RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD1301246
BRANCH OF SERVICE:  Army	BOARD DATE:  20140408
Separation Date:  20090925

SUMMARY OF CASE:  The available evidence of record indicates this covered individual (CI) was an active duty PV1/E-5 (68W/Healthcare Specialist) medically separated for three orthopedic conditions.  The CI reported twisting her right ankle in basic training in January 2009 and aggravated this condition on a road march shortly thereafter.  She was eventually told this injury was a stress fracture and the condition was treated with convalescent leave.  In March 2009, the CI strained her right (dominant) shoulder while using a weight machine for exercise.  In May of the same year, she developed right hip pain after a fall.  These three conditions could prevent completion of Basic Training, so she was referred for a Medical Evaluation Board (MEB).  The three conditions, characterized as “chronic right shoulder pain…,” “chronic right hip pain…,” “chronic right ankle pain…” and “chronic bilateral heel pain…,”  were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded four other conditions (including one mental health [MH] condition; see chart below) for PEB adjudication, all were considered medically acceptable.  The PEB adjudicated “right, dominant, shoulder pain…,” “right hip pain,” and “bilateral heel pain and right ankle pain” as unfitting, rated 10%, 0% and 0% (respectively), citing criteria of the VA Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “#1, I could hardly walk on my rt foot, #2 my back & neck were never treated, #3 my mental condition was not treated by a Dr & I was totally misdiagnosed & mistreated.  #4 – I never saw a Dr for anything.”

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.  In addition, the CI was notified by the Army that her case may eligible for review of the military disability evaluation of any MH condition in accordance with Secretary of Defense directive for a comprehensive review of Service members who were referred to a disability evaluation process between 11 September 2001 and 30 April 2012, and whose MH diagnoses were changed or eliminated during that process.  In accordance with Secretary of Defense directive for a comprehensive review of mental health diagnoses that were changed during the Disability Evaluation System process, the applicant’s case file was reviewed regarding diagnosis change, fitness determination, and rating of unfitting MH diagnoses in accordance with the VASRD §4.129 and §4.130.  The CI is also eligible for PDBR review of other conditions evaluated by the PEB and has elected review by the PDBR.  The rating for the unfitting right shoulder, right hip and bilateral heel and right ankle conditions are addressed below.  The fitness determinations for the not unfitting upper back pain and MH conditions are also in the scope of the Board; rating recommendations will also be provided for any conditions recommended as unfitting.  No other conditions are in the scope of this 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 (BCMR).

RATING COMPARISON:

Service IPEB – Dated 20090903	VA - (2 & 3 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder Pain…	5099-5003	10%	Right Shoulder Arthritis	5010-5201	10%	20091125	
Right Hip Pain…	5099-5003	0%	Right Hip Bursitis	5024-5252	10%		
Bilateral Heel Pain and Right Ankle Pain…	5284	0%	Stress Fracture, Right Heel and Ankle Pain	5271-5284	10%		
			Left Heel…Stress Fracture	5284	0%		
History of Upper Back Pain…	Not Unfitting	Chronic Neck Strain	5237	10%		
Generalized Anxiety Disorder…		Generalized Anxiety Disorder with Bipolar Disorder	9432-9400	70%	20091217	
History of Fractured Tooth…		No VA Rating	
History of Dizziness…			
No Additional MEB/PEB Entries	No Additional VA Entries	
Combined:  10%	Combined:  80%	
Derived from VA Rating Decision (VARD) dated 20100528, closest to date of separation

ANALYSIS SUMMARY:  The Board acknowledges the CI’s assertions that her disabilities were not treated correctly.  It is noted for the record that the Board has no jurisdiction to investigate or render opinions in reference to such allegations.  These issues may be addressed by the BCMR and/or the United States Judiciary system.  IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on ratable severity at the time of separation.

The PEB rated the bilateral heel pain and right ankle pain under the single code 5284 (other foot injuries).  This coding approach is countenanced by AR 635-40 (B.24 f.), but IAW DoDI 6040.44 the Board must apply only VASRD guidance to its recommendation.  The Board must therefore apply separate codes and ratings in its recommendations if compensable ratings for each joint are achieved IAW VASRD §4.71a.  If the Board judges that two or more separate ratings are warranted in such cases; however, it must satisfy the requirement that each “unbundled” condition was reasonably justified as unfitting in and of itself, with the caveat that the final recommendation may not produce a lower combined rating as that of the PEB.

Right Dominant Shoulder Pain Condition.  The CI injured her right shoulder on a weight lifting machine in March 2009.  Since the injury, she had daily shoulder pain with flare-ups when she lifted her arm above the shoulder; this increased pain continued until the arm was lowered.  The MEB narrative summary (NARSUM) exam accomplished approximately 2 months prior to separation documented chronic right shoulder pain and despite therapy there was no improvement.  The physical exam findings from the NARSUM are summarized in the chart below.  In preparation for the MEB, the CI was also evaluated by physical therapy (PT), those exam findings are also summarized in the chart below.  The commander’s statement noted that the CI’s injuries prevented return to basic training.  The CI was given a permanent U3/L3/S2 profile that identified her chronic right shoulder pain condition.  The VA Compensation and Pension (C&P) exam (performed approximately 2 months after separation) noted the right shoulder joint was painful on motion; those C&P physical exam findings are also summarized below.  Those three goniometric range-of-motion (ROM) evaluations, with additional ratable criteria, which the Board weighed in arriving at its rating recommendation, provided the following data:

Right Shoulder ROM (Degrees)	MEB 3.5 Mos. Pre-Sep	PT 3.0 Mos. Pre-Sep	VA C&P 2.0 Mos. Post-Sep	
Flexion (180 Normal)	175	170*	180	
Abduction (180)	180	180*	180	
Comments - Right hand dominant	Pain in all planes; + impingement; tenderness to palpation (TTP) over supraspinatus, trapezius; pain, tingling forearm	*With pain; visible atrophy right shoulder deltoid	ROM with pain; painful joint motion; tenderness over right shoulder joint line	

The Board directs attention to its rating recommendation based on the above evidence.  The PEB coded the right shoulder pain condition as 5099 analogous to 5003 (degenerative arthritis) and rated it 10%, referencing application of 4.10 (functional impairment), 4.40 (functional loss), 4.45 (the joints) and §4.59 (painful motion).  The VA applied the analogous code of 5010-5201, limitation of arm motion, and rated it 10%.  All documents in evidence consistently identified non-compensable ROM measurements with painful motion of the right shoulder.  The Board considered all reasonable alternative coding options, but no option would achieve a rating greater than 10%.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded there was insufficient cause to recommend a change in the PEB adjudication for the right (dominant) shoulder pain.

Right Hip Pain condition:  The CI injured her right hip in May 2009 when she slipped off of a bunk and fell to the floor.  Since this incident, the CI complained of right hip pain on a daily basis.  The NARSUM documented chronic right hip pain and that despite therapy there was no improvement.  The CI was evaluated by PT (exam findings reflected in the chart below).  The commander’s statement noted the CI’s injuries prevented a return to basic training.  The CI was given a permanent U3/L3/S2 profile that identified her right hip condition. The C&P exam noted the CI had chronic right hip pain and tenderness.  There were three goniometric ROM evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation, which are summarized below:

Right Hip (Thigh) ROM (Degrees)	MEB ~2.5 Mos. Pre-Sep 	PT ~2 Mos. Pre-Sep	VA C&P ~2 Mos. Post-Sep	
Flexion (125 Normal)	115 	115	90	
Extension (20)	20	20	10	
External Rotation (45)	-	-	40	
Abduction (0-45)	55 	55*	45	
Adduction (45)	-	-	45	
Comment	TTP over right greater trochanter; guarding; “pain behavior” in all planes of motion	*with pain; goniometer used	*With pain; Antalgic gait; difficulty squatting; tenderness over right hip	

The Board directs attention to its rating recommendation based on the above evidence.  The PEB coded the right hip pain condition as 5099 analogous to 5003 (degenerative arthritis) and rated it 0%, referencing VASRD 4.10, 4.40, 4.45 and §4.59.  The VA coded the right hip bursitis condition as 5024 (tenosynovitis) with 5252 (limitation of flexion of the thigh) and rated it 10%.  All exams proximate to separation documented painful motion of the right hip, though the NARSUM examiner termed it “pain behavior.”  The Board considered all reasonable coding alternatives and none offered a rating greater than 10%.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right hip pain.

Bilateral Heel Pain and Right Ankle Pain Condition:  The Board first considered whether the bilateral heel pain and right ankle pain conditions, having been de-coupled from the combined PEB adjudication, were each reasonably justified as independently unfitting.  Both the NARSUM and the VA exams documented the CI had pain in the right ankle and that a stress fracture existed in the right heel.  The left heel also had a mild calcaneal stress fracture, though there was no mention of a left ankle injury in those exams.  Therefore, it is reasonably justified that the CI be found unfit for continued military service in her Military Occupational Specialty (MOS) due to left heel pain and right heel and ankle pain as separate (unfitting) conditions.  Board members agreed that the left heel pain and right heel and ankle pain conditions, as isolated conditions, would each have rendered the CI incapable of continued service within her MOS, so each merits a separate rating.

The three goniometric ROM evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation, are summarized in the chart below:

Ankle ROM (Degrees)	MEB ~2.5 Mos. Pre-Sep	PT ~2 Mos. Pre-Sep	VA C&P ~2 Mos. Post-Sep	
	Left	Right	Left	Right	Left	Right	
Dorsiflexion (20 Normal)	10 	10 *	10 	15*	No ROM	10*	
Plantar Flexion (45)	45 	45 *	45 	45*		30*	
Comment	No pain noted	*with “pain behavior”; TTP entire lateral aspect	* with pain		*with pain; pain on inversion; antalgic gait; difficulty walking on heels and toes	

The CI twisted her right ankle in February 2009 when she stepped on a rock and further aggravated the right ankle after a three day road march.  She developed a stress fracture in the right ankle.  A left heel X-ray showed a mild calcaneal stress fracture.  A bilateral heel X-ray revealed healing bilateral calcaneal stress fractures.  Since this incident the CI complained of right ankle hip pain.  The MEB NARSUM documented chronic right ankle pain which was made worse with standing for prolonged periods.  The MEB NARSUM exam findings are summarized in the chart above.  The CI was evaluated by PT and the exam findings are summarized in the chart above.  The commander’s statement noted the CI’s injuries prevented her from returning to basic training.  The CI was given a permanent U3/L3/S2 profile for her right ankle and bilateral heel pain.  The C&P exam noted the CI had chronic right ankle pain which would last for weeks and right heel pain which would last for approximately 2 hours daily.  The examiner noted that the CI required heel supports.  The C&P physical exam findings are summarized in the chart above.

The Board directs attention to its rating recommendation based on the above evidence.  As described above, the PEB bundled the conditions and assigned a 0% rating with application of 4.10, 4.40, 4.45 and §4.59.  The VA assigned a disability rating of 10% to the stress fracture, right heel and ankle pain and coded as 5271 (limited motion of the ankle) with 5284 (other injuries of the foot).  The VA assigned a disability rating of 0% for the left heel stress fracture and coded as 5284.  The MEB NARSUM exam focused on the right ankle and heel and noted painful motion along with a healing calcaneal stress fracture.  The left heel was noted to be pain free.  The C&P examiner noted right ankle painful motion and difficulty walking on heels and toes.  The left heel and ankle were not examined.  After due deliberation in consideration of the totality of the evidence, the Board concluded that the left heel pain and right heel and ankle pain were each reasonably justified as unfitting.  Considering all of the evidence and mindful of VASRD §4.3 reasonable doubt, the Board recommends a disability rating of 10% coded 5284-5003 IAW VASRD §4.71a for the right heel pain and right ankle pain and 0% coded 5284 IAW VASRD §4.71a for the left heel pain.

Contended PEB Conditions.  The contended conditions adjudicated as not unfitting by the PEB were history of upper back pain and generalized anxiety disorder (GAD).  The Board’s first charge with respect to these conditions is an assessment of the appropriateness of the PEB’s fitness adjudications.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

History of Upper Back Pain Condition:  The NARSUM contained only one reference to upper back pain.  That reference was contained in the “Past Medical History” section and stated that the upper back pain in May 2009 was “resolved.”  This condition was not profiled nor was this condition implicated in the commander’s statement.  This condition was not judged to fail retention standards.  This condition was reviewed by the action officer and considered by the Board.  There was no indication from the record that this condition significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded there was insufficient cause to recommend a change in the PEB fitness determination for the history of upper back pain, so no additional disability rating can be recommended.

Generalized Anxiety Disorder:  The Board reviewed the records for evidence of inappropriate changes in diagnosis of the MH condition during processing through the Disability Evaluation System.  The evidence of the available records shows a diagnosis of anxiety disorder NOS (not otherwise specified) was rendered and no change in diagnosis was made at any time; therefore, this case did not meet the inclusion criteria in the Terms of Reference of the MH Review Project.  A psychiatric addendum was prepared approximately 3 weeks prior to separation.  The examiner reported the CI self-referred for MH treatment in May 2009 (approximately 4 months after entering military service) with complaints of generalized anxiety, low frustration tolerance, increased irritability and insomnia.  She reported a 12-year history of intermittent outpatient treatment for anxiety and depression.  She was initially diagnosed with adjustment disorder, rule-out anxiety disorder and started on medication and behavioral therapy.  Despite treatment, she continued to endorse problems with generalized anxiety, irritability and insomnia.  The CI denied panic attacks and psychotic symptoms, reported no history of manic symptoms and no suicidal or homicidal ideations.  The Behavioral Health provider made several changes to the CI’s psychiatric medications in an effort to reduce her anxiety, depression and insomnia symptoms.  The examiner opined that the CI’s most functionally impairing symptoms in the military environment were related to her medical problems, not psychiatric ones.  The examiner documented the CI had experienced similar psychiatric symptoms prior to the Army and that these symptoms did not impact her ability to be successfully employed.  The examiner also noted the CI’s main source of anxiety and irritation were the cadre members of the physical training and rehabilitation program in which she was enrolled at the time.  The examiner diagnosed GAD and indicated the CI met retention standards from a psychiatric perspective.  The CI agreed with the MEB psychiatric NARSUM.  She was given a permanent S2 profile for GAD.  The VA C&P MH exam (approximately 2 months prior to separation) indicated the CI showed emotional lability, poor judgment, anxiety and anhedonia.  The examiner diagnosed adjustment disorder with anxious and depressed mood.  No MH condition was specifically implicated by the commander’s statement; it referred to physical injuries only (there was no mention of a MH condition).  No MH condition was judged to fail retention standards.  The MH condition was reviewed by the action officer and considered by the Board.  There was no indication from the record that this condition significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded there was insufficient cause to recommend a change in the PEB fitness determination for the GAD, so no additional disability rating can be recommended.

BOARD FINDINGS:  In the matter of the right shoulder pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the right hip pain condition and IAW VASRD §4.71a, the Board unanimously recommends disability rating of 10% coded 5099-5003 IAW VASRD §4.71a.  In the matter of the bilateral heel pain and right ankle pain conditions, the Board unanimously recommends the conditions be unbundled and adjudicated as follows: right heel pain and right ankle pain with a disability rating of 10% coded 5284-5003 IAW VASRD §4.71a, and the left heel pain with a disability rating of 0% coded 5284 IAW VASRD §4.71a.  In the matter of the contended history of upper back pain and the GAD conditions, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review.

RECOMMENDATION:  The Board recommends the CI’s prior determination be modified as follows and, that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective the date of her prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Right Dominant Shoulder Pain	5099-5003	10%	
Right Hip Pain	5099-5003	10%	
Right Heel Pain and Right Ankle Pain	5284-5003	10%	
Left Heel Pain	5284	0%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130910, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXX, AR20140013580 (PD201301246)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to recharacterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.  

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:

	a.  Providing a correction to the individual’s separation document showing the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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