RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00567
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050321

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Field Artillery Tactical Data System Specialist, medically separated for “chronic pain left knee” (should be “ankle”) with a disability rating of 10%.  

CI CONTENTION:  The VA rated him higher for the condition.  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 Medical Evaluation Board (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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20050207	VARD - 20050809	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain Left Ankle	5099-5003	10%	Talor Dome Fracture Left Ankle, Chronic Left Ankle Sprain	5271	10%	20050725	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40% 	

ANALYSIS SUMMARY:  

Chronic Pain Left Ankle.  According to the service treatment record and the MEB narrative summary (NARSUM), the CI’s condition began on 12 May 2003 when he fell nine feet from a guard tower while deployed. The CI was seen within 10 minutes and treatment consisted of ice and Motrin.  At an orthopedic clinic visit on 18 June 2003 the CI had diffuse ecchymosis (black and blue discoloration) and tenderness with point tenderness at the deltoid ligament and at the syndesmosis (of the distal tibia and fibula).  X-rays were normal.  The examiner’s impression was a syndesmotic ankle inversion injury that was radiographically normal.  Treatment was initially for a sprained ankle, which was determined after x-rays to be a class IV sprain.  The CI was then treated with a cast and returned to duty after the cast was removed on 17 August 2003.    On 21 January 2004 the CI reported pain in the left foot, although the ankle had improved until 1 month earlier when improvement leveled off.  There was tenderness of the anterolateral portion of the ankle joint.  An MRI on 9 June 2004, ordered for pain and catching of his ankle, showed a large joint effusion in the tibiotalar joint space and a talar dome fracture in the lateral aspect which measured 11 mm in diameter and extended into the talus 6 mm. The CI underwent left ankle surgery on 22 July 2004 for transection and resection of an impingement lesion and removal of a cartilage flap and loose osseous debris.  Holes to penetrate (chondral picking) the more sclerotic subchondral bone (osteochondral defect) were also made. Postoperatively, the CI still had left ankle pain and tenderness over the lateral arthroscopy portal sites, but an examination was otherwise normal.  A repeat MRI on 16 December 2004 showed a focal osteochondral defect of the lateral aspect of the talar dome and a suggestion of an intraarticular loose body.  On 1 December 2004 the CI had ankle joint swelling on the left in the anterolateral region.  Another surgery was recommended; however, the CI decided against it.  

Physical therapy (PT) ROM measurements on 19 January 2005 of the left ankle were dorsiflexion of negative 1 degree (normal 20) with 6/10 pain (10 being the worst pain), and plantar flexion 33 degrees (normal 45) with 3/10 pain.  Inversion was 25 degrees with no pain and eversion was 12 degrees with pain.  During the 25 January 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, the CI reported a talar dome fracture and surgery on the left ankle. Physical examination revealed decreased left ankle active ROM with crepitus (grinding sensation) and tenderness at the anterolateral aspect of the ankle.  There were also two healed scars on the lateral surface of the left ankle.  The 25 January 2005 MEB NARSUM examination noted the complaint of left ankle pain.  Physical examination incorporated the PT measurements of 19 January 2005 and mild crepitation (grinding sensation) was present for both ankles.  Anterior and posterior drawer tests to determine laxity were negative.  There was no edema, hyperemia, swelling, or induration.  There was tenderness over the anterolateral surface of the left ankle and over the anterior tibiofibular ligament.  The peroneal tendons were nontender and the Achilles tendon was normal.  Weight bearing, gait, and stance were normal.  

At the 25 July 2005 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported constant pain in the left ankle.  Physical examination showed equal leg length and no abnormal weight bearing signs on the feet.  The CI’s gait was abnormal with a limp on the left, but he did not require an assistive device for ambulation.  There was swelling and tenderness medially of the left ankle, but there was no deformity.  The ROMs of the left ankle were 20 degrees dorsiflexion and 45 degrees plantar flexion, both with painful motion.  Joint function was additionally limited by repetition, but the examiner could only speculate on the limitation in degrees.  Left ankle x-rays were within normal limits.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee (should be “ankle”) condition 10%, analogously coded 5099-5003 (arthritis, degenerative), citing the U.S. Army Physical Disability Agency pain policy and rated as slight.  The VA rated the left ankle condition 10%, coded 5271 (ankle, limited motion of), based on the C&P examination, citing moderate limited motion.  

The panel considered whether the limitation of motion was moderate or marked when considered under 5271, limitation of ankle motion.   The panel noted dorsiflexion was negative 1 degree and plantar flexion was 33 degrees with painful motion at the PT evaluation for the NARSUM, and determined that was more than moderately limited and more nearly approximating a marked degree of limitation.  Members noted that the VA ROMS were normal, but assigned more probative value to the PT measurements as they were more proximate to and preceded separation.  The panel then considered alternative VASRD ankle and analogous codes, but all were less applicable and not advantageous to rating.  However, code 5284 (foot injuries, other) does offer a 20% rating for a moderately severe injury, which was confirmed by both preoperative and postoperative MRIs as well as the recommendation for additional surgery that the CI declined.  A 30% rating for a severe injury could not be supported since the ROM normalized, albeit was painful and the CI walked with a limp.  

After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 20% for the chronic pain left ankle condition, coded 5284.  

BOARD FINDINGS:  In the matter of the chronic pain left ankle condition, the panel majority recommends a disability rating of 20%, coded 5284 IAW VASRD §4.71a.  The single voter for dissent recommends no change and did not elect to submit a minority opinion.  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 the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Pain Left Ankle 	5284	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170216, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record  

AR20180007947, 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