RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02627
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20021222

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Healthcare Specialist) medically separated for left ankle arthritis and right shoulder pain.  These conditions could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty (MOS).  He was issued a permanent U3-L3 profile and referred to a Medical Evaluation Board (MEB).  Left ankle post traumatic arthritis and right shoulder chronic tendinitis with impingement were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded four other conditions (low back pain, migraine headaches, irritable bowel syndrome and recurrent hemorrhoids) for PEB adjudication.  The Informal PEB adjudicated “post traumatic degenerative arthritis…left ankle…” as unfitting, rated 10% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD); and “chronic right shoulder pain…” as unfitting, rated 0% with application of the US Army Physical Disability Agency (USAPDA) pain policy.  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI requests the Board consider all conditions.  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/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 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 20021025	VA* - (~1 Mo. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Arthritis…Left Ankle…	5010	10%	Left Ankle…Osteophyte Excision	5271	10%	20021125	
…Right Shoulder Pain...	5099-5003	0%	Right Shoulder s/p Surgery	5019	10%		
…Low Back Pain	Not Unfitting 	Lumbar Myofascial Strain	5295	0%		
Migraine Headaches		Migraine Headaches	8100	0%		
Irritable Bowel Syndrome		Irritable Bowel Syndrome	7319	0%		
Recurrent Hemorrhoids		Hemorrhoids	7336	0%		
Other MEB/PEB Conditions x 0 (Not in Scope) 	Other x 11	
RATING:  10%	COMBINED RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20030113 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:   

Left Ankle Condition.  After a left ankle injury in 1997, the CI required surgical intervention in 1998 to address degenerative changes.  In October 2001 left ankle surgery was again performed to remove an osteophyte and small accessory bone of the left ankle.  Post-operatively, pain did not respond sufficiently to physical therapy and he was unable to resume running.  An orthopedic evaluation on 14 August 2002 (4 months prior to separation) noted a complaint of recurrent left ankle swelling and persistent pain that was 4-5/10 severity most of the time.  He was unable to march or run.  Physical exam showed no left ankle swelling.  Ankle strength was normal and there was no joint instability.  At the VA Compensation and Pension (C&P) exam performed a month before separation, the CI reported ankle pain occurred when crossing or twisting the legs, or when walking 500 feet.  Examination showed a normal gait and no ankle swelling.

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.

Left Ankle ROM
(Degrees)	Ortho ~4 Mos. Pre-Sep	MEB ~2 Mo. Pre-Sep	VA C&P ~1 Mo. Pre-Sep	
Dorsiflexion (20 Normal)	20	15	10	
Plantar Flexion (45)	35	45	40	
Comment		+Painful motion; no swelling or tenderness	+Painful motion	
§4.71a Rating	10%	10%	10%	
	
The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the ankle at 10% under the 5010 code (post-traumatic arthritis), citing “pain limits full range of motion, no joint instability” as the rationale.  The VA rated under the 5271 code (ankle; limited motion) also at 10%.  Board members agreed that the 10% rating was justified for “moderate” limitation of ankle motion documented on the exams in evidence.  “Marked” limitation of ankle motion was not present, thus the highest 20% rating under this code was not supported.  There was no ankylosis, thus higher ratings under 5270 (ankle, ankylosis of) or 5272 (subastragalar or tarsal joint, ankylosis of) pathways were not warranted.  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 left ankle condition.

Right Shoulder Condition.  The right handed CI underwent right shoulder arthroscopies in 1998 and 2000 to address a labral (joint rim) tear and rotator cuff tendon tear.  Chronic pain continued to impair overhead lifting.  An orthopedic examination on 14 August 2002 (4 months prior to separation) reported the absence of shoulder tenderness.  Specific exam maneuvers for tendon and labral sources of pain were negative, but painful motion was otherwise not mentioned.  The commander’s statement on 16 August 2002 stated that the CI was “seen regularly guarding his arm from pain.”  At the NARSUM exam the CI reported chronic right shoulder pain that was aggravated by overhead lifting, throwing, and reaching.

The CI presented for acute care on 4 November 2002 (2 months prior to separation) with a complaint of shoulder pain for 3 days.  He reported that his pain began while he was performing “a lot of overhead work.”  Examination showed full ROM and one positive sign for tendon impingement.  At the VA C&P exam on 25 November 2002 (a month before separation), the CI reported that any movements above shoulder level caused pain.  Examination showed no instability.  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)	MEB ~2 Mos. Pre-Sep	VA C&P ~1 Wk. Pre-Sep	
Flexion (180 Normal)	180	180	
Abduction (180)	180	160	
Comments	+ Tenderness	+Painful motion	
§4.71a Rating	0% or 10%* (PEB 0%)	10% (VA 10%)	
			*Conceding VASRD §4.59 (painful motion)

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under the 5003 code (degenerative arthritis) with application of the USAPDA Pain Policy.  The VA’s 10% rating under the 5019 code (bursitis) cited painful motion as a rationale.  The VASRD §4.71a threshold for a compensable rating is ROM limited to “at shoulder level”, i.e., 90 degrees.  All service exams showed completely normal ROM while the VA exam demonstrated non-compensable limitation of motion.  The Board debated if there was sufficient evidence of functional loss or painful motion to warrant a 10% rating IAW VASRD §4.40 or §4.59, and agreed that these pathways were reasonably conceded.  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.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that recurrent low back pain, migraine headaches, irritable bowel syndrome and recurrent hemorrhoids 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.  

Recurrent Low Back Pain: According to the NARSUM examiner, the CI experienced “occasional low back pain requiring temporary profiles.”  On the MEB DD Form 2807, Report of Medical History, the CI marked “No” for “recurrent back pain or any back problem.”

Migraine Headaches: The CI noted on the DD Form 2807 that he was treated for severe headaches throughout his career, and the NARSUM examiner confirmed that he was diagnosed with migraine and tension headaches.  The C&P examiner reported that headaches occurred once or twice per month for which he took over the counter medication.

Irritable Bowel Syndrome and Hemorrhoids: The CI noted on the DD Form 2807 that he had frequent intestinal problems including severe diarrhea and rectal bleeding.  The NARSUM noted that a complete evaluation for intestinal complaints was normal.  The C&P examiner reported that hemorrhoids were clinically stable.

None of the above conditions were permanently profiled or implicated in the commander’s statement.  On the DD Form 2697, Report of Medical Assessment, dated 2 September 2004 the CI wrote that only the right shoulder and left ankle conditions limited his ability to perform his MOS.  The NARSUM examiner considered all of the above conditions to meet retention standards.  All of these conditions were reviewed and considered by the Board.  There was no performance based evidence from the record that any of these conditions 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 any of the contended conditions 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.  As discussed above, PEB reliance on the USAPDA pain policy for rating chronic right shoulder pain was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the post traumatic degenerative arthritis following left ankle fracture condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic right shoulder pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the contended low back pain, migraine headaches, irritable bowel syndrome and recurrent hemorrhoids 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 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	
Post Traumatic Degenerative Arthritis Following Left Ankle Fracture	5010	10%	
Chronic Right Shoulder Pain	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140512, 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 XXXXXXXXXX, AR20160003423 (PD201402627)

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