RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01884
BRANCH OF SERVICE:  Army	BOARD DATE:  20140924
DATE OF PLACEMENT ON TDRL:  20050610
Date of Permanent SEPARATION:  20061128

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard SPC/E-4 (92A/Logistics Clerk) medically separated for a right wrist, right knee and left shoulder condition.  The wrist, knee and shoulder conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was issued a permanent U3/L2/S3 profile and referred for a Medical Evaluation Board (MEB).  The wrist, knee and shoulder conditions were characterized by the MEB as “RSD of the right wrist,” “right anterior knee pain” and “supraspinatus tendinosis of left rotator cuff” and forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded mood disorder for PEB adjudication.  The Informal PEB (IPEB) adjudicated “reflex sympathetic dystrophy of the right dominant hand,” as unfitting, rated at 30% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).   The IPEB combined both “chronic right knee pain” and “pain in the left rotator cuff” as a single unfitting condition, rating it at 10%, with application of the US Army Physical Disability Agency (USAPDA) pain policy.  The Mood disorder condition was not separately unfitting and therefore not rated.  The CI concurred with the IPEB finding and recommendation of placement on the Temporary Disability Retirement List (TDRL) effective dated 10 June 2005.  The TDRL’s re-evaluation IPEB adjudicated the right wrist, right knee and left shoulder as a single unfitting condition, rated at 20%.  The CI non-concur with the TDRL IPEB findings and requested and was granted a Formal IPEB (FPEB).  The FPEB reviewed the TDRL IPEB proceedings, and reaffirmed its findings of combining the “chronic right knee pain” and “pain in the left rotator cuff” as a single unfitting condition, although rated the single condition at 20%, with application of the USAPDA pain policy.  The CI non-concurred with the TDRL FPEB findings and recommendations, appealed to the USAPDA, whom adjudged the TDRL FPEB’s proceedings as unprejudiced, removed the CI from the TDRL and was permanently retired. 

CI CONTENTION:  “Please consider all conditions.”

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.  The ratings for the unfitting right wrist, right knee and left shoulder are addressed below.  The mood disorder which was determined to be not unfitting is likewise addressed below.  There were no additional conditions within the DoDI 6040.44 defined purview of the 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.  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; and, to review those fitness determinations within its scope (as elaborated above) consistent with performance-based criteria in evidence at separation.

RATING COMPARISON:

Final Service FPEB - 20061108	VA (6 Mo. Post TDRL Placement*) - Effective 20050610	
On TDRL - 20050610	Code	Rating	Condition	Code	Rating	Exam	
Condition		TDRL	Sep.					
RSD Right Hand 	8799-8715	30%	-	Right Wrist w/RSD and Chronic Pain Syndrome	5215	10%*	20051214	
Right Knee Pain and Pain in Left Rotator Cuff	5009-5003	10%	-	Right Knee Degenerative Arthritis	5003	10%	20051214	
				Left Shoulder Supraspinatous Tendonosis	5202	0%**	20051214	
Chronic Pain Right Hand, Right Knee and Left Shoulder 	5099-5003	-	20%					
Mood Disorder	Not Unfitting	-	-	Mood Disorder w/Depressive Features	9435	10%	20051215	
Other x 0 (Not in Scope)	Other x 5	20051214	
Combined:  40% → 20%	Combined: 30%	
5215 previously rated 0% effective 19940913; 5202 increased to 10% effective DOS on 20070329 VARD.

ANALYSIS SUMMARY:  The PEB combined the right knee and left rotator cuff condition as a single unfitting condition, coded analogously to 5003 and rated 10% at TDRL placement.  At permanent separation, the PEB added the condition of chronic right hand pain to the already bundled conditions noted above.  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.  The Board must apply separate codes and ratings in its recommendations if compensable ratings for each condition are achieved IAW applicable VASRD sections.  If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the reasonable requirement that each “unbundled” condition was unfitting in and of itself or at least an indispensable element of a combined effect rating.  Thus the Board must maintain 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.

Reflex Sympathetic Dystrophy Right Hand with Wrist.  The treatment records indicated this right hand dominant CI injured her right wrist with fracture of the scaphoid bone, right knee and left shoulder after sustaining a fall in September 2003 during training.  She was initially treated with anti-inflammatory medication; however, felt no relief.  Orthopedic entry dated 3 February 2004 recorded the diagnosis of reflex sympathetic dystrophy (RSD) of the right wrist, radial distribution.  The narrative summary (NARSUM), dated 2 September 2004 (9 months prior to TDRL placement), recorded range-of-motion (ROM) of the right wrist palmar flexion of 15 degrees and dorsiflexion 20 degrees.  The examiner noted marked decrease in grip strength and recorded that pain was “out of proportion to stimulus.”  The right hand demonstrated good vascularity.  Tests of sensory function and reflexes were not documented.  The examiner did state the CI was unable to use her right hand and wrist and was unable to move her wrist.  After the NARSUM, the CI underwent stellate ganglion block injections, lidocaine with bertylium infusion therapy, and had a permanent stimulator placed (cervical dorsal column of cervical spine) in the effort to control her RSD pain.  Physician treatment note dated 9 December 2004 recorded good response to the stimulator; however, dysesthesias (numbness, tingling, etc.) of the right arm continued.  The CI also reported she had difficulty driving which the physician opined was likely related to the moving of the spinal cord during head rotation.  The CI took medications to address RSD sensory symptoms.  There was no evidence of tropic skin changes or muscle atrophy.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition at 30% coded analogously 8799-8715 (median nerve paralysis, moderate) and placed the CI on the TDRL, IAW §4.124 (maximum rating).  The NARSUM examiner (9 months prior to TDRL placement), stated the CI could not move her right wrist and was unable to use the right hand.  However, there was no evidence of atrophy, or recorded inability to flex her fingers, and no evidence of tropic changes in the wrist or hand.  The examiner also noted that pronation and supination of the right hand was 80 degrees, a finding that was inconsistent with the report that the CI could not move her hand.  The Board agreed code 5125 (loss of use of hand) was not appropriate.  All Board members agreed the evidence supported a rating no higher than 30%.  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 rating for the RSD condition at the time of TDRL placement.  

The Board next considered the rating at permanent separation.  The record sufficiently demonstrated the condition was stable.  The VA Compensation and Pension examination (6 months after TDRL placement), recorded normal wrist ROM measurements.  The physician recorded the single finding of right hand tenderness.  The TDRL NARSUM recorded a moderate decrease in dorsiflexion but normal palmar flexion and radial and ulnar deviation measurements.  There was no evidence of atrophy, vascular compromise, or tropic changes in the skin.  Strength was mildly decreased; however, effort was considered poor.  She had full ROM of all joints of the fingers, and no signs of nerve entrapment.  The physician recorded “previous diagnosis of RSD right upper extremity” and noted current assessment reflected chronic right wrist pain without objective findings.  The PEB noted that the CI’s right upper extremity no longer had physical findings compatible with RSD diagnosis, and therefore did not adjudicate the condition at permanent separation.  However, the PEB combined the condition of the right hand with the right knee and left shoulder and rated the conditions under the pain policy.  

The Board members agreed, at the time of permanent separation, the record sufficiently documented pain, in fact, treatment entry dated 13 October 2006 (approximately a month prior to separation), recorded the report of pain in multiple joints, thought to be suggestive of fibromyalgia.  A week later, progress note stated her pain was not adequately controlled with the stimulator.  Neither entries recorded issues with ROM, numbness or tingling.  All Board members agreed, the condition of RSD had likely resolved and the CI was left with chronic right hand pain, poorly responsive to treatment.  The Board agreed that the evidence reasonably supports that the right hand pain condition was separately unfitting at the time of permanent separation, and reflected a 10% disability rating under criteria §4.59 (painful motion), coded 5099-5003. The use of code 5215 (wrist, limitation of motion) for a compensable rating would requires a dorsiflexion of less than 15 degrees, which was not evident.

Right Knee.  The PEB bundled the right knee and left shoulder conditions as discussed above.  The right knee condition was profiled L2 and considered to be medically acceptable.  The NARSUM exam documented full ROM with no evidence of knee instability or functional loss.  There were no radiographic findings of right knee pathology.  Her profile limited running, walking, biking and swimming, but did not specify the limitations were due to knee condition.  The Board agreed the evidence reasonably supports that the right knee was not separately unfitting at the time of TDRL placement.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that the condition of right knee pain was not separately unfitting and therefore not ratable.

Left Rotator Cuff (Shoulder).  The CI related the onset of this condition in 2003 related to the fall reported above.  In addition to the left shoulder pain, the CI reported right knee pain and fracture of the right scaphoid bone of the wrist.  The CI underwent steroid injections and took anti-inflammatory medications to treat left shoulder pain.  Magnetic resonance imaging in December 2003 was consistent with partial tearing of the left rotator cuff and the presence of inflammation that suggested either tendinitis or bursitis.  The NARSUM recorded the CI reported last steroid injection was in May 2004.  The CI noted she had not had any significant relief from pain.  Treatment records were scarce; however, available treatment records consistently documented pain.  The NARSUM dated 2 September 2004 noted ROM abduction to 120 degrees with pain at approximately 90 degrees.  The CI had findings consistent with tendonitis of the rotator cuff.  There was no evidence of shoulder instability.  The CI’s profile prohibited upper body weight training and restricted lifting and carrying items no heavier than five pounds.  The left shoulder ROM was decreased.  The Board agreed that the evidence reasonably supports that the left shoulder condition was separately unfitting at TDRL entry.  The Board next considered the rating recommendation.  The Board considered the 5201 code (arm, limitation of motion) and determined the condition was not compensable under that code.  A compensable rating under the 5201 code requires limitation of motion at least at shoulder level.  The recorded ROM abduction was 120 degrees.  The Board undertook a careful review of the evidence in hand and agreed that the record sufficiently documented pain.  The NARSUM examiner recorded the presence of painful motion during the examination.  

Therefore, all Board members agreed, the evidence supported a 10% rating for painful motion IAW §4.59, coded analogously 5099-5003 at TDRL placement.  The Board next considered the rating at the time of permanent separation.  The TDRL NARSUM recorded left shoulder pain was present daily and worsened with lifting.  ROM of the left shoulder recorded flexion to 170 degrees with global tenderness.  The shoulder was stable without evidence of instability on load-shift.  Shoulder strength was slightly decreased on tests of motor strength; however, the examiner noted effort was questionable.  The Board agreed the left shoulder condition remained unfitting at the time of permanent separation.  The Board considered the 5201 code and all members agreed the evidence did not support a rating under this code based on the ROM.  Board members concluded there was sufficient evidence to support a rating using code 5099-5003 for pain.  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 painful motion IAW §4.59 coded analogously 5099-5003 at permanent separation.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the condition of mood disorder related to her medical condition was not unfitting.  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.  Although the mood disorder was profiled, there was no performance based evidence from the record that this condition significantly interfered with satisfactory duty performance.  The psychiatry NARSUM recorded the diagnosis of mood disorder due to chronic pain, with depressive features, a condition that does not reflect a primary mental health (MH) disorder.  The Board acknowledged the NARSUM’s examiner assessment that the condition did not meet retention standards; however, noted the absence of MH treatment prior to January 2005 (approximately 4 months prior to the NARSUM).  The Board agreed that evidence of the record reflected minimal MH related symptoms and unanimously agreed there was not the preponderance of evidence to support that the MH condition was unfitting.  The condition was appropriately adjudicated by the PEB as not unfitting due to it being an integral, comorbid component of the RSD condition and therefore not rated as single unfitting condition IAW VASRD §4.14.(avoidance of pyramiding). 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 the mood disorder and so no additional disability rating is 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.  As discussed above, PEB reliance on the USAPDA pain policy DoDI 1332.39 for rating right hand pain, right knee pain and left rotator cuff pain was operant in this case and the conditions were adjudicated independently of that policy.  In the matter of the RSD of the right hand, the Board unanimously recommends no change in the PEB adjudication at TDRL placement.  At the TDRL removal, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.59.  In the matter of the left rotator cuff and left shoulder pain condition and IAW VASRD §4.71a, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.59 at both TDRL placement and removal.  In the matter of the right knee condition, the Board determined the preponderance of the evidence did not support an unfit determination at TDRL placement and therefore no rating is applicable.  In the matter of the contended mood disorder condition, 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 for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
RSD Right Hand	8799-8715	30%	10%	
Left Rotator Cuff	5099-5003	10%	10%	
COMBINED (w/ BLF)	40%	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140429, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			
XXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

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, AR20150006708 (PD201401884)

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,   I accept the Board’s recommendation to modify the individual’s disability description without modification of the combined rating or recharacterization 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:

Encl		     XXXXXXXXXXXXXXXXXX
			     Deputy Assistant Secretary of the Army				         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA