RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02489
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070416

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Ammunition Specialist, medically separated for “right ankle decreased ranges of motion (ROM) and pain” with a disability rating of 20%.  

CI CONTENTION:  Review requested of the separating condition and additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by 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 - 20070110	VARD - 20071016	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Ankle Decreased 
ROM  and Pain	5271	20%	Post Traumatic Arthritis Status Post Fixation Bimalleolar Fracture, Right Ankle with Scars	5271-5270	20%	20070625	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Right Ankle Decreased ROM and Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent open reduction and internal fixation as well as repair of the anterior and posterior aspects of the interosseous ligament of his right ankle in May 2005 due to a Weber type C fracture (distal one-third fibula and comminuted medial malleolus fracture with subluxation of the ankle joint).  Once ambulatory, the CI was treated with physical therapy (PT) where it was noted he had a dorsiflexion deficit.  In July 2005, he had a screw removed from the right ankle at the medial malleolus/distal tibia, which was impeding active ROM.  A note dated 30 August 2005 indicated the ankle was locked.  At an orthopedic clinic visit on 18 October 2005, ankle ROM was significantly limited.  Dorsiflexion was not to neutral and there was approximately 20-30 degrees of plantar flexion.  X-rays revealed a possible medial talus dome injury, no signs of implant failure, generalized osteopenia, and a fibula fracture with no significant callus, but good cortical alignment.  

In November 2005, he was seen by orthopedic surgery.  X-rays revealed healing fractures of the distal third of the fibula as well as the medial malleolus with anterior and posterior joint line calcifications evident.  Imaging studies on 19 January 2006 showed a healed fracture of the right ankle with posttraumatic arthritis.  X-rays on 13 February 2006 demonstrated a completely healed medial malleolar fracture and almost completely healed distal fibular fracture, both in near anatomic position with the hardware intact and no evidence of loosening with almost complete resolution of the disuse atrophy and mild degenerative joint disease of the ankle joints.  A CT scan of the right ankle dated 27 March 2006 showed prior fixation of the medial malleolar and distal fibula fracture with evidence of healing; osseous slivers were seen in the anteromedial and posterolateral joint spaces along with degenerative changes of the ankle joint.  

At an orthopedic visit on 25 April 2006, he complained of right anterior and medial ankle pain and an inability to get his heel to touch the floor; he was unable to walk without a significant limp.  On examination, he had about a 20 degrees equinus contracture and his posterior heel remained about 2 cm from the floor.  A 2 cm heel lift of the right shoe was dispensed and physical therapy was continued.  On 19 June 2006 active dorsiflexion was -15 degrees (- degrees indicates CI could not achieve a neutral position) and plantar flexion was 40 degrees with painful motion.  Right foot X-rays cited on 10 July 2006 were otherwise normal except for disuse osteopenia and X-rays of the right ankle showed disuse osteopenia and posttraumatic degenerative change of the ankle joint with significant narrowing of the medial ankle joint with intact hardware for the medial malleolus repair and the repair of the distal fibular diaphysis (shaft).  There was no evidence of syndesmotic (the ligament connecting the tibia and fibula) instability or widening of the medial clear space on stress views.  

At an orthopedic clinic visit on 9 August 2006, after discussion with another consultant, the examiner determined a surgical procedure would not return the CI to constructive active duty military service or place him in a position where he would have satisfactory ROM of the right ankle.  However, the CI requested a referral for surgical consideration in the community since he could not be provided with transportation to the military treatment facility.  

The 25 October 2006 MEB NARSUM examination, 6 months prior to separation, noted complaints of ankle pain and ROM loss with an inability to bear weight on the foot when attempting to assume a plantigrade position (foot flat on the ground).  He could only ambulate with the assistance of a cane.  He could not run or jump, and had difficulty climbing.  Physical examination showed the CI walked with an antalgic gait initially upon the toes of the right foot.  He had extreme difficulty placing the foot in a neutrally dorsiflexed position. Right ankle ROM was decreased; the ankle and foot could not be brought to neutral and lacked to 10-15 degrees due to a plantar flexion contracture.  There was decreased sensation at the distal portion of the foot below the medial malleolar operative sites and on the lateral aspect of the distal third of the right leg.  Motion of the toes was decreased on the right.  During the PT clinic visit on 8 December 2006, the CI’s right ankle showed no swelling or erythema.  The CI demonstrated partial weight bearing requiring a cane to ambulate.  ROM, measured with an inclinometer, showed the CI dorsiflexion of -15 degrees (normal 20 degrees) and plantar flexion of 20 degrees (normal 45 degrees).  

At the 25 June 2007 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported chronic pain and was unable to walk any significant distances because of severe pain.  He walked with a significant limp, indicated the pain was constant, although he was not taking medication.  He had flare-ups with increased pain in the morning when he got out of bed.  He used a cane to facilitate his walking, but no ankle brace was required.  Physical examination showed he could only flex to 15 degrees and only had extension to 0 degrees.  Repetition caused significant pain and weakness, but no fatigue.  He had no instability of the ankle laterally, medially, anteriorly, or posteriorly and had tenderness of the medial and lateral aspects of the ankle, but no swelling.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right ankle pain condition 20%, coded 5271 (ankle, limited motion), citing limitation of motion.  The VA rated the right ankle pain condition 20%, dual coded 5271-5270 (ankle, limited motion - ankle ankylosis), based on the C&P examination, citing marked limitation of right ankle motion.  

Panel members considered code 5299-5262 (tibia and fibula, impairment) warranting a 30% rating since the CI had a fracture of the fibula, which, although almost healed with retained hardware at the time of separation, represented a malunion with disuse osteopenia and posttraumatic degenerative change of the ankle joint with significant narrowing of the medial joint with marked ankle disability.  This was further evidenced by the measured -15 degrees of dorsiflexion, 20 degrees of plantar flexion and need for a cane to walk on uneven surfaces  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the right ankle pain condition, coded 5299-5262.  

BOARD FINDINGS:  In the matter of the right ankle pain condition, the panel recommends a disability rating of 30%, coded 5299-5262 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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Ankle Decreased Ranges of Motion and Pain	5299-5262	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170322, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20190006025, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay, providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation. 

	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,					      
Enclosure