RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00752
BRANCH OF SERVICE:  Army 	date of SEPARATION:  20060821

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Signal Support System, medically separated for “chronic pain left sternoclavicular joint and left metatarsals secondary to an arthritis process of undermined nature,” rated at 20%.

CI CONTENTION:  CI contends a higher rating to include shoulder pain and rotator cuff surgery. The applicant’s complete submission, with attachments, 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 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 PEB - 20060707	VARD - 20061207	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain Left Sternoclavicular Joint and Left Metatarsals…	5099-5003	20%	Degenerative Joint Disease, Left Sternoclavicular Joint Claimed as Shoulder Pain	5201-5010	10%	20061030	
			Synovitis and Hallux Valgus Deformity, Left Metatarsal Phalangeal Joint (MTP), Great Toe	5280	0%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Pain Left Sternoclavicular Joint (Left Clavicle).  An early note in the service treatment record (STR) dated 2 August 2004 indicated the CI had left shoulder pain, for 4 months, anteriorly, which radiated to the clavicle in the absence of trauma or fracture.  On examination the left clavicular head (medial) subluxed, but was stable.  The range-of-motion (ROM) was normal with tenderness at the ROM extremes.  Treatment consisted of Bextra (a nonsteroidal anti-inflammatory drug [NSAID]).  X-rays of the left clavicle in August 2004 showed no osseous, joint or tissue abnormalities, while magnetic resonance imaging (MRI) demonstrated a small left sternoclavicular (SC) joint effusion with a vacuum phenomenon (intraarticular gas in the joint).  A bone scan revealed post-traumatic or stress related changes of the right SC joint (not in scope) and the left 3rd metatarsal phalangeal joint (see below).  Evaluation on 6 October 2004 revealed a full ROM of the left shoulder with atrophy.  Rheumatoid factor and Lyme disease laboratory tests were inconclusive.  Rheumatology examination confirmed the bone scan findings were actually on the left corresponding to the CI’s history and symptoms.  He opined that isolated involvement of the SC joint was “vanishingly uncommon” and could not associate a pattern of long term forefoot soreness (see below) with this more recent SC joint issue.  Treatment consisted of a trial of Celebrex (celecoxib, an NSAID).  The CI received an intraarticular steroid injection in late November 2004.  In March 2005, Feldene (piroxicam, an NSAID) replaced other pain medications that were not effective.  Examination in July 2006 revealed pain on motion of the shoulder, which seemed to originate within the SC joint, but there was no clear impingement over the acromioclavicular (AC) joint region although there was crepitus.  There was asymmetry of the clavicle with significant swelling over the SC joint.  Treatment was modified to etodolac (an NSAID) and cyclobenzaprine (a muscle relaxer).  A computerized tomography scan on 24 January 2006 revealed hypertrophy of the sternum and medial end of the clavicle at the SC joint and a linear small bone fragment at the medial clavicle.  Additionally, there was a mild separation and elevation of the medial end of the left clavicle.  In February 2006 there were no symptoms or abnormalities in the ROM of the entire right upper extremity, but there was visible enlargement of the SC joint and tenderness.  In March 2006, naproxen (an NSAID) and Tylenol 3 (acetaminophen and codeine, a narcotic) were prescribed.  An exhaustive workup for infection and rheumatoid arthritis was negative.  ROM measurements of the shoulder were forward flexion 130 degrees with pain, abduction 90 degrees with pain, internal rotation to L5, and external rotation 45 degrees.  There was palpable swelling over the medial left SC joint, which was painful to palpation, but there was no instability of the shoulder with the ROM movements.  A physical medicine physician added tramadol (an opioid-like medication) to the medication protocol. 

The commander’s statement dated 2 May 2006 indicated the CI was limited by her profile and was unable to perform duties normally expected of a soldier or her specialty.  At the Medical Evaluation Board (MEB) examination the CI reported a painful shoulder and collarbone and numbness in the shoulder depending on her position when lying down.  She also had difficulty sleeping due to shoulder pain, and an inability to move in “certain ways” with the shoulder.  The examiner noted on a DD Form 2808 dated 5 May 2006, left SC joint tenderness to palpation with SC joint prominence and clavicle tenderness to palpation.  The left shoulder posterior aspect was tender to palpation and the ROM was limited.  Pain was elicited by cervical rotation to the right and lateral flexion to the right as well as by all ROMs.  Motor strength was normal.  A permanent U3L3 profile for left shoulder pain, traumatic arthritis and foot arthritis was issued in June 2006 with limitations of all military activities except wearing protective mask and all chemical defense equipment and all physical fitness training as well as lifting and carrying, avoidance of parade rest, and no field gear.

The MEB narrative summary (NARSUM) dated 20 June 2006 indicated the CI was evaluated by a surgeon, but there were no surgical options.  Furthermore, the CI stated she was unable to tolerate wearing her gear or wielding her weapon due to pain.  On examination there was tenderness to palpation over the left sternoclavicular joint associated with warmth, swelling, and crepitus.  Pain was elicited by motion of the shoulder in all planes, which was localized to the left sternoclavicular joint.  There was no evidence of acromioclavicular (AC) impingement, but there was left AC crepitus.   

At the VA Compensation and Pension (C&P) examination dated 30 October 2006, performed 2 months after separation, the CI reported intermittent flare-ups of pain in the left sternoclavicular joint on moving the left arm and rotation of the left shoulder.  On examination there was swelling of the joint along with tenderness to palpation.  The ROM measurements were flexion to 130 degrees, external rotation to 90 degrees and internal rotation to 60 degrees.  Movements of the shoulder were performed slowly with pain at the end of all the movements.  There was no evidence of additional loss of ROM with repetition.   

Chronic Pain Left Metatarsals (Left Foot) Secondary to an Arthritic Process of Undetermined Nature Condition.  A note dated 22 July 2003 indicated the CI complained of left foot pain and swelling for 3 weeks that made walking and running difficult.  Examination revealed swelling of the left 2nd toe and tenderness of the 2nd MTP [metatarsal phalangeal] joint.  Treatment consisted of naproxen (an NSAID).  Laboratory studies for rheumatoid factor and ANA (to check for connective tissue disease) were negative and the ESR (sedimentation rate) was mildly elevated.  A trial of Indocin (indomethacin, an NSAID) was instituted.  Physical therapy treatments were carried out in March 2004 for presumptive left foot extensor tenosynovitis.  A note in June 2004 indicated the CI had been on profile for more than a year for her left foot condition and had been in a cast and took a course of oral steroids without relief.  An X-ray series of the left foot in June 2004 demonstrated a mild periosteal reaction around the shaft of the proximal phalanx of the left 3rd toe, which was interpreted as a stress reaction or adjacent mass or inflammation.  A bone scan in October 2004 demonstrated post traumatic or non-specific stress changes of the left 3rd MTP.  An X-ray series of the left foot in January 2006 demonstrated sclerosis (thickening of bone) and irregularity at the base of the third proximal phalanx with narrowing of the third MTP joint and mild sclerosis of the base of the fourth proximal phalanx without degenerative changes in the fourth MTP joint, the findings of which could be related to post-traumatic degenerative changes or psoriatic arthritis.  MRI of the left lower extremity in January 2006 demonstrated considerable inflammatory changes at the distal third and fourth metatarsals with fluid collection at the distal third metatarsal.  The etiology was not clear, but infection and rheumatoid arthritis were considered.  Aspiration of the left third MTJ and excisional biopsy of the left MTP was carried out in February 2006.  

At the MEB examination, the CI reported her “foot swells up” and she was diagnosed with chronic synovitis and had swollen painful joints in the left foot.  The MEB physical examiner noted tenderness to palpation of the ball of the left foot.  There was no edema or erythema.  Pain was elicited by flexion of the toes.  Gait was normal, but the CI was unable to perform a toe walk.  A permanent U3L3 profile was issued in June 2006 with limitations related to the foot included no running, wearing shoes of choice, no impact activities, and no functional military activities other than wearing a protective mask and all chemical defense equipment.  The commander’s statement relative to the CI’s foot condition included her inability to stand in formation for more than 10 minutes or to perform any field duties or those duties normally expected of a soldier.   

The MEB podiatry narrative summary (NARSUM) dated 2 June 2006 noted the CI related she had difficulty with shoe gear and could not wear any dress or tennis shoes due to the pain.  The biopsy pathology was consistent with hypertrophic synovitis, but could not rule out rheumatoid arthritic conditions.  On examination there was moderate edema of the second and third rays (metatarsals) of the left foot without evidence of erythema or infection.  There was decreased sensation to the second interspace and there was decreased ROM of the second and third toes with pain with all ROMs of those toes as well as tenderness to palpation on the dorsal and plantar aspects of the foot; and, the joints appeared stable.

At the VA Compensation and Pension (C&P) examination dated 30 October 2006, performed 2 months after separation, the CI reported chronic pain and swelling in the left foot in the metatarsal bones on prolonged walking or standing for a long time, and she occasionally limped.  On examination there was a well-coordinated gait without any assistive device.   Examination of the left foot revealed a mild hallux valgus deformity.  The left hallux showed dorsiflexion to 20 degrees and plantar flexion to 20 degrees with pain and weakened movement against resistance due to pain.  The VA examiner’s diagnosis was chronic synovitis of the left first MTP joint.   

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating using code 5099-5003 (Degenerative arthritis) for chronic pain left sternoclavicular joint and left metatarsals secondary to an arthritic process of undetermined nature.  The VA assigned a 10% rating using code 5201-5010 (Arm limitation of motion-Arthritis due to trauma) for degenerative joint disease, left sternoclavicular joint and assigned a 0% rating using code 5280 (Hallux valgus, unilateral) for synovitis and hallux valgus deformity, left MTP joint, great toe.

Board Approach to PEB Consolidated Rating.  The PEB combined the chronic pain of the left sternoclavicular joint and left metatarsal secondary to an arthritic process of undetermined nature conditions as a single unfitting condition coded 5099-5003 and rated 20% with application of the USAPDA pain policy Memorandum #13 IAW AR 635-40, B-24f.  The approach by the PEB commonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The Board also noted that “bundling,” the combining of two or more major joints may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the chronic pain left SC joint and left metatarsals secondary to an arthritic process of undetermined nature conditions was presented separately.  The first consideration was whether each condition was reasonably justified as separately unfitting.  The Board discussed the relevant findings of each condition independently and determined that chronic pain of the left SC joint was separately unfitting as was the painful left metatarsals condition (consisting of the third and fourth metatarsals of the left foot in contradistinction to the VA finding of the left great toe/first MTJ) as compared to the PEB, which rated the separate anatomical sites together as moderate/constant without offering separate ratings. 
 
The Board then sought a route to rate the left SC pain and noted code 5203 (Clavicle or scapula impairment) warrants a 20% rating based on dislocation, which was demonstrated on an MRI that showed mild separation and elevation of the medial end of the left clavicle.  Alternatively, code 5201 (Arm limitation of motion at the shoulder level) warrants a 20% rating for an abduction ROM of 90 degrees.  The Board was unable to find a route to a higher rating in the absence of a greater limitation of motion of the left arm.

The Board then sought a route to rate the left metatarsals pain condition.  First the Board members discussed code 5283 (Tarsal or metatarsal bones malunion or nonunion), but the metatarsals showed sclerosis with degenerative changes of the third and without degenerative changes in the fourth, but no malunion or nonunion.  However, code 5299-5279 (Metatarsalgia, unilateral or bilateral) affords a 10% rating as does code 5099-5003 for noncompensable ROMs with painful motion.  There were no reported incapacitating episodes reported for the left foot, although the CI was on profile for greater than a year.  Therefore, the Board was unable to find a route to a higher rating.   

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the chronic pain left sternoclavicular joint (left clavicle) condition.  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 chronic pain left metatarsals (left foot) condition.  

BOARD FINDINGS:  In the matter of the chronic pain left sternoclavicular joint condition, the Board unanimously recommends a disability rating of 20%, coded 5203 IAW VASRD §4.71a.  In the matter of the chronic pain left metatarsals condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  

The Board, therefore, 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 her prior medical separation:  

CONDITION	VASRD CODE	RATING	
Chronic Pain Left Sternoclavicular Joint 	5203 	20%	
Chronic Pain Left Metatarsals Secondary to an Arthritic Process of Undetermined Nature	5099-5003	10	
RATING	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140201, 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, AR20160005605 (PD201400752)

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 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 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 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:
						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA