RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01012
BRANCH OF SERVICE:  AIR FORCE 	SEPARATION DATE:  20051017

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Communications Computer Systems Plans and Implementation, medically separated for “chronic left ankle pain, status post lateral ankle reconstruction” with a disability rating of 10%.  

CI CONTENTION:  “Review all conditions.”  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 - 20050830	VARD – Unk - Ratings Effective 20051018	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Ankle Pain, Status Post Lateral Ankle Reconstruction	5271	10%	Residuals, Left Ankle Surgery, with Partial Tear of the Lateral Ligament Complex and Subchondral Degenerative Changes of the Talus and Distal Fibula	5271	10%	Unk	
Gastroesophageal Reflux Disease	7399-7346	Cat II	Acid Reflux Condition (GERD)	7399-7346	10%	Unk	
Adjustment Disorder …	Cat III	Anxiety Disorder	9400	NSC	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Left Ankle Pain, Status Post Lateral Ankle Reconstruction.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent left ankle surgery in September 2004 for lateral collateral ligament reconstruction following a basketball injury.  The 19 January 2005 Physical Therapy (PT) evaluation, 9 months prior to separation (4 months after surgery), noted the CI continued to wear a left ankle brace and had pain and swelling off and on.  Physical examination documented mild swelling and weak ankle strength (3+/5 in all planes except 3-/5 for eversion).  Range of motion (ROM) of the left ankle was dorsiflexion of -20 degrees (normal +20) and plantar flexion of 35 degrees (normal 45).  

The 18 February 2005 PT evaluation, 8 months prior to separation and 5 months after surgery, noted continued painful motion and feeling of instability with weight bearing with use of a brace.  The therapist indicated “significantly improved ankle ROM” and ankle measurements were dorsiflexion of 0 degrees (normal 20) and plantar flexion of 45 degrees (normal 45).  Swelling had decreased and was described as minimal.  The 15 April 2005 PT progress note covering treatment from 19 January through 15 April 2005 noted a symmetric gait and stated:  “ankle ROM (passively) is full, and active ROM has significantly improved.”  The therapist also indicated that the ankle was still limited by pain, the CI felt unsteady with weight-bearing, and had evident weakness/instability with weight-bearing exercises.  No active ROM measurements were recorded.  Recommendation was to continue PT.  

The 20 July 2005 MEB NARSUM, 3 months prior to separation, noted continued complaints of left ankle pain and instability, with weakness provoked mainly by pain.  Physical examination did not include ankle ROM measurements or details beyond vital signs.  There was no VA examination in evidence proximate to separation, although remote evidence from 2009 showed near-normal ankle ROMs with flare-ups.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 10%, coded 5271 (ankle, limited motion of).  The VA also rated the left ankle condition 10%, coded 5271 (ankle, limited motion of), with an increase to 20% effective November 2008.  The panel considered if the limitation of motion was “moderate” or “marked” when considered under 5271, limitation of ankle motion.  The panel consensus was that the PT progress note indicating “significant improvement” of active ROM was closest to separation and not consistent with the next higher “marked” (20%) limitation of motion.  The panel considered alternative VASRD ankle and analogous codes, but all were less applicable and/or not advantageous to rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel consensus was that there was insufficient cause to recommend a change in the PEB adjudication for the left ankle condition.  

Contended PEB Conditions:  Gastroesophageal Reflux Disease and Adjustment Disorder.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition of GERD was not unfitting.  Adjustment disorder was not a physical disability condition IAW DODI 1332.38 in effect at the time, and is therefore not compensable.  None of the conditions were profiled, implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that the GERD condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended GERD condition or the category III determination for anxiety disorder, and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the chronic left ankle pain, status post lateral ankle reconstruction condition and IAW VASRD §4.71a, the panel majority recommends no change in the PEB adjudication.  The single voter for dissent submitted the appended minority opinion.  In the matter of the contended gastroesophageal reflux disease conditions the panel unanimously recommends no change from the PEB determination as not unfitting.  In the matter of the contended and adjustment disorder condition, the panel unanimously agrees that it cannot recommend it for additional disability rating.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170223, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MINORITY OPINION.  The minority voter strongly advocates for a 20% rating for marked limitation of ankle motion.  

All measured active ROMs after surgery documented inability to dorsiflex the ankle beyond a neutral position of 0 degrees, as opposed to a normal 20 degrees of dorsiflexion.  Inability to dorsiflex the ankle is clearly greater than a moderate limitation of motion.  The PT progress note general statement of “significantly improved” was used on both the 18 February 2005 (0 degrees dorsiflexion) and 15 April 2005 summaries, while the only recorded active ROMs were -20 degrees from 19 January 2005 and 0 degrees from 18 February 2005.  

It is therefore mere speculation that the pain-limited ankle ROM on 15 April 2005 was greater than the earlier recorded measurements in the record, with the same statement of improvement from the beginning of therapy, and rating on that phrasing would not be based on an adequate examination (IAW VASRD §4.70 and §4.46).  It would also take undue conjecture to rate based on the anticipated continued post-surgical trend of improved ROM for a less restricted ROM at the time of separation.  

Given the measured active ROM limitation closest to separation was 0 degrees of dorsiflexion, which represents complete loss of dorsiflexion and a marked limitation of motion, the minority strongly recommends that 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, Status Post Lateral Ankle Reconstruction	5271	20%	

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-01012.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

						Sincerely,

								XXXXXXXXXXXXXXXXXX
								Director
								Air Force Review Boards Agency

Attachment:
Record of Proceedings