RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	              CASE:  PD-2014-00724
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20020613

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Health Care Specialist) medically separated for left ankle and right shoulder conditions.  These conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent U3/L3 profile and referred for an Medical Evaluation Board (MEB).  Left ankle anterior impingement with subtalar arthrosis and right shoulder multidirectional instability conditions were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated chronic pain, left ankle and right shoulder conditions as unfitting, rated 0% with cited application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  He was given higher ratings for his right shoulder conditions by the VA.  His right shoulder continues to worsen.  His complete submission is at Exhibit A.

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 condition 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 confined to 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 IPEB – Dated 20020412	VA* - (~3 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Left Ankle and Right Shoulder	5099-5003	0%	Right Shoulder…Instability	5203	20%	20020828	
			Arthritis R Shoulder & L Ankle	5010	10%	20020828	
			Left Ankle Anterior…	5010-5024	10%	20020828	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 5	
RATING:  0%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20020928 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:  The PEB combined the left ankle chronic pain and right shoulder condition as a single unfitting condition, coded analogously to 5003 and rated 0%. The PEB relied on the USAPDA pain policy for not applying separately compensable VASRD codes.  The Board must apply separate codes and ratings in its recommendations if compensable ratings for each condition 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 unfitting in and of itself.  Not uncommonly this approach by the PEB reflects its judgment that the constellation of conditions was unfitting, and that there was no need for separate fitness adjudications, not a judgment that each condition was independently unfitting.  Thus the Board must exercise the prerogative of separate fitness recommendations in this circumstance, with the caveat that its recommendations may not produce a lower combined rating than that of the PEB.

Left Ankle.  The record shows that the CI sprained his left ankle playing volleyball on 1 January 2000.  He noted persistent pain and increased swelling over the next 2 days and was evaluated in primary care on 3 January 2000.  On X-ray, an avulsion fracture was noted (when a ligament tears away a small piece of bone).  He was treated conservatively with elevation, rest, ice, and referred to orthopedics.  He continued conservative management and initially did well, but presented on 28 November 2000 with persistent pain.  He was again seen in orthopedics and thought to have a possible impingement of the ankle when seen on 28 January 2001.  An MRI apparently showed a ganglion cyst per the orthopedic note.  He was next seen that July and reported a 3-year history of left ankle instability which had been aggravated by the injury described above.  On examination, the range-of-motion (ROM) was reduced and signs of instability present.  He had surgery on 22 September 2001 for left ankle impingement.  This was successful, but he then had inflammation of the peroneal tendon (a tendon that runs behind the outside ankle bone).  In physical therapy on 6 December 2001, the CI had a normal gait with minimal swelling about the lateral (outside) ankle.  Dorsiflexion (toes up) was reduced, but only 3 degrees less than the unaffected right side.  Strength was normal.  One test for instability was positive.  In orthopedics on 5 February 2002, the CI was noted to have a stable ankle and slightly reduced, but painful, ROM (charted below).  On the DD Form 2808, Report for Medical Examination, dated 5 February 2002, 4 months before separation, the CI reported a painful left ankle that locked up.  No specific comment was made on examination.  At the MEB narrative summary (NARSUM) examination, dated 27 March 2002, 3 months before separation, the CI reported persistent pain, locking, and trouble with stairs.  One test for instability was slightly positive.  The ROM is charted below.  The CI was tender to palpation, but swelling was absent.  He was thought to have anterior impingement with arthrosis (degeneration of the joint) seen on the prior arthroscopy.  On 3 April 2002, the CI was given a permanent L3 profile for the left ankle and the MEB noted that it did not meet retention standards.

At the VA Compensation and Pension (C&P) examination dated 28 August 2002, 3 months after separation, the CI reported flares of his ankle pain 1-2 times a week which lasted up to 3 days.  He reported that he could climb stairs, drive, take out the trash, and mow a lawn.  On examination, the left ankle appeared normal and the ROM was normal.  The goniometric 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)	Orthopedic
~4 Mo. Pre-Sep	MEB Orthopedic
~3 Mo. Pre-Sep	VA C&P General
~3 Mo. Post-Sep	
Dorsiflexion (20 Normal)	15	20	20	
Plantar Flexion (45)	30	30	45	
Comment	Some pain with motion	Eversion and Inversion without pain	Discomfort with ROM	
§4.71a Rating	10%	10%	10%	

The Board first considered if the ankle was separately unfitting.  It was issued an L3 profile and specifically referred to the PEB for adjudication by the MEB.  The Board determined that the evidence supports a finding that the left ankle was separately unfitting.  The Board then directed its attention to its rating recommendation based on the above evidence.  The loss of motion with painful motion (IAW VASRD §4.59) support a 10% rating.  The VA rated the ankle at 10% using a dual code of 5010 (Traumatic arthritis) and 5024 (Tenosynovitis).  The Board noted that code 5271 (Limited motion of the ankle) provided a better description although no rating advantage to the CI.  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 left ankle condition, coded 5271.

Right Shoulder.  The record shows that the right dominant CI injured his shoulder on 1 September 1999.  This is initially recorded as both the right and left shoulder, but subsequent notes the next year are for the right shoulder.  An MRI on 20 December 2000 noted inflammation of a bursa (fluid filled sac) beneath the acromion process (part of the shoulder).  In orthopedics a week later, he was noted to have findings consistent with a SLAP tear (a tear of the labrum, the cartilage lining of the joint).  This was surgically repaired on 2 February 2001 along with resection of the distal clavicle (collar bone) and rotator cuff repair (muscles that help with shoulder movement and stability).  By 5 April 2001, he had regained full ROM and was regaining his strength.  He was thought to be progressing well.  On 24 May 2001, he was seen in orthopedics and noted to have normal ROM and strength.  In physical therapy on 13 August 2001, he reported a ‘catching’ “when quickly lifting his arm up and back.”  He was able to do 50 push-ups without pain (prior to the surgery, he had been able to do 100 in 1 minute).  In orthopedics on 3 January 2002, the CI reported continued pain with overhead activities and a sensation of subluxation doing side straddle hops.  Tests for anterior instability (apprehension and load shift) and one for a possible labral tear (O-Brien testing) were positive.  He was thought to have anterior instability.  On the DD Form 2807, Report of Medical History, and /DD Form 2808, dated 5 February 2002, 4 months before separation, the CI reported pain in his right shoulder.  He was noted to have a positive apprehension and relocation (for anterior instability) sign.  At the MEB narrative summary (NARSUM) examination, dated 27 March 2002, 3 months before separation, and dictated by a treating orthopedic surgeon, the CI reported diffuse pain in the right shoulder aggravated by overhead activities and push-ups.  The examiner did not document dislocation or subluxation (a partial dislocation).  A test for acromio-clavicular joint (ACJ, the collar bone and part of the shoulder) was positive (the cross-arm adduction test).  An apprehension test was positive for both anterior and posterior instability.  However, the sulcus sign (another test for instability) was negative.  The ROM was full and strength normal.  An MRA (MRI arthrogram, not otherwise in evidence) was negative for a rotator cuff tear (the muscles that provide shoulder stability and some of the movement), a labral tear, or for impingement.  He was diagnosed with multi-directional instability, indicative of a general laxity of the shoulder, but noted with either subluxation or dislocation.

At the VA C&P examination dated 28 August 2002, 3 months after separation, the CI reported pain with overhead activities and intermittent paresthesia (abnormal sensations such as tingling).  He was able to take out the trash, mow the lawn, vacuum, and shower.  On examination, the shoulder appeared normal.  The ROM was reduced as charted below.  On X-ray, he was thought to have a Grade II or III AC separation (the Board noted that the distal clavicle had actually been resected and found no indication that the radiologist had been made aware of this) with mild arthritis of the joint.  The actual shoulder joint and labrum appeared normal.  The CI was diagnosed with a Grade II-II separation of the ACJ with mild arthritic changes.  The Board noted that an X-ray report of the right shoulder on 15 December 2004 was normal.  The goniometric 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.

Right Shoulder ROM
(Degrees)	Orthopedic
~5 Mo. Pre-sep	MEB Orthopedic
~3 Mo. Pre-Sep	VA C&P General
~3 Mo. Post-Sep	
Flexion (180 Normal)	Full Active ROM	180	170	
Abduction (180)	“	180	140	
Comments	Painful motion not cited	Painful motion	Painful motion	
§4.71a Rating	10%	10%	10%	

The Board first considered if the right shoulder was separately unfitting.  It was issued an U3 profile and specifically referred to the PEB for adjudication by the MEB.  The Board determined that the evidence supports a finding that the right shoulder was separately unfitting.  The Board then directed its attention to its rating recommendation based on the above evidence.  The VA rated the right shoulder at 20%, coded 5203 (Impairment of the scapula or clavicle, dislocation or non-union with loose movement), for multidirectional instability and at 10% for arthritis of the right shoulder (and ankle) coded 5010 (Traumatic arthritis).  In 2005, the VA later severed the rating for arthritis from the ankle and rated the shoulder at 20%, coded 5203, for instability, and 10%, coded 5201-5010 (Limitation of motion-traumatic arthritis), for right shoulder arthritic changes, all effective 27 July 2004.  As noted, the PEB rated the shoulder and ankle together with application of the pain policy.  The Board noted that the CI was diagnosed with multi-directional instability by the treating orthopedic surgeon.  As noted above, this implies a general laxity of the ligaments of the shoulder rather than subluxation or frank dislocation; the latter two conditions would support a rating under VASRD code 5202, but were not documented.  The X-ray report showed a possible Grade II-III separation, but this appearance is also consistent with the history of resection of the distal clavicle (part of the collar bone near the shoulder rather than the sternum).  The Board noted that the record does not document an ACJ separation prior to separation and that a later post-separation X-ray was normal.  Ankylosis was not present.  The ROM loss on the C&P was non-compensable.  Painful motion was present and the distal clavicle had been resected.  This supports a rating of 10% under 5203 (Impairment of the clavicle) for malunion.  No route to a higher rating was found.  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 coded 5203.

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 left ankle and right shoulder conditions was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the left ankle condition, the Board unanimously recommends a disability rating of 10%, coded 5271 IAW VASRD §4.71a.  In the matter of the right shoulder condition, the Board unanimously recommends a disability rating of 10%, coded 5203 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:

CONDITION	VASRD CODE	RATING	
Chronic Left Ankle Pain due to Anterior Impingement…	5271	10%	
Chronic Right Shoulder Pain due to Multi-directional Instability	5203	10%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140207, 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, AR20160002618 (PD201400724)

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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization 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:

CF: 
(  ) DoD PDBR
(  ) DVA