Search Decisions

Decision Text

AF | PDBR | CY2013 | PD-2013-01226
Original file (PD-2013-01226.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX       CASE: PD-2013-01226
BRANCH OF SERVICE: NAVY  BOARD DATE: 20150206
SEPARATION DATE: 20040714


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Passenger Terminal LPO-9) medically separated for a left ankle condition. This condition could not be adequately rehabilitated to meet the physical requirements of his Rating or satisfy physical fitness standards. He was placed on limited duty and referred for a Medical Evaluation Board (MEB). The “extreme and recalcitrant left ankle pain, s/p multiple procedures w/,” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E. No other condition was submitted by the MEB. The Informal PEB adjudicated “extreme and recalcitrant left ankle pain…” as unfitting, rated 10%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION: “I injured my ankle while in the service and it’s documented as such.”


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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting. Any conditions outside the Board’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/Naval Records. Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate. The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation. The Board 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, operating under a different set of laws. The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.


 RATING COMPARISON :
IPEB – Dated 20040331
 VA* - (~4 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Extreme and Recalcitrant Left Ankle Pain… 5271 10% S/P Left Ankle Arthroscopy… 5271 0% 20041109
Other x 0 (Not In Scope)
 Other x 1
RATING: 10%
 RATING: 10%
*Derived from VA Rating Decision (VARD) dated 20050225 (most proximate to date of separation (DOS))





ANALYSIS SUMMARY:

Left Ankle Condition. Treatment records evidence that the CI sustained a left talus (heel) fracture in February 1996 with surgical repair (open reduction internal fixation). The CI continued to report left ankle pain and a magnetic resonance imaging study dated 13 March 1998 revealed a moderate sized heel bone defect and ankle (flexor hallicus longus) tenosynovitis. The CI underwent a bone graft (osteochondral autograft) in 1998. The records were silent for left ankle pain until 2001 when the CI presented with “severe incapacitating left ankle pain” with swelling. The CI underwent two arthroscopic debridements of the left ankle (11 May 2001 and 24 April 2002). An orthopedic evaluation dated 17 April 2003 noted reports of constant left ankle pain. The examiner noted a treatment history which included physical therapy and pain medications. The physical examination revealed left ankle tenderness to palpation, crepitation, and decreased range-of-motion (ROM).

At the MEB narrative summary examination dated 21 November 2003, approximately 8 months prior to separation, the CI reported constant left ankle pain made worse with impact activities. The physical examination demonstrated discrete tenderness to palpation without obvious soft tissue swelling, edema, or erythema. There was pain noted with dorsiflexion. Plantar flexion was limited to 30 degrees (45 degrees is the normal ROM).

At the VA Compensation and Pension examination dated 9 November 2004, approximately 4 months after separation, the CI reported constant left ankle pain made worse with weekly flare ups with prolonged walking. The examiner noted a stable, nontender scar on the left ankle. The physical examination was significant for mild left ankle swelling without pain, fatigue, weakness, lack of endurance, or incoordination. The examiner documented pain with repetitive use. The ROM was noted as 20 degrees of dorsiflexion (normal) and 40 degrees of plantar flexion.

The Board directed its attention to its rating recommendation based on the above evidence. The PEB adjudicated the left ankle pain condition as unfitting. The PEB and VA coded the left ankle condition as 5271 (ankle limitation of motion). The PEB rated the condition at 10% and VA at 0%. The board considered whether there was evidence for a higher than 10% disability rating. There was no evidence of severe limitation of motion nor ankle or talar ankylosis for a 20% rating. Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that a disability rating of 10% for the left ankle pain condition was appropriately recommended in this case.


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 pain 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 re-characterization of the CI’s disability and separation determination.
The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130909, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record








                                                              
XXXXXXXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review



 MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS
 Subj:    PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATION
Ref:     (a) DoDI 6040.44
(b) CORB ltr dtd 16 Jun 15

In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual's records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy' s Physical Evaluation Board:

-        XXXXXXXXXXXXXXXXXXXX, former USN
-        XXXXXXXXXXXXXXXXXXXX, former USMC
-        XXXXXXXXXXXXXXXXXXXX, former USMC
-        XXXXXXXXXXXXXXXXXXXX, former USN
-        XXXXXXXXXXXXXXXXXXXX, former USMC
-        XXXXXXXXXXXXXXXXXXXX, former USMC






XXXXXXXXXXXXXXXXXXXX
Assistant General Counsel (Manpower & Reserve Affairs)

Similar Decisions

  • AF | PDBR | CY2012 | PD2012 01148

    Original file (PD2012 01148.rtf) Auto-classification: Denied

    Ratings for unfitting conditions will be reviewed in all cases. The orthopedic evaluations on 18 November 2002 and 12 December 2002 recommended MEB, stating the ankle instabilityhad persisted despite repeated surgery, and that he had “worsening ankle pain due to physical activity,” and was unable to run, hike, march, or to perform his required duties.The MEB narrative summary (NARSUM) examination dated 21 March 2003 recorded “bilateral ankle with tenderness to palpation along lateral and...

  • AF | PDBR | CY2013 | PD-2013-01692

    Original file (PD-2013-01692.rtf) Auto-classification: Denied

    Left Ankle Condition . Left Knee Condition . At the MEB examination on 20 January 2004, 6 months prior to separation, the CI reported left knee pain.

  • AF | PDBR | CY2013 | PD-2013-01544

    Original file (PD-2013-01544.rtf) Auto-classification: Denied

    Right 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 right ankle condition and IAW VASRD §4.71a, the Board unanimously...

  • AF | PDBR | CY2014 | PD-2014-02698

    Original file (PD-2014-02698.rtf) Auto-classification: Denied

    It is limited 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 PEB, but determined to be not unfitting. The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of theVASRD standards to the unfitting medical condition at the time of separation. Various STR clinic entries throughout the course...

  • AF | PDBR | CY2013 | PD-2013-02413

    Original file (PD-2013-02413.rtf) Auto-classification: Denied

    The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation. Pre-Separation) ConditionCodeRatingConditionCodeRatingExam Right Ankle Decrease ROM and Chronic Pain527110%S/P Surgery, R Ankle with Deg Changes and Post-op Residuals527120%20071119Other MEB/PEB Conditions x 0 (Not In Scope)Other x 5 RATING: 10%RATING: 20% *Derived from...

  • AF | PDBR | CY2012 | PD2012-00316

    Original file (PD2012-00316.pdf) Auto-classification: Approved

    The MEB forwarded chronic right ankle pain to the Physical Evaluation Board (PEB). Sub-talar motion 20 degrees 10% N/A 10% §4.71a Rating N/A At the MEB exam performed on 1 November 2005, the CI reported pain and swelling of the right ankle. The VA coded the ankle 5271 and rated it 10% for moderate limitations in ROM.

  • AF | PDBR | CY2012 | PD2012 01144

    Original file (PD2012 01144.rtf) Auto-classification: Denied

    The PEB adjudicated “s/p left ankle bimalleolar fracture” as unfitting, rated 10% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). I believe that the Decision Board didn't take in consideration all the medical evidence in my favor thus making an erroneous decision; in this case: "when the disability was likely to have occurred or was aggravated, rather than make the assumption it occurred when the claim was originally filed, in addition this is a "faulty...

  • AF | PDBR | CY2013 | PD-2013-02352

    Original file (PD-2013-02352.rtf) Auto-classification: Approved

    SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) was an active dutyE-4(Unit Supply Specialist)medically separated for left ankle pain.The condition could not be adequately rehabilitated to meet the physical requirementsof his Military Occupational Specialty (MOS).He was issued a permanent L3 profileand referred for a Medical Evaluation Board (MEB).The “left ankle pain status post reconstructive surgery” was forwarded to the...

  • AF | PDBR | CY2012 | PD2012 01155

    Original file (PD2012 01155.rtf) Auto-classification: Denied

    Twoleft ankle conditions, characterized as “chronic ankle pain, left” and “synovitis of the left ankle,” were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E. The hepatitis C condition was not specifically requested by the CI, and will not be adjudicated by the Board. The Navy PEB and the VA chose different coding options for the unfitting left ankle condition, but both assigned a disability rating of 10%.

  • AF | PDBR | CY2012 | PD 2012 00577

    Original file (PD 2012 00577.rtf) Auto-classification: Denied

    The other conditions forwarded by the MEB and adjudicated as not unfitting by the PEB were left ankle instability s/p modified Brostrom procedure, left ankle Achilles tendonitis s/p Achilles tendon debridement, recurrent and chronic left ankle synovitis, and chronic left ankle pain. Left Achilles Tendonitis s/p Debridement;Left Ankle Synovitis;Chronic Left Ankle Pain .None of these conditions were separately profiled while on LIMDU, implicated in the commander’s assessment, or noted as...