RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02857
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20050509

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve O3, Field Artillery Officer, medically separated for “right ankle pain” with a disability rating of 0%.  “Left ankle pain” was determined to have existed prior to service (EPTS), was not permanently service aggravated (PSA), and not rated. 

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 - 20050322	VARD - 20060502	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Ankle Pain	5010	0%	Degenerative Joint Disease of the Right Ankle	5010-5271	20%	20050607	
			Scar, Right Ankle, Post Ligament Repair	7804	10%		
Left Ankle Pain	5099-5003	EPTS	Left Ankle Pain	5299-5271	NSC		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:

Right Ankle Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI twisted his right ankle while on a patrol in Iraq in May 2003 causing immediate pain and swelling.  An MRI revealed torn ankle ligaments with bony fragments, and he underwent a Bromstrom surgical repair on 13 August 2004.
During the 11 February 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported constant pain and numbness, “little to no use” of the right ankle, and severe bilateral ankle arthritis.  Physical examination revealed decreased ankle strength and pain with passive range of motion (ROM).  At the February 2005 MEB physical therapy (PT) evaluation, the CI exhibited mild guarding during passive ROM testing.  Active right ankle dorsiflexion was 0 degrees (normal 20) and plantar flexion was 25 degrees (normal 45).  Gait, swelling, and crepitus were not addressed.  

The 23 February 2005 MEB NARSUM examination, 2 month before separation, noted complaints of right ankle pain with any type of activity.  Physical examination showed a tender surgical scar over the lateral aspect of the ankle with decreased sensation but no inflammation.  Sensation was intact over the dorsum and plantar aspect of the foot; gait and crepitus were not addressed.  Right ankle dorsiflexion was 10 degrees and plantar flexion was 20 degrees; painful motion was not addressed.  

At the 7 June 2005 VA Compensation and Pension (C&P) joint examination, 1 month after separation, the CI reported constant right ankle pain, stiffness, swelling, giving-way, locking, fatigability and lack of endurance with flares after walking 1/4-mile.  He denied any instability and did not require the use of an assistive device for ambulation.  Physical examination showed a non-antalgic gait with the surgical scar tender and sensitive to touch.  There was no evidence of inflammation or deformity, but the examiner noted tenderness around the lateral malleolar area and mid ankle joint.  Right ankle ROM showed dorsiflexion “only to neutral position -20 degrees” and plantar flexion to 40 degrees; painful motion was not addressed.  The examiner noted the ankle was “stable in inversion and eversion” with “small swelling” on the right after comparing measurements to the left; X-rays showed degenerative changes and osteophytes (bony projections), but no evidence of a healed fracture.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right ankle condition 0%, coded 5010 (arthritis, due to trauma), citing no use of medications, ROM measurements limited by CI guarding, and radiographs noting post-operative changes with only one joint involved.  The VA rated the right ankle condition 20%, coded 5010-5271 (arthritis, due to trauma-ankle, limited motion), based on the C&P examination, citing limitation of motion.  The panel majority agreed that the right ankle dorsiflexion measurements proximate to separation were consistent with “marked” limitation of motion required for the maximum 20% rating under code 5010, as recorded by the MEBPT and VA examinations.  Because there was no ankylosis, nonunion or malunion, VASRD §4.71a offers no applicable joint code for a rating higher than 10%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 20% for the right ankle condition, coded 5010-5271.

Left Ankle Pain.  According to the STR, the CI injured his left ankle in July 1997 while playing basketball, and in February 2001 while playing baseball as a cadet at West Point.  He was diagnosed with left ankle sprains, and after entering the service, he again sprained his left ankle in November 2001 while playing baseball.

At a podiatry evaluation on 9 April 2004, 13 months prior to separation, the CI reported bilateral ankle pain for the previous 4-6 weeks, right greater than left, due to instability.  The examiner noted left ankle ligament tenderness with sensation intact, and assessed left ankle instability.  An MRI on 15 April 2004 showed no bone or soft tissue abnormality or acute fracture evidence.  The left ankle injury was not implicated by the commander’s statement, but was permanently profiled (L3) on 23 February as “bilateral ankle pain secondary to injury while in Iraq.”  

At the MEB PT evaluation, left ankle dorsiflexion was 9 degrees and plantar flexion was 38 degrees with mild guarding noted during passive ROM testing.  Gait, swelling, crepitus were not addressed.  The MEB NARSUM examination noted left ankle dorsiflexion was 15 degrees and plantar flexion was 30 degrees; painful motion was not mentioned.  During the C&P joint examination, the provider note “examination of both ankles was done for comparative reasons,” and that the left ankle ROM was “normal” compared to the right.

The panel directed attention to its rating recommendation based on the above evidence.  The left ankle pain was determined by the PEB to be an EPTS condition which was not PSA and therefore not rated. The VA did not service-connect the left ankle condition, based on the C&P examination, citing no permanent residual or chronic disability. 

Members agreed the CI’s left ankle condition did exist prior to service based on documentation of two ankle sprains which occurred at West Point.  The panel next determined if the condition was permanently service-aggravated and noted the CI’s service entry examination and medical history were not in evidence to allow members to determine if a pre-service left ankle condition was identified and/or examined.  He successfully completed basic and advanced individual training as reflected by his designated military occupational specialty, and his ankle condition became symptomatic on 21 November 2001, 6 months after entering the service.  The left ankle was permanently profiled as bilateral ankle pain, and limited the CI from performing any Army Physical Fitness Test aerobic events, moving with a fighting load, constructing an individual fighting position, and performing 3-5 second rushes.  Although the PEB cited the CI had pre-service left ankle arthroscopic examination and treatment, this evidence was not documented by the available STR nor reported by the CI.  The panel majority determined the presumption of service-aggravation was not overcome by a preponderance of competent medical evidence and accepted medical principles that the natural progression of the pre-existing left ankle condition was clearly unaltered by any consequence of the CI’s military service.  

The panel directed attention to its rating recommendation based on the above evidence, and the majority agreed that although the STR documented limited non-compensable ROM with mild guarding, the VA examination most proximate to separation was normal.  Therefore there was no evidence to support a rating higher than 0% IAW VASRD §4.71a (schedule of ratings-musculoskeletal system), and thus no advantage to the CI to recommend a separate rating.  After due deliberation, considering all of 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 left ankle condition.

BOARD FINDINGS:  In the matter of the right ankle pain condition, the panel majority recommends a disability rating of 20%, coded 5010-5271 IAW VASRD §4.71a.  In the matter of the left ankle pain condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  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	
Right Ankle Pain	5010-5271	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170331, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180008223, 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