RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXX		CASE: PD-2017-03480 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20090427

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Combat Engineer, medically separated for “right ankle limited motion” with a disability rating of 10%.

CI CONTENTION: “My first PEB found me medically unfit due to ankle problems and recommended a rating of 10%, which was never received through benefits.” 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 - 20090122	VARD - 20090805	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Ankle Limited Motion	5271	10%	Right Ankle Instability s/p Ligament Repair Surgeries	5271	0%	STR	
Left Ankle Instability to the Calcaneofibular and Anterior Talofibular Ligaments	Not Unfitting	Left Ankle Condition	5271	NSC	STR	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 10%	
	
ANALYSIS SUMMARY:

Right Ankle Limited Motion. According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent right ankle Brostrom reconstruction surgery in August 2005 (Brostrom). In April 2008, he had right percutaneous lateral ankle ligament reconstruction with allograft.          During the 3 September 2008 physical

therapy clinic examination, 8 months prior to separation, the CI reported right ankle pain (4- 5/10). On examination he walked with a slight antalgic gait. There was tenderness at the lateral aspect and strength was 4/5. Right ankle range of motion (ROM) showed dorsiflexion of 10 degrees (normal 20) and plantar flexion of 40 degrees (normal 45). At the primary care clinic appointment 5 days later the CI reported right ankle pain (4/10). On examination there was swelling, tenderness and instability. Motion was abnormal and pain was elicited by motion. There was no redness or crepitus, the ankle was not warm, and did not show laxity and anterior drawer sign was not observed.

During the 15 October 2008 MEB addendum examination, 6 months prior to separation, the CI reported right ankle pain. Physical examination revealed tenderness over the anterior talofibular ligament and over the calcaneofibular ligament. There was instability with evidence of significant ligament laxity present over the bilateral calcaneofibular and anterior talofibular ligament. Right ankle ROM showed dorsiflexion of 13 degrees and plantar flexion of 52 degrees after repetition. No significant pain was produced with ROM testing. The CI was unable to do heel walking or toe walking secondary to pain. At the time of the 22 October 2008 MEB consultation examination the CI reported right ankle pain that was exacerbated with activity. On examination there was tenderness about the lateral ankle and negative anterior drawer and talar tilt. He had a 2+ dorsalis pedis pulse. Sensation was intact to light touch in the sural, saphenous, superficial peroneal, deep peroneal and tibial distributions. Right ankle ROM showed dorsiflexion of 10 degrees and plantar flexion of 20 degrees. Diagnosis was right ankle instability status post (s/p) multiple surgeries. Right ankle X-rays revealed s/p lateral reconstruction. The ankle mortise and talar dome were within normal limits. There was mild soft tissue swelling and no change when compared to prior study done on 4 April 2008.

The 17 November 2008 MEB NARSUM examination, 5 months prior to separation, noted complaints of severe right ankle pain that interfered with running, jumping, or doing any type of prolonged walking. The CI stated pain was primarily at a 5 or 6/10 level. Prolonged walking and standing reproduced his pain and sitting or lying down gave some relief. He described the pain as a sharp or tearing-type sensation. The examiner noted instability on the right ankle. 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 right ankle condition 10%, coded 5271 (ankle, limited motion), citing ROM and moderate loss. The VA rated the right ankle condition 0%, coded 5271, based on the STR, citing evidence of an ankle injury with failure to report for a scheduled VA examination. The panel considered if the limitation of motion was “moderate” or “marked” when considered under 5271. The panel agreed that the ROM examinations proximate to separation were consistent with the “moderate” limitation of motion required for the 10% rating under this code. The panel considered alternative VASRD ankle and analogous codes, but all were less applicable and 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.

Contended PEB Condition: Left Ankle Instability. The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting. The contended condition was not profiled or implicated specifically in the commander’s statement, and did not fail retention standards. There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation. After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.

BOARD FINDINGS: In the matter of the right ankle condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. In the matter of the contended left ankle condition, the panel recommends no change from the PEB determination as not unfitting. 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.

PD-2017-03480

AR20190010666, XXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXX

	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.

PD-2017-03480