262.  There are no other applicable codes.  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 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 20160914, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record  

AR20180001860, XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

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