RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02082
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040826

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Aircraft Structural Repairer) medically separated for back pain and left ankle and bilateral wrist pain.  The conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent U3L3 profile and referred for a Medical Evaluation Board (MEB).  The “left ankle pain after subtalar surgery without evidence of degenerative changes,” “mechanical low back without spasm or neurologic finding,” and “bilateral wrist pain without objective findings,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The Informal PEB (IPEB) adjudicated “chronic subjective back pain, without neurologic abnormality,” and “chronic pain left ankle and bilateral wrists” as unfitting, rated 10% and 0% respectively.  The CI made no appeals and was medically separated.

CI CONTENTION:  The applicant has asked for consideration of all conditions in his application.  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 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 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 20040640	VA* - based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic  Subjective Back Pain	5299-5237	10%	Mechanical Low Back Pain	5237	10%	STR	
Chronic Pain Left Ankle and Bilateral Wrist	5099-5003	0%	Status Post Left Subtalar Surgery	5271	0%	STR	
			Scars of the Left Ankle	7801	0%	STR	
			Left Wrist Condition	5299-5215	NSC	STR	
			Right Wrist Condition	5299-5215	NSC	STR	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 4 	
RATING:  10%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20040827(most proximate to date of separation (DOS)).  
ANALYSIS SUMMARY:  The PEB combined the ankle and bilateral wrist conditions as a single unfitting condition coded 5099-5003 (analogous to degenerative arthritis) and rated 0%, with application of the USAPDA pain policy and AR 635-40 B24.f.  The approach by the PEB not uncommonly 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.  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 Disability Evaluation System (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 ankle and bilateral wrist conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate ratings if indicated.  

Back Condition.  The narrative summary (NARSUM) noted the CI developed thoracolumbar (TL) back pain without specific trauma in the timeframe of May to June 2003.  An orthopedic note 11 February 2004 indicated that the CI reported back pain aggravated by sit-ups without lower extremity (LE) or other neurological symptoms and exam of the back was normal with full range-of-motion (ROM).  Magnetic resonance imaging (MRI) of the lumbar spine on 11 February 2004, 7 months after separation, noted a normal anatomical variant and no abnormalities.  Conservative treatment failed to resolve the TL back pain.  

At the MEB exam on 29 February 2004, 6 months before separation, the CI reported back pain.  The MEB physical exam noted normal strength and reflexes of the bilateral LEs, and straight leg raise (SLR) testing was negative.  There was no tenderness to palpation (TTP) or muscle spasm.  Physical therapy ROM for the MEB 8 June 2004 was lumbar flexion of 110 degrees (normal 90) and combined ROM of 235 degrees (normal 240), with pain.  The therapist indicated the lumbar measurements were taken from the L1 level with an inclinometer.

There were no VA Compensation and Pension (C&P) examinations in record and the original VA Rating Decision (VARD) dated 1 November 2004 was based upon service medical records.  A VA primary care (PC) visit on 2 November 2004 for a stomach issue, 2 months after separation, noted there was painless, full ROM of all joints.  A VA PC follow-up visit on 10 May 2005, 8 months after separation, the CI reported increasing back pain, aggravated by walking.  The exam noted a normal gait and knee reflexes, with negative SLR bilaterally.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB and VA both rated the back pain condition 10%.  The PEB coded the back condition as 5299-5237 (analogous to lumbosacral strain) and the VA coded it as 5237.  The Board agreed that the evidence supports a 10% rating according to the VASRD General Rating Formula for the Spine in effect on the date of separation based upon combined TL spine ROM “not greater than 235 degrees”.  The Board noted that the physical therapy ROM examination on 8 June 2004 was performed using an inclinometer.  This methodology does not conform to the VASRD rating formula which is based on measurement of combined thoracolumbar ROM with a goniometer; however, the values reported are consistent with VA normal ROM for the combined TL spine.  

The Board reviewed to see if the next higher evaluation was supported, but there was no evidence of limited ROM meeting the threshold or muscle spasm or guarding as specified for the 20% rating.  The Board considered if the back condition could be rated based upon incapacitating episodes but there was no evidence of intervertebral disc syndrome (IVDS) or incapacitating episodes as defined by the VASRD (periods of symptoms due to IVDS that require bed rest prescribed by a physician and treatment by a physician).  There also was no evidence of peripheral nerve impairment due to the back condition to recommend additional rating on that basis.  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 adjudication for the back condition.  

Left Ankle Condition.  The NARSUM notes the CI initially sprained his left ankle in April 2000.  Notes in the service treatment record indicated the CI continued to have pain in the ankle and an MRI scan 15 February 2002 noted a previous injury to the anterior talofibular ligament (ATFL), moderate degenerative changes, and mild joint effusion.  The CI was deployed but could not perform his duties and underwent arthroscopic surgery September 2003 to remove a bone fragment from the subtalar joint.  Following the surgery the CI continued to have ankle pain.  A primary care visit 18 December 2003 noted the CI had post-traumatic arthritis with chronic ankle pain and indicated he was fit for duty with a P2 profile.  A PT visit on 11 February 2004, 7 months before separation, noted chronic ankle pain.  The exam noted ankle ROM of dorsiflexion (DF) 5 degrees (normal 20) and plantar flexion (PF) 50 degrees (normal 45), with painful motion noted.  A second ankle MRI 27 February 2004 again noted a small effusion adjacent to the ATFL, without other abnormalities noted.  An orthopedic evaluation on 5 March 2004 noted ankle ROM of 10 degrees to 45 degrees with normal sensation and strength and no instability.  

Four temporary profiles in 2003 in record noted duty limitations due to ankle pain.  The permanent profile dated 2 April 2004 listed the ankle pain condition with duty limitations of no running, jumping, hopping, marching, or rucking.  The commander’s statement did not specifically identify the CI’s medical condition, but indicated that the CI’s inability to take the Army Physical Fitness Test or wear a ruck sack impaired his duty performance.  

The Board first considered if the left ankle condition having been unbundled from the combined PEB adjudication, remained separately unfitting as established above.  The permanent profile listed the ankle condition and limitations referable to the ankle were specified and the commander’s statement implicated the ankle condition as impairing the CI’s duty performance.  The CI was on multiple profiles and underwent surgery for the ankle condition, with residual chronic pain documented.  The Board concluded that the evidence supports that the ankle condition was reasonably justified as separately unfitting at separation and was eligible for rating.  The Board therefore considered its rating recommendation for the ankle condition at the time of separation.

At the MEB exam the CI reported left ankle pain.  The MEB physical exam noted normal LE strength and reflexes.  Toe walking and heel walking were normal.  There was no evidence of instability.  Physical therapy ankle ROM on 8 June 2004 was reported as P 95 degrees and PF 135.  The therapist indicated the ankle ROM was measured with a goniometer.

As previously noted there were no VA C&P examinations in record and the original VARD was based upon service medical records.  A VA primary care visit on 2 November 2004 for a stomach issue noted there was painless, full ROM of all joints, but noted joint pain was managed with a prescription anti-inflammatory medication.  At VA PC follow-up visit 8 months after separation, the CI reported continued problems with his ankle, aggravated by walking.  The exam did not address the ankle, but noted a normal gait.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated a single condition of chronic left ankle and bilateral wrist pain 0%, coded 5099-5003, and cited the USAPDA pain policy.  The VA rated the ankle condition 0%, coded 5271 (limited ankle motion) noting that the MEB exam and MEB PT ROM evaluations did not note limited motion of the ankle or painful motion.  The Board first considered rating the ankle for limited motion coded as 5271, with subjective rating criteria of 10% for `moderate’ and 20% for `marked’ limited ankle motion.  The Board discussed the ROM evaluations in evidence, which other than the PT evaluation seven months before separation (which noted DF of 5 degrees and PF of 50 degrees), were not documented in a clear fashion..  Three weeks after the PT evaluation, the orthopedic specialist described ankle ROM as “10° to 45°”and the MEB PT ROM noted DF of 95 degrees and PF of 135 degrees.  The Board speculated that the orthopedic notation was reasonably interpreted as DF of 10 degrees, given its close proximity to the aforementioned PT ROM, but interpretation of the MEB PT ROM was not readily apparent to the Board.  The therapist indicated the ankle ROM was measured with a goniometer, but the Board noted that DF of 95 degrees and PF of 145 degrees are not in line with the VASRD normal values of DF 20 degrees and PF 45 degrees obtained with a goniometer and the therapist provided no normal values or explanation of how the measurements were determined.  The Board discussed various interpretations of the measurements, but concluded that they may have reflected DF of anywhere from 5 degrees to greater than normal ROM values (likewise the PF was not readily evident) and agreed to disregard the MEB PT ROM measurements in its deliberations for this reason.  The Board next noted that shortly after separation, the CI reportedly had normal and painless ROM of all joints at an outpatient VA PC visit and at a VA PC visit 8 months after the separation, the exam noted a normal gait.  Therefore, the Board concluded that a 10% rating was supported by the totality of the evidence based on either `moderate’ limited ankle ROM or pain with use considerations IAW VASRD §4.59 (Painful motion) and §4.40 (Functional loss), but no higher.  The Board reviewed to see if a higher rating was supported with any other ankle code, but there was no evidence of limited ROM of the ankle that could be characterized as `marked’; ankle or subtalar joint ankylosis, or malunion; or, deformity (astralgalectomy[removal of the talus bone]) of the ankle  The Board also noted that a 10% rating could be achieved alternatively coded as 5020 (synovitis) according to 5003 rating criteria based upon the finding of a persistent mild effusion on both ankle MRI scans.  However, the next higher evaluation under 5003 requires involvement of two or more joints with occasional incapacitating episodes, not in evidence in this case.  The Board determined that the evidence supports a 10% rating for the ankle, coded 5299-5271, and no higher.  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 ankle condition, coded 5299-5271.  

Bilateral Wrist Condition.  The NARSUM noted the CI also reported bilateral wrist pain in the timeframe May to June 2003, without specific trauma.  He was treated with medications, rest, and physical therapy without benefit.

An orthopedic evaluation  noted chronic wrist pain that began insidiously, without evidence of chronic or acute inflammation.  On exam there was full wrist ROM with a “totally normal exam” and X-rays were normal.  An occupational therapy evaluation 23 February 2004 indicated that the CI reported wrist pain that was “feeling better”.  The exam noted full wrist ROM and normal strength bilaterally.  There was TTP bilaterally, without painful ROM or pain with resisted movements and the therapist indicated the cause of the wrist pain was not clear.  An orthopedic evaluation noted full wrist and elbow ROM and tests for instability of the hand or wrist bones were negative (negative Watson’s and piano key testing).  Wrist X-rays were noted to be negative.

A temporary U2L2 profile, dated 4 February 2004, noted wrist pain and limitation of no sit-ups or pull-ups.  The permanent U3L3 profile dated 2 April 2004 listed the wrist pain and noted duty limitations referable to the wrists of no push-ups, pull-ups, or sit-ups.  The commander’s statement did not specifically identify the CI’s medical condition, but indicated that the CI’s inability to take the Army Physical Fitness Test or lift over 30 pounds impaired the performance of the duties of his MOS.  The NARSUM noted that the CI was unable to use hand and power tools as required in his MOS due in part to his wrist pain and the NARSUM and MEB indicated that the bilateral wrist condition failed retention standards.

The Board first considered whether the bilateral wrist condition having been unbundled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, a bilateral wrist condition was determined to fail retention standards, was profiled, and was implicated by the duty limitations noted in the commander’s statement and the NARSUM.  Scant notes in the STR noted reported bilateral wrist pain, but exams of both wrists were normal.  The Board engaged in lengthy discussion regarding whether the evidence supports that both wrists were unfitting, either individually or together, at separation.  After deliberating, Member consensus was that the issue of the limited medical evidence regarding both wrists would be relevant to rating, but the administrative evidence, especially the permanent profile and the NARSUM (which implicated wrist pain as impairing the CI’s performance of the duties of his MOS) reasonably supports that the wrist pain was unfitting at separation.  Moreover, since all references to wrist pain in record noted bilateral pain and evaluations and there was no discrimination between the wrists, the Board concluded that each wrist was reasonably supported as separately unfitting and eligible for disability rating.  The coding and rating features were essentially identical for both wrists, therefore the Board considered its rating recommendation for the left and right wrist conditions together at the time of separation.  

At the MEB exam the CI reported bilateral wrist pain.  The MEB physical exam noted normal sensation and strength of both upper extremities.  There was diffuse tenderness of both wrists, with negative testing for tendonitis at the thumb aspect of the wrist.  Specific testing for instability of the carpal bones and the radioulnar joint or thumb tendonitis was negative.  Physical therapy ROM for the MEB noted left wrist extension of 67 degrees (normal 70) and flexion of 65 degrees (normal 80) with forearm pronation of 60 degrees (normal 80) and supination of 40 degrees (normal 85) .  Right wrist ROM was extension of 75 degrees and flexion of 75 degrees with forearm pronation of 80 degrees and supination of 45 degrees.  Under diagnoses, the MEB examiner noted “bilateral wrist pain…without objective findings.”

As previously noted there were no VA C&P examinations in record and the original VARD was based upon service medical records.  A VA primary care visit for a stomach issue noted there was painless, full ROM of all joints, but noted joint pain was managed with a prescription anti-inflammatory medication.  

The Board directed its attention to its rating recommendation based on the above evidence.  Again, the PEB rated a single condition of chronic left ankle and bilateral wrist pain 0%, coded 5099-5003, and cited the USAPDA pain policy.  The VA did not service-connect either wrist condition and cited the lack of diagnoses, noting that “complaints of pain are a subjective finding” and “there must be evidence of a disabling condition causing…pain.”  The Board first reviewed coding the wrist conditions according to 5003 rating criteria for two or more joints.  A 10% rating requires evidence of degenerative arthritis on imaging studies or, if associated codes rated according to 5003 criteria are utilized, such as (5024) tenosynovitis (5024) or synovitis (5020), no imaging evidence is required.  However, the Board agreed that a diagnosis, or at a minimum, objective findings on exam were required and there was no diagnosis in record for either wrist and no abnormalities were noted on X-rays.  The Board next deliberated whether there was evidence to provide either wrist with a 10% rating for limitation of motion of a single joint.  However, the VASRD states when limitation of motion is non-compensable under the appropriate ROM codes, a 10% rating for limitation of motion is supported by 5003 criteria, but “limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion.”  The Board noted that there was no such objective confirmation of limitation of motion in record.  Therefore, the Board turned its attention to coding each wrist 5215 (limited wrist motion) and noted that neither wrist met a 10% rating based on ROM criteria alone, and for the same reasons as noted for rating with 5003, the Board agreed that a minimum 10% rating IAW VASRD §4.59 (Painful motion) was not warranted for either wrist.  The Board noted a 0% rating may be applied IAW VASRD §4.31 (Zero percent evaluations), which states “in every instance where the schedule does not provide a zero percent evaluation…, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met.”  Additionally, there was no evidence of ankylosis of either wrist to support a higher rating.  The Board thus determined that each unfitting wrist condition could be rated 0% and no higher and chose to code each wrist as 5215.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating as follows: an unfitting left wrist condition and an unfitting right wrist condition, each rated 0%, and both coded 5215.  

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 the left ankle and bilateral wrist condition was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left ankle and bilateral wrists condition, the Board unanimously recommends a disability rating as follows: an unfitting left ankle condition, rated 10%, coded 5299-5271; an unfitting left wrist condition and an unfitting right wrist condition, each rated 0%, coded 5215, all 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 Back Pain Condition	5299-5237	10%	
Chronic Left Ankle Pain Condition	5299-5271	10%	
Chronic Pain Left Wrist Condition	5215	0%	
Chronic Pain Right Wrist Condition	5215	0%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140507 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
(AH RC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXX, AR20160002783 (PD201402082)

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