RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00090
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060422

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E5, Motor Transport Operator, medically separated for “low back pain,” “right olecranon bursitis,” “right shoulder pain,” and “right and left trochanteric bursitis with healed right impacted proximal femoral fracture,” rated 10%, 0%, 0% and 0% respectively, with a combined disability rating of 10%.

CI CONTENTION: “Initial discharge rating was 10%.  Receiving Social Security Disability due to PTSD and Service Connected Disabilities.”  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 based upon a review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (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:  

SERVICE PEB - 20060309	VARD - 20110831	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Degenerative Disc Disease, L4-L5	5010-5242	10%	20110305	
Right and Left Trochanteric Bursitis	5019	0%	Trochanteric Bursitis, Right Hip	5019	10%	20110305	
			Trochanteric Bursitis, Left Hip	5019	NSC	20110305	
Post-Traumatic Stress Disorder	Not Unfitting	Post-Traumatic Stress Disorder	9411	50%	20110917	
Right Shoulder Pain	5099-5003	0%	No VA Placement	
Right Olecranon Bursitis	5019	0%		
Right Ulnar Neuropathy	Not Unfitting		
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI reported non-radicular back pain since his injury in Iraq when he was riding in a HUMVEE that was hit by an IED.  The CI’s condition was treated conservatively and significantly improved until August 2005 when he strained his back in a slip that led to a fall.  The MRI in August 2005 showed degenerative disc disease (DDD) and facet disease of lumbar spine greater at L4-5.  He was not a surgical candidate.  Despite treatment, the CI’s condition did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded lumbar DDD for PEB adjudication.

Physical Therapy (PT) range of motion (ROM) for the MEB was conducted on 20 October 2005, 6 months before separation, and documented forward flexion to 60 degrees after three trials (normal 90 degrees) and extension of 10 degrees (normal 30 degrees).  Muscle strength was slightly reduced to 4/5.  Painful motion was not documented.

The MEB NARSUM examination on 23 November 2005, 5 months prior to separation, noted complaints of “right elbow pain, right arm pain, right hip pain.”  The CI reportedly stated that his back condition had not interfered with his assigned MOS duties (heavy wheeled vehicle operator), but he was unable to perform the basic soldier skills.  He reported low back pain; however, precipitating or alleviating factors, or intensity or frequency of his pain was not recorded.  Physical examination showed there was tenderness to palpation in lumbar muscles and no evidence of radiculopathy.  The examiner noted that ROM testing was performed by PT (see above).

The VA Compensation and Pension (C&P) examination was performed almost 5 years after separation and had no probative value since it was too remote from separation.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain) citing tenderness to palpation and ROM within acceptable norms.  The VA also rated the back condition 10%, coded 5010-5242 (Degenerative Disc Disease L4-5).  The ROM recorded at the PT clinic was flexion of 60 degrees, and, therefore, the Board agreed that a 20% rating, but no higher, was justified for limitation of flexion (thoracolumbar flexion not greater than 60 degrees).  The C&P examination had no probative value.

The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The CI reported radiating pain; however, the NARSUM examination revealed no objective findings of radiculopathy that would impact duty performance.  The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting.  While the CI may have suffered additional pain from the nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  Therefore the critical decision is whether or not there was a significant motor weakness which would impact military occupation-specific activities.  There was no evidence in this case that motor weakness existed to any degree that could be described as functionally impairing.  The Board therefore concluded that an additional disability rating was not justified.

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 back condition.  

Right Olecranon Bursitis (Left Hand Dominant).  According to STR and the MEB NARSUM, the CI’s right elbow condition began in April 2004 after a fall.  The initial impression was that he had sustained right elbow contusion with lateral epicondylitis.  He reported right lateral arm numbness and “pulling pain” in the region of the lateral elbow and lateral forearm.  Electro diagnostic studies in July 2004 were normal; however, repeat EMG in February 2005 showed mild right ulnar neuropathy.  The CI underwent cortisone injection therapy with the pain clinic and participated in PT.

At the MEB NARSUM examination dated November 2005, 5 months prior to separation, the CI reported he had right elbow and arm pain.  The examiner noted that the CI had continued to complain of decreased motion in his right elbow despite full ROM and normal muscle strength testing.  PT ROM testing 6 months before separation recorded pronation and supination of the right elbow at 90 degrees (normal 80 and 85 respectively), and flexion to 148 degrees.  Pain on motion was not recorded.  As noted above, the VA Compensation and Pension (C&P) examination was performed almost 5 years after separation and had no probative value since it was too remote from separation.

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 0% rating under the 5019 code (bursitis), citing ROM and muscle strength within acceptable norms and not independently ratable.  The VA did not rate the elbow joint.  The Board found no evidence to support a rating higher than 0% under any of the ROM codes (5205-5208), and there was no evidence of fracture of the ulnar or radius bones to justify a rating consideration under codes 5209-5213.  There was no evidence to support a rating under any of the peripheral nerve codes for the mild ulnar nerve neuropathy since functional impairment was not documented and therefore not unfitting.  

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 right elbow condition.  

Right Shoulder Pain.  According to STR and the MEB NARSUM, the CI’s right shoulder condition began in May 2004 after being hit by an IED.  He was diagnosed with a slight right rotator cuff tear which did not require surgery and tendinosis.  There was no sign of frank tear or fracture, or dislocation of the shoulder.  Orthopedic treatment record in February 2005 noted that the right shoulder tendinitis with small partial tear of the right rotator cuff no longer required further treatment.

PT ROM for the MEB was conducted on 20 October 2005, 6 months before separation, and documented forward flexion of 140 degrees after three trials (normal 180 degrees) and abduction of 121 degrees (normal 180 degrees).  Muscle strength was slightly reduced to 4/5.  Painful motion was noted.

At the MEB NARSUM examination dated November 2005, 5 months prior to separation, the CI reported his right shoulder pain continued and impacted his daily activities.  The CI reported that he would be able to perform his MOS duties; however, he was not able to perform his military APFT requirements due to right upper extremity pain and weakness.  An EMG was completely normal.  An MRI revealed a small partial thickness tear involving the supraspinatus tendon not requiring surgery.  Improvement was noted with PT.  

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 0% rating under an analogous 5099-5003 code (arthritis, degenerative), citing application of the USAPDA Pain Policy.  The VA did not rate the shoulder joint.  The VA 5201 code (arm limitation of motion) threshold for ROM impairment is “at shoulder level” (90 degrees from the side) and the ROM in evidence demonstrated motion above this level.  Although there was insufficient limitation of motion to support a rating under 5201, Board members agreed that a 10% rating was justified with application of VASRD 4.59 (painful motion).  There was no malunion or recurrent dislocation of the humerus to justify a rating under the 5202 code (humerus, other impairment of), and no non-union with loose movement of the clavicle to warrant the next higher 20% rating under the 5203 code (clavicle or scapula, impairment of), and there was no ratable peripheral neuropathy to justify the use of a nerve code.  

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 shoulder condition.  

Right and Left Trochanteric Bursitis with Healed Right Impacted Femoral Fracture.  According to STR and the MEB NARSUM, the CI’s bilateral hip condition began in May 2004 after being hit by an IED.  The NARSUM noted that the CI injured his right hip and that radiographs taken in July 2004 were normal.  The CI also underwent electrodiagnostic study of the right lower extremity in July 2004 which was normal.  His condition was treated conservatively with PT and medication.  Despite treatment, the right and left trochanteric condition did not result in improvement sufficient to allow unrestricted duty.  

The CI was evaluated and treated by an orthopedic specialist and in February 2005, the orthopedic physician noted that the CI had injured his right elbow, right shoulder and right hip in the IED blast.  The physician suspected fracture of the right femoral neck which was confirmed by MRI.  The fracture subsequently healed.  He was discharged from orthopedic care in February 2005, and his condition progressed satisfactorily following therapy, rest, and anti-inflammatory medication.

PT ROM for the MEB was conducted on 20 October 2005, 6 months before separation, and documented right hip flexion of 115 degrees and left hip flexion of 104 degrees after three trials (normal 125 degrees).  Right hip extension was 21 degrees and left hip extension was 10 degrees (normal 20 degrees).  There was no significant finding of weakness, but pain on motion was recorded for both right and left hip.

At the MEB NARSUM dated 23 November 2005, 5 months before separation, the CI noted that he was unable to perform the APFT events, but could perform his MOS requirements.  He reported that he was unable to walk without cane assistance.  It was noted that the CI was authorized to perform the 2.5 mile walk for the APFT test.  Physical examination recorded tenderness to palpation of the right and left trochanteric bursa.  The examiner noted ROM testing was performed by PT (see above).

The PEB combined the right and left trochanteric bursitis under a single disability rating, coded 5019.  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  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 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.  
The Board directed attention to its rating recommendation based on the above evidence.  The Board must consider separate ratings for PEB bilateral musculoskeletal/joint adjudications; although, separate fitness assessments must justify each disability rating.  In this case only the right hip pain was profiled.  The commander’s statement did not provide any information which would permit the Board to discriminate the performance limitations attributable to either hip over the other.  The commander stated “The soldier’s current limitations are unknown to the 706th at this time (March 2005).  Examination of both hips was normal at the NARSUM, and the examiner stated “all the conditions, individually, should not limit the soldier to the extent that he states, but in combination interfere with satisfactory performance of his basic soldier skills and APFT events.”  The CI reported that he was able to perform the duties of his MOS but was unable to perform the APFT with the exception of the 2.5 mile walk.  The Board could not find evidence in the STR that indicated any significant interference with the performance of duties related to his left hip condition; however, there was radiographic evidence of right hip fracture, and right hip rehabilitation treatment, and right hip profile.  Therefore, Board members agreed, the preponderance of evidence supports an unfit finding for the right hip but not for the left.

The Board then considered its rating recommendation for the unfitting right hip condition at the time of separation.  The Board noted the absence of a compensable ROM under any of the ROM codes for the hip joint, but painful motion was sufficiently documented during the examination.  The 5019 code is compatible with both the pathology and disability of its default code 5003 and appropriately rated at 10% IAW VARSD § 4.59 for painful motion.  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 hip condition, coded 5019.  

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that PTSD and right ulnar neuropathy conditions were not unfitting.  Right arm numbness and pain was profiled, but was not judged to fail retention standards or implicated in the commander’s statement.  The PTSD was not specifically listed on the profile but an S2 was designated.  The psychiatric evaluation in March 2005 noted that the condition met retention standards and that his symptoms had “declined significantly.”  PTSD was not implicated in the commander’s statement and was not judged to fail retention standards.  There was no performance based evidence from the record that the contended conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for PTSD and right ulnar neuropathy conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the right shoulder pain condition, the Board recommends a disability rating of 10%, coded analogously 5099-5003 IAW VASRD §4.71a, and §4.59.  In the matter of the low back condition, the Board recommends a disability rating of 20%, coded 5237 IAW VASRD §4.71a.  In the matter of the right olecranon bursitis condition and IAW VASRD §4.71a, the Board recommends no change in the PEB adjudication.  In the matter of the left and right trochanteric bursitis conditions, the Board unanimously recommends the right trochanteric bursitis condition is separately unfit with a disability rating of 10% coded 5019, IAW VASRD 4.71a and 4.59.  The Board unanimously agrees that the left trochanteric bursitis is not separately unfit and cannot recommend it for additional service disability rating.  In the matter of the contended PTSD and right ulnar neuropathy conditions, the Board recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  

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

CONDITION	VASRD CODE	PERMANENT RATING	
Low Back Pain	5237	20%	
Right Olecranon Bursitis	5019	0%	
Right Shoulder Pain	5099-5003	10%	
Right Hip Bursitis	5019	10%	
COMBINED	40%	
The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131221, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXX AR20160016219 (PD201400090)

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 re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 40% 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 that 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 40% 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:

Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA