RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY 

CASE NUMBER: PD1201428 SEPARATION DATE: 20080305 

BOARD DATE: 20130130 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty SPC/E-4 (35T10/Military Intelligence System 
Maintenance), medically separated for a left ankle injury prior to entry on active duty with 
tearing of ligaments and fracture of the fibula. He initially injured his left ankle prior to service 
on a couple of occasions between 1994 and 1996 with the most severe being a tear of 3 outside 
ligaments, for which he had a ligament repair in April 1996. He entered active duty in 1999 on a 
waiver for his ankle and a year later had an avulsion fracture that led to 4 weeks in a cast. He 
seemed to improve until 2004 when he had a recurrence of the ankle pain accompanied by shin 
splints and was diagnosed with chondromalacia of the talar dome with subchondral cysts. In 
2006 he underwent arthroscopic surgery. Despite physical therapy (PT), surgery and profiles 
the CI did not improve adequately with treatment to meet the physical requirements of his 
Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a 
permanent L3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded 
no other conditions for Physical Evaluation Board (PEB) adjudication. The PEB adjudicated the 
left ankle condition as unfitting, rated 10% with application of the Veteran’s Affairs Schedule for 
Rating Disabilities (VASRD). An administrative correction to the PEB was published 4 months 
later noting changes to the National Defense Authorization Act 2008 were now being applied; 
however, it did not change the rating. The CI made no appeals, and was medically separated 
with a 10% disability rating. 

 

 

CI CONTENTION: “Conditions continue to worsen without any continued trauma or impact.” 

 

 

SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 
6040.44, Enclosure 3, paragraph 5.e.(2) is limited to those conditions which were determined 
by the PEB to be specifically unfitting for continued military service; or, when requested by the 
CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings 
for unfitting conditions will be reviewed in all cases. Any conditions or contention not 
requested in this application, or otherwise outside the Board’s defined scope of review, remain 
eligible for future consideration by the Army Board for Correction of Military Records. 

 

 

RATING COMPARISON: 

 

Service IPEB – Dated 20071214 

VA (9 Mos. Post-Separation) – All Effective Date 20080306 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Left Ankle Injury EPTS 

5271 

10% 

Osteoarthritis S/P Surgery, Lt 
Ankle Strain 

5010-5271 

10% 

20081210 

.No Additional MEB/PEB Entries. 

0% X 3 / Not Service-Connected x 1 

20081210 

Combined: 10% 

Combined: 10% 



 

 


ANALYSIS SUMMARY: The Board acknowledges the CI’s contention regarding the significant 
impairment with which his service-connected condition continues to burden him; but, must 
emphasize that the Disability Evaluation System has neither the role nor the authority to 
compensate members for anticipated future severity or potential complications of conditions 
resulting in medical separation. That role and authority is granted by Congress to the 
Department of Veterans Affairs, operating under a different set of laws. 

 

Left Ankle Condition. The goniometric range-of-motion (ROM) evaluations in evidence which 
the Board weighed in arriving at its rating recommendation, with documentation of additional 
ratable criteria, are summarized in the chart below. 

 

Left Ankle ROM 

(Degrees) 

Podiatry ~5 Mo. Pre-Sep 

(20070911) 

PT ~5 Mo. Pre-Sep 

(20070924) 

MEB (PT) ~3 Mo. Pre-Sep 

(20071212) 

VA C&P ~9 Mo. Post-Sep 

(20081210) 

Dorsiflexion (0-20) 

10 

20/20/20 

5/4/4 

20 

Plantar Flexion (0-45) 

20 

45/45/45 

40/41/40 

20 

Comment 

tender; edema; 
decreased inversion 

“Motion 
restriction due to 
reconstructive 
surgery and with 
continued pain 
with 
weightbearing” 

pain, tissue tightness; 
muscle contracture; 
NARSUM (20071029); 
pain; antalgic gait 

painful motion; 

negative DeLuca 

§4.71a Rating 

10% 

10% 

10% 

10% 



 

The CI received a waiver for military service in September 1999 for an existed prior to service 
(EPTS) left ankle injury/surgery performed when he was 15 years old. Eight months after 
enlistment; the CI again injured his left ankle and received treatment for an avulsion fracture of 
the left distal fibula. Conservative treatments provided him intermittent relief over the next 6 
years with periods of pain exacerbation. Arthroscopic surgery in 2006 failed to provide long-
term pain resolution. At the MEB exam, the CI reports constant left ankle pain worse with 
prolonged standing and better with rest and elevation. The MEB physical exam noted painful 
ROM with an antalgic gait favoring the left lower extremity. The exam is summarized above. 
Radiographs demonstrated osteoarthritic changes. At the VA Compensation and Pension (C&P) 
examination (9 months after separation), the CI reported daily left ankle pain and difficulty in 
prolonged standing, prolonged walking and stair climbing, and related these difficulties to 
(bilateral) ankle pain. Additionally, the CI claimed needing the use of a cane, but the VA 
examiner noted no use of a cane or other assisted device at the examination. The ROM exam is 
summarized above. 

 

The Board directs attention to its rating recommendation based on the above evidence. The 
PEB and VA both rated the ankle under code 5271 criteria at 10% and the PEB specified 
permanent service aggravation and no EPTS deduction. It is obvious that there is a clear 
disparity in the dorsiflexion ROM at the PT examination dated 12 December 2007 as compared 
to examinations performed during 5 months prior to separation and 12-months after-
separation which could have significant implications regarding the Board's rating 
recommendation. Therefore, the Board thus carefully deliberated its probative value 
assignment to these conflicting evaluations, and carefully reviewed the service treatment 
record (STR) for corroborating evidence in the 12-month period prior to separation. The 
consideration of this one measurement being an error was entertained by the Board. However, 
the PT examination on 12 December 2007 was the only note that specifically mentioned 
“muscle contracture” being present. Although the specific muscle was not identified, a 
contracture (spasm) of one’s lower leg calf muscles could indeed reflect such poor ankle 


dorsiflexion. The STR do not reveal any recurrent injury or other development in explanation of 
the more marked impairment reflected by the MEB measurement of dorsiflexion. The PT 
examiner does not make mention of the CI’s gait status whereas the narrative summary 
(NARSUM) examiner approximately 6 weeks earlier specifically mentioned an antalgic gait. The 
STR X-rays were consistent with expected post surgical findings as well as early degenerative 
disease. There were no incapacitating exacerbations of his condition. Upon deliberation the 
Board agreed in this case that the listed ROM is consistent with the PT examiner’s comments of 
tissue tightness and muscle contraction. The Board considered that, at the time of separation, 
the CI had ROM loss of his ankle and deliberated if the level were moderate (10%), or rose to 
the level of marked (20%) limitation. There was no evidence of joint ankylosis and therefore 
not meeting criteria above 20%. The Board also considered possible rating under code 5262 
(impairment of tibia and fibula) at moderate (20%) or marked (30%) ankle disability. After due 
deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the 
Board concluded that there was insufficient cause to recommend a change in the PEB 
adjudication for the left ankle condition. 

 

 

BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or 
guidelines relied upon by the PEB will not be considered by the Board to the extent they were 
inconsistent with the VASRD in effect at the time of the adjudication. The Board did not 
surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD 
were exercised. In the matter of the left ankle injury condition and IAW VASRD §4.71a, the 
Board unanimously recommends no change in the PEB adjudication. There were no other 
conditions within the Board’s scope of review for consideration. 

 

 

RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of 
the CI’s disability and separation determination, as follows: 

 

UNFITTING CONDITION 

VASRD CODE 

RATING 

Left Ankle Injury 

5271 

10% 

COMBINED 

10% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120808, w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

 

xxxxxxxxxxxxxxxxxxxxxxxxxx, DAF 

Acting Director 

Physical Disability Board of Review 


SFMR-RB 


 

 

MEMORANDUM FOR Commander, US Army Physical Disability Agency 

(TAPD-ZB / xxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 

 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation 
for xxxxxxxxxxxxxxxxxxxxxxxxxx, AR20130003932 (PD201201428) 

 

 

I have reviewed the enclosed Department of Defense Physical Disability Board of 
Review (DoD PDBR) recommendation and record of proceedings pertaining to the 
subject individual. Under the authority of Title 10, United States Code, section 1554a, 
I accept the Board’s recommendation and hereby deny the individual’s application. 

This decision is final. The individual concerned, counsel (if any), and any Members of 
Congress who have shown interest in this application have been notified of this decision 
by mail. 

 

 BY ORDER OF THE SECRETARY OF THE ARMY: 

 

 

 

 

Encl xxxxxxxxxxxxxxxxxxxxxxxx 

 Deputy Assistant Secretary 

 (Army Review Boards)