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AF | PDBR | CY2013 | PD-2013-01115
Original file (PD-2013-01115.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX  CASE: PD-2013-01115
BRANCH OF SERVICE: Army  BOARD DATE: 20141119
SEPARATION DATE: 20031114


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (71L10/Administrative Specialist) medically separated for chronic bilateral ankle pain. The ankle condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS). He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The ankle condition, characterized as “chronic ankle pain”, was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB adjudicated “chronic bilateral ankle pain” as unfitting, citing the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals and was medically separated.


CI CONTENTION: “Do to multiple bilateral inversions and ligamentous laxity, going back to a normal civilian life was and is hard every day, the more time that past the more that make my mobility around my daily bases, and even to find a job is extremely hard do [sic] to my ankle's. Do to that condition my knees and lower back have been impact to create the limitation more difficult. At this time for all the issues that I past I am going to metal treatment and also unemployed this have make my life harder every day. I am requesting the board for a consideration do to the severity of the situation and injuries.”


SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The rating for the unfitting bilateral ankle condition is addressed below and no additional conditions are within the DoDI 6040.44 defined purview of the Board. 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 Board for Correction of Military Records.

The Board acknowledges the CI’s statements 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.







RATING COMPARISON :

Service IPEB – Dated 20030721
 VA - (30 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Bilat Ankle Pain 5099-5003 0% S/P Left Ankle Sprain w/Arthralgia Residuals and Limitation 5271 20% 20060525
S/P Right Ankle Sprain w/Arthralgia Residuals and Limitation of Lateral Flexion 5271 10% 20060525
Other x 0 (Not in Scope)
 Other x 3
Combined: 0%
 Combined: 60%
* Derived from VA Rating Decision (VA RD ) dated 200 60815 (most proximate to date of separation )


ANALYSIS SUMMARY: The PEB combined the left and right ankle conditions under a single disability rating, coded analogously 5003. Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for each individual compensable joint. The Board must follow suit, IAW DoDI 6040.44, if the PEB combined adjudication is not compliant with the latter stipulation, provided that each “unbundled” condition can be reasonably justified as separately unfitting in order to remain eligible for rating. If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended, with the stipulation that the result may not be lower than the overall combined rating from the PEB. The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.

Chronic Bilateral Ankle Pain. The service treatment record revealed that the CI initial ankle injury was in September 1999, where he reportedly twisted his left ankle and was treated conservatively. There were two recorded documentation in the service treatment records of acute “twisting” or “inversion” ankle injury. The first injury was documented as a “minor” ankle injury in October 1999, without specifying which ankle. An incident in March 2001, document the CI obtained “severe sprain” of the right ankle while at the Headquarter National Training Center, Fort Irwin, CA. Although he still complained of pain 2 months later, exam showed no tenderness and painless range-of-motion (ROM). The CI also experienced episodes of bilateral Achilles tendinitis that was reported to be an overuse injury associated with running in 2000. In June 2002 he reported “chronic Achilles pain” and while treatment and physical therapy was not deemed significantly helpful, on 24 October 2002, the CI successfully completed his physical fitness test (walking as alternated cardio event). The CI noted that the location of his pain had changed and an examination in December 2002, revealed lateral ankle bone tenderness, however an abnormal gait was not reported. The permanent profile dated 5 February 2003 indicated that the CI could walk, perform unlimited bicycling and swimming, lift up to 40 pounds and perform push-ups.

The MEB examination DD Form 2808 dated 18 February 2003 (9 months prior to separation), noted decreased ROM of each ankle with dorsiflexion of -5 degrees (20 degrees normal) and plantar flexion of 25 degrees (normal 45 degrees). Tenderness was present of the right medial malleolus (inner right ankle bone) and left lateral malleolus (outer left ankle bone). Gait was reported as normal.

The commander’s statement dated 7 May 2003, reports that the bilateral ankle pain inhibited the CI’s ability to perform his duty. On 16 May 2003 (6 months prior to separation), the CI successfully completed an alternate event (bike) for his physical fitness test.

At the MEB orthopedic evaluation dated 12 June 2003 (5 months prior to separation) the CI’s chief complaint was bilateral ankle pain that was reportedly present since his initial injury in September 1999. CI stated that he was unable to run. During physical examination, the examiner noted that both ankles were “exquisitely tender with all provocative tests…pain is out of proportion to history.” Tenderness was present medially and laterally and over the talar dome (bone at front top of ankle). There was no mention of Achilles or posterior ankle tenderness. All tests of ligament laxity or instability were normal. Bilateral ankle ROM showed plantar flexion of 20 degrees (normal 45 degrees) and dorsiflexion of 0 degrees (normal 20 degrees). Passive ROM was resisted. An abnormal gait was not reported. The examiner noted that X-ray images and magnetic resonance imaging (MRI) of both ankles were normal and that the etiology of the CI’s chronic ankle pain was not clear.

During the narrative summary (NARSUM) on 27 June 2003 the CI reported that since the initial injury of the left ankle in September 1999, he continued to experience ankle inversions, right worse than left. He reported his pain was constant and that his “ankles just give out”. He also felt “very unstable as his ankle swell while standing”. He could only run about 300 meters before he had to stopped due to pain and swelling. He reported he could perform all duty activities but would fall out of physical training runs, was unable to climb hills or walk on uneven ground. Examination made no mention of an abnormal gait. There were no outpatient visits for ankle problems in evidence for approximately a year prior to separation.

During a VA clinic on 6 May 2004 (6 months after separation), the CI was seen for complaint of “moderate ankle area pain since 3-4 months ago.” The examiner noted no extremity swelling and X-ray images were normal.

The Board directed attention to its rating recommendation based on the above evidence. The PEB combined the two ankle conditions into a single unfitting condition characterized as: “Bilateral ankle pain”, coded 5099-5003, rated at 0%. Both ankles were addressed by the MEB examiners, implicated in the commander’s statement and were permanently profiled. Each would have likely rendered the CI incapable of continued service within his MOS and accordingly each condition merits separate service ratings. The VA rated the ankles separately, but based on an exam remote from separation that held no probative value in the Board’s deliberations.

Board members agreed that there were no objective findings indicating one ankle was more or less severe than the other and therefore identical ratings for each ankle was warranted. The Board agreed that there was sufficient evidence of painful motion to warrant a 10% rating for each ankle IAW VASRD §4.59 (painful motion). The Board assessed the significant limitation in ROM in the context of inconsistent details. For example, the MEB orthopedist reported the presence of pain out of proportion to historical examinations and MRI findings that were not consistent with the CI’s complaint of ankles that were “unstable” or would “give out.” Board members also noted that 0 degrees of dorsiflexion is not compatible with a normal gait and there was no report of any gait abnormality during the year prior to separation. Likewise, this degree of limited motion is not consistent with the ability to run 300 meters (as the CI reported he could do), to perform some activities allowed on his permanent profile, or to complete alternate aerobic fitness events. Finally, the VA note 6 months after separation suggested that the ankle pain was not “constant” as previously reported by the NARSUM examiner. The Board ultimately concluded that in consideration of the totality of this evidence, the limited ankle motion was most accurately depicted by the “moderate” descriptor and therefore a 10% rating was supported via this pathway. Other pathways to a higher rating were also considered, but since ankylosis was not present, rating under code 5270 or code 5272, was not supported. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right ankle condition and 10% for the left ankle condition, using code 5271.

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. As discussed above, PEB reliance on the USAPDA pain policy for rating chronic pain of the left and right ankle was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the chronic bilateral ankle pain condition, the Board unanimously recommends that it be rated for two separate unfitting conditions as follows: chronic left ankle pain condition coded 5271 and rated 10%; and chronic right ankle pain condition coded 5271 and rated 10%; both IAW VASRD §4.71a. There were no other conditions within the Board’s scope of review for consideration.


RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

UNFITTING CONDITION
 VASRD CODE RATING
Chronic Left Ankle Pain 5271 10%
Chronic Right Ankle Pain 5271 10%
COMBINED (w/ BLF)
 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130812, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record








                          
         XXXXXXXXXXXXXXXXX
         President
         Physical Disability Board of Review


 SAMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557


 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXX , AR20150006410 (PD201301115)
1. 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 to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation. This decision is final.

2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.

3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

Encl                                                  XXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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