RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01661
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040508

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Light Wheel Vehicle Mechanic, medically separated for “right ankle pain” with a disability rating of 0%.

CI CONTENTION:  His condition should have been rated higher.  The complete submission is 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 - 20040227 	VARD - 20040902	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Ankle Pain	5099-5003	0%	Residuals Right Ankle Injury	5271	10%	20040722	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:

Right Ankle Pain.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right ankle condition began in 2000 during a unit run.  Orthopedics diagnosed right ankle instability, and on 6 November 2001, the CI underwent a right ankle Evans reconstruction (to treat mechanical instability of lateral ankle ligaments).  

A physical therapy visit in April 2002 noted constant right ankle pain and no progression with running.  Examination revealed “good” range of motion (ROM) and strength.  In July 2002, the CI reported reinjuring the right ankle when he rolled off a curb; magnetic resonance imaging (MRI) showed possible tearing of the peroneal brevis tendon reconstruction.  At an orthopedic visit in September 2002, the examiner noted no further surgical options for the right ankle pain.
The 12 November 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, noted right ankle pain with prolonged standing.  At the 23 January 2004 MEB NARSUM examination, 4 months prior to separation, the CI complained of chronic right ankle pain secondary to the reconstruction surgery, but was not taking medication or undergoing physical therapy.  Physical examination showed mild right ankle swelling and tenderness, no instability, and normal bilateral strength.  Right ankle goniometric-measured dorsiflexion was 15 degrees (normal 20) and plantar flexion was 60 degrees (normal 45); painful motion was not addressed.  X-rays also taken on 23 January 2004 revealed good ankle alignment with no tibial or talar arthrosis.  There was evidence of ossification (bone formation) at the Evans ankle reconstruction site, which did not appear to touch other bony surfaces.

At the 22 July 2004 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported constant right ankle pain with stiffness but without weakness.  He did not use any braces, assistive devices, or corrective shoes.  Physical examination showed normal posture and gait without pain, mild right ankle swelling, tenderness, and no heat or skin discoloration.  Dorsiflexion was 18 degrees and decreased to 13 degrees with repetition.  Plantar flexion was 35 degrees and decreased to 30 degrees with repetition; painful motion increased with repetition.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right ankle condition 0%, analogously coded 5099-5003 (degenerative arthritis), citing moderate/intermittent pain.  The VA rated the right ankle condition 10%, coded 5271 (ankle, limited motion), citing moderate limited motion.  Members agreed the right ankle limitation of motion did not reach a “marked” level for a 20% rating, but was more appropriately rated as a “moderate” disability which supports a 10%.  There was no ankylosis of the ankle or subastragalar (sub-tarsal) joints, no malunion of the os calcis (calcaneus) or astragalus (talus), and no astragalectomy for consideration under the respective diagnostic codes (5270, 5272, 5273 or 5274).  The panel also considered VASRD code 5284 (foot injuries, other); however, members agreed that the impairment did not more nearly approximate “moderately severe” to support a 20% rating under this code.  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 pain condition, coded 5271.

BOARD FINDINGS:  In the matter of the 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 the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Right Ankle Pain	5271	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161011, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 
AR20180002569, 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