RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02232
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051213

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E1, Trainee, medically separated for “chronic left ankle pain” with a  disability rating of 10%.  

CI CONTENTION:  Review of all conditions requested.  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 - 20051118	VARD - 20060124	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Ankle Pain	5099-5003	10%	Postoperative Residuals, Left Ankle Fracture	5271	0%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0% 	

ANALYSIS SUMMARY:  

Chronic Left Ankle Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s left ankle condition began in June 2005 when he fractured his left distal tibia in hand-to-hand combat training during the third week of basic training.  X-rays revealed a fracture dislocation of the ankle with posterior translation of the talus from the tibia.  Subsequent X-rays demonstrated a long comminuted fibular fracture with mortise widening.  Open reduction internal fixation surgery was performed on 17 June 2005.  Postoperatively, the CI was trained to use crutches and by 6 weeks after surgery he was advised by an orthopedist to begin weight bearing as tolerated and referred to physical therapy (PT).  By 22 August 2005 he had achieved full weight bearing.  An orthopedic note dated 19 September 2005 indicated the CI had a fracture of the proximal tibia as a child with no sequelae.  
  
At the 19 September 2005 MEB NARSUM examination, 3 months prior to separation, the CI complained of continued left ankle pain.  The examiner noted the CI was 3 months status post-surgery and felt that he would achieve full functional recovery within 12 months of the date of his injury, but prior to that time he would be prohibited from participating in any military training.  Therefore, the CI was recommended to be medically separated with the option of enlisting again in the future once his ankle fully healed.   The CI was able to walk unaided up to approximately a half mile, but was not able to run.   Physical examination showed well-healed surgical scars over both aspects of his left ankle.  The range of motion (ROM) of both the tibiotalar and subtalar joints were normal.  There was no swelling or inflammation and the examination was otherwise normal.   

At the time of the PT clinic appointment on 1 November 2005, one month prior to separation, the CI reported left ankle pain at 2/10. The examiner noted there was no numbness, tingling, or tenderness, although there was minimal edema.  The surgical scars were well-healed and the left lower extremity was neurovascularly intact. The left ankle ROM was 10 degrees dorsiflexion (normal 20) and 35 degrees plantar flexion (normal 45) with 4-/5 plantar flexion strength.   The CI’s gait was normal and he was able to heel-to-toe walk.  There was no VA examination proximate to separation in evidence.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 10%, analogously coded as 5003 (arthritis, degenerative), citing the pain as “slight, frequent.”  The VA rated the left ankle condition 0%, coded 5271 (limited motion of the ankle), based on the STR, citing no evidence of functional impairment shown, and a good prognosis for full recovery.  

The panel considered rating under the diagnostic code 5271 (ankle, limited motion).  Under VASRD diagnostic code 5271 (ankle limitation of motion), a 10% rating is supported by a “moderate” limitation of motion.  The PT ROM examination proximate to separation recorded limitation of motion (dorsiflexion 10 degrees and plantar flexion 35 degrees); however, there was no evidence of a marked limitation of motion to warrant a 20% rating. 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 whether the VASRD code for other foot injuries (5284) provided for a higher rating (§4.7).  However, panel members agreed that the impairment did not approximate “moderately severe” to support the 20% rating under this code.   The panel noted that the underlying cause for the ankle impairment was as a result of a fracture of the tibia, so a rating using the VASRD diagnostic code 5262 (tibia and fibula, impairment) was considered.  While there was no apparent nonunion or malunion present at the time of separation to support use of code 5262, the analogous code 5299-5262 does offer a 20% rating for a moderate disability of the ankle.   Panel members discussed whether there was sufficient evidence to support a moderate disability based on dorsiflexion of 10 degrees, plantar flexion of 35 degrees and decreased plantar flexion strength.  However, the CI had normal ROMs of both the tibiotalar and subtalar joints, his gait was normal, and although he could not run, he was able to heel-to-toe walk as well as walk up to a half mile..  While the orthopedic examiner noted no edema, the PT examiner noted mild edema.  Therefore, panel members felt there was insufficient evidence to support a 20% rating using code 5299-5262.After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the chronic left ankle pain condition.  
BOARD FINDINGS:  In the matter of the left ankle condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  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 20170225, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180015068, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.

Sincerely,					       

Enclosure