RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	    CASE:  PD-2014-01165
BRANCH OF SERVICE:  Army	Date of sepAration: 20081031

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2 (Chemical Operation Specialist) medically separated for a right shoulder and bilateral feet conditions.  These conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty.  She was issued a permanent U3L3 profile and referred for a Medical Evaluation Board (MEB).  “Shoulder pain” and “foot pain” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded five medically acceptable conditions (asthma, headaches, numbness in right hand, slight frequency of urinations and depressive disorder NOS) for PEB adjudication.  The Informal PEB adjudicated right shoulder pain and bilateral metatarsalgia as unfitting, rated each.  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.  

CI CONTENTION:  The applicant was not evaluated for latent TB.   Her 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 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 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:  

IPEB - Dated 20080818	VA* - (~2 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder Pain	5099-5003	10%	Right Shoulder Instability	5201	10%	20081209	
Metatarsalgia, Bilateral	5279	10%	Status Post Stress Fxs...	5020-5279	10%	20081231	
Depressive Disorder	Not Unfitting	Major Depressive Disorder 	9400-9434	30%	20081231	
Numbness in Right Hand		No VA Placement	
Other MEB/PEB Conditions x 3 (Not In Scope)	Other x 2 	
RATING:  20%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20090224 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Right Shoulder Condition.  The first record in evidence for the right shoulder condition is an X-ray report dated 27 March 2007 which noted that the CI had a 6-year history of chronic subluxation (a partial slippage of the shoulder out of joint, but not a complete dislocation).  The X-ray was normal.  Magnetic resonance imaging (MRI) on 14 May 2007 was also normal.  The CI was seen 2 days later in primary care and reported that she had dislocated her shoulder in a basketball game and requested a profile as she had an upcoming road march.  It was noted that she had no limitations in throwing.  She was then seen in orthopedics on 2 August 2007 and noted to have some component of multidirectional instability although no laxity, subluxation, or dislocation of the shoulder joint was noted on examination.  She reported that she had injured her shoulder in basic combative training 8-9 months previously and recently aggravated it playing basketball.  When seen again in orthopedics on 20 December 2007, she was noted to have laxity and instability.  On 26 December 2007, an MRI arthrogram was normal.  The CI was again seen in orthopedics on 24 February 2008 and reported that she had dislocated her shoulder by leaning on it with it relocating on its own “it just pops back in.”  On examination, motion was painful.  Atrophy was not present.  In orthopedics on 8 March 2008, she reported a prior history of instability prior to accession, but that she had been told “not to worry” at MEPS.  On examination, she had stigmata of hyper-laxity.  At the MEB examination on 2 April 2008, the CI reported that she had injured her right shoulder in combatives in basic training.  The examiner noted that she could not raise her arm above the shoulder.  The narrative summary (NARSUM) was dated 8 July 2008.  The CI reported that she had only had one problem with her shoulder prior to accession and this was at age 8 without sequelae.  She reported that it repeatedly slipped out of position, but had never required reduction.  She also reported numbness of the right hand for which no etiology had been found.  Motor function was normal and no subluxation was elicited on examination.  

At the VA Compensation and Pension (C&P) examination performed on 31 December 2008, 2 months after separation, the CI reported that she first injured her right shoulder in a fall during basic training and was first seen after she injured it during combative training.  She noted intermittent pain aggravated by use and subjective instability.  Electrodiagnostic testing had been normal (for the history of numbness).  On examination, the shoulder was symmetric with the left and no signs of inflammation (swelling, warmth, redness) were present.  The shoulder was non-tender and atrophy absent.  Instability was not present although aggressive maneuvers were not performed.  The neurological examination was normal.  She was diagnosed with right shoulder instability with prior dislocation, per history.  The goniometric range-of-motion (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)	PT ~3 Mo. Pre-Sep	VA C&P 2 Mo. Post-Sep	
Flexion (180 Normal)	150/153/155/155	150	
Abduction (180)	180/179/180/184	140	
Comments	Limited by pain	Limited by pain	
§4.71a Rating	10%	10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder 10% for painful motion, coded 5099-5003 (analogous to degenerative arthritis).  The VA also rated the shoulder at 10%, for painful and limited motion, coded 5201 (limitation of motion).  The Board considered the code 5202 for frequent dislocations, but noted that this was never documented other than by history with self-reduction or spontaneous reduction.  Subluxation, a less serious condition, was recorded on some examinations, but not others.  The objective evidence does not support the use of this code.  The code 5201 better describes the condition than the 5003 code used by the PEB, but provides no rating advantage to the CI.  The Board found no route to a rating higher than the 10% adjudicated by both the PEB and VA.  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 shoulder condition.  

Bilateral Metatarsalgia Condition.  The first record in evidence for the metatarsalgia condition (painful feet) is a podiatry note dated 19 January 2008.  The CI reported bilateral foot pain since May 2007 which had not resolved with the use of medications, stretching, and orthotics.  She was noted to be obese and diagnosed with plantar fasciitis.  She was advised to lose weight and issued a night splint and orthotics.  At a neurological evaluation, for her hand numbness, on 24 April 2008 the was noted to weigh 184 pounds, an increase of 28 pounds from the accession physical and 38 pounds from a measurement on 11 July 2007.  Her gait and stance were normal including toe-heel walking, turning and tandem walking.  At the MEB examination, the CI reported plantar fasciitis.  The examiner noted severe, symptomatic pes planus (flat feet).  The podiatry evaluation on 10 June 2008 recorded that the outer aspect of both feet no longer hurt since she had her orthotics adjusted.  Palpation of the ball of the second toe was tender bilaterally, but the plantar fasciitis was resolved.  Pes planus was not documented, but she was noted to have “Morton’s toes” a congenital condition in which the second toe is longer than the great toe and which is associated with foot pain.  She was diagnosed with second (toe) metatarsalgia (pain of the long bones of the feet).  X-rays that day noted changes in both feet at the second and third metatarsals consistent with either stress changes or healed stress fractures.   The NARSUM noted that the CI had stress fractures in basic training which had resolved.  She reported that the foot pain was equal in each foot and aggravated by activity.  The examiner did not note pes planus (consistent with the podiatry evaluation).  On examination, the CI had excellent mobility of the feet with slight (perhaps) flattening of the arch.  The second metatarsal head (ball) was tender bilaterally along with some tenderness over the forward aspect of the heel bone on the right and the plantar fascia on the left.  At the VA C&P examination performed 2 months after separation, the examiner noted that the CI was first seen for foot pain on 30 October 2006 after a 15K road march.  She reported that the use of orthotics aggravated her foot pain and that she stopped using them (inconsistent with the history given to the podiatrist).  The arches were normal with weight bearing, but both feet were painful to palpation on the outside of both feet, at the arch, and the insertion of the plantar fascia into the heel bones.  No evidence of abnormal weight bearing was present.  At the neurological evaluation the same day by the same examiner, her gait was normal including tandem, toe and heel walk.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral foot condition (metatarsalgia) at 10%, coded 5279 (metatarsalgia).  The VA also rated the bilateral foot condition at 10%, but used the dual codes 5020 (synovitis) and 5279.  The Board noted that the code 5279 specifically describes the foot condition as recorded by multiple examiners and supports a 10% rating for either a unilateral or bilateral condition.  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 bilateral metatarsalgia condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the right hand numbness and depressive disorder were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  Neither condition was profiled, specifically implicated in the commander’s statement, or judged to fail retention standards.  Both were reviewed and considered by the Board.  There was no performance based evidence from the record that either condition significantly interfered with satisfactory duty performance.  After due deliberation 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 either contended condition and so no additional disability ratings are recommended.  

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 shoulder condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral metatarsalgia condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended right hand numbness and depressive disorder conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 20140306, 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, AR20160003638 (PD201401165)

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,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA