RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03124
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20090618

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E4, Radio Operator Maintainer, medically separated for “right ankle pain” with a disability rating of 10%.  

CI CONTENTION:  No specific contention was made.  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 - 20090506	VARD - 20110401	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Ankle Pain	5099-5003	10%	Right Ankle, Status Post Arthroscopy and Ligament Repair with Suture Migration	5271	10%	20090817	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Right Ankle Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s right ankle condition began in April 2003 after an inversion injury.  He underwent arthroscopic surgery on 28 October 2008 (debridement and Brostrom ligament reconstruction) for ankle pain and instability.  The 12 March 2009 MEB NARSUM examination, 3 months prior to separation, noted CI complaints of prolonged pain with standing.  Physical examination showed a normal heel-toe reciprocal gait.  The right ankle had mild lateral swelling and tenderness about the lateral incision wound with no erythema; peroneal and posterior tibialis strength was normal.  Anterior drawer and Taylor tilt tests were negative and ankle alignment was normal.  Right ankle range of motion (ROM) measurements showed dorsiflexion to 10 degrees (normal 20) and plantar flexion to 35 degrees (normal 45), with a note that ROM appeared to be limited by mechanical block.  The 13 April 2009 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months before separation, noted right ankle pain elicited by motion. On 31 May 2009, X-rays showed soft tissue swelling with no evidence of fractures or dislocations.  On 16 July 2009, the CI underwent right ankle debridement and removal of irritating sutures.  

At the 17 August 2009 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported pain with prolonged walking and standing.  The examiner found right ankle edema, redness and tenderness, but no ankle instability or tendon abnormality.  Measured ROM revealed right ankle dorsiflexion was to 10 degrees and plantar flexion to 30 degrees with no evidence of painful motion or changes after repetition.  Radiographic imaging showed a normal right ankle with mild soft tissue swelling and no degenerative changes.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right ankle condition 10%, analogously coded 5099-5003 (arthritis, degenerative), citing degenerative arthritis with some loss of motion.  The VA also rated the right ankle condition 10%, but coded 5271 (ankle, limited motion of), likely based on the STR and C&P examinations (VARD not in evidence).  Panel members agreed that the MEB NARSUM and VA C&P ROM examinations proximate to separation were consistent with the “moderate” limitation of motion required for the 10% rating under code 5271.  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 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 right ankle condition.  

BOARD FINDINGS:  In the matter of the right 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:

[AR NUMBER], 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.

			      
Enclosure