RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2021-00102
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060510

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Information System Operator-Analyst, medically separated for “chronic pain, left ankle, status post [s/p] reconstruction” with a disability rating of 20%.

CI CONTENTION: “During my discharge from service it was a rushed process, and I don't feel as all issues were evaluated.  My medical evacuation from Iraq and discharge from the Army happened withing a short time frame.  I have painful scars on my ankle, migraines with vertigo that I was being treated for in Iraq, and severe mental health issues [sic].”  The CI also requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and/or 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 the 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 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 – 20060425 	VARD - 20070831	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Left Ankle	5099-5003	20%	Ankle Strain S/P Reconstructive Stabilization Procedure	5271	10%	20070625 	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20% 	

ANALYSIS SUMMARY:  

Left Ankle Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s left ankle pain began in October 2003 when he rolled his ankle while running during physical training.  He underwent a left ankle Brostrom lateral reconstruction in May 2004, which improved pain and stability; however, in 2005, he began to complain of increasing diffuse pain about the left ankle.  Post-operative X-rays remained within normal limits except for soft tissue swelling.  An MRI showed typical post-surgical changes but no evidence of osteochondral defect in the ankle.
At an orthopedic visit on 7 February 2006, 3 months prior to separation, the provider noted that although the CI’s ankle stability had improved, his pain had increased, and the overall condition was slowly worsening.  Full range of motion (ROM) was recorded along with diffuse tenderness.  

During the integrated 23 February 2006 MEB separation/VA examination, 2 months before separation, the CI reported left ankle pain which caused difficulty sleeping.  The examiner recorded a normal gait with l dorsiflexion to 20 degrees (normal) and plantar flexion to 25 degrees (normal 45), after repetitive motion.   On the same day, the MEB NARSUM examination was conducted by the same orthopedic provider for the 7 February 2006 evaluation.  The examiner noted complaints of moderate, constant left ankle pain, which worsened with navigating stairs and standing for longer than 15 minutes.  The CI also reported he could not walk more than one-half mile without ankle pain.  Physical findings showed diffuse ankle tenderness, and left ankle dorsiflexion of “approximately 15 degrees short of neutral” (it is unclear what the examiner was trying to communicate in this ROM description).  

At the 25 June 2007 VA Compensation and Pension (C&P) examination, 13 months after separation, the CI reported left foot pain that began 4-6 months after the ankle operation.  He had foot pain when he walked or wore shoes that were too tight.  On examination, posture and gait were normal, with left ankle dorsiflexion to 15 degrees and plantar flexion to 25 degrees, after repetition; painful motion was noted.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 20%, analogously coded 5099-5003 (degenerative arthritis), citing the US Army Physical Disability Agency pain policy.  The VA rated the left ankle condition 10%, coded 5271 (limited motion of the ankle), based on the C&P examination, citing moderate, limited ankle motion.  Panel members agreed that a 10% rating, but no higher, was warranted for moderate left ankle ROM limitation.  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 left ankle 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.  

AR20230002059, XXXXXXXXXX 

Dear XXXXXXXXXX:

	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.