RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	      CASE:  PD-2014-02972
BRANCH OF SERVICE:  Army                                                                   SEPARATION DATE:  20050525

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Field Artillery Firefinder Radar Operator, medically separated for “bilateral ankle pain…” and “left shoulder pain…,” rated 10% and 0% respectively, with a combined disability rating of 10%.

CI CONTENTION:  The applicant requests that, in addition to his bilateral ankle and left shoulder conditions, several other conditions that were not forwarded to the PEB for adjudication, be evaluated.  The CI’s complete submission 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 - 20050420	VARD - 20050708	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Ankle Pain…	5099-5003	10%	Residuals of a L Ankle Fx…	5271	10%	20050505	
			Residuals of a R Ankle Injury….	5271	10%	20050505	
Left Shoulder Pain…	5099-5003	0%	Left Shoulder SLAP Lesion…	5203	10%	20050505	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Left Shoulder.  The left arm dominant CI was first seen for left shoulder pain in 1998, but then the record falls silent until 2004 when he reported persistent pain.  An X-ray and magnetic resonance imaging arthrogram (dye study of the joint) were normal, but clinically his examination was suspicious for a tear in the cartilage lining of the shoulder joint.  Arthroscopy performed on 8 September 2004 showed excessive connective tissue; it was excised.  Despite rehabilitation in physical therapy (PT), he was unable to meet full duty requirements and referred for a Medical Evaluation Board (MEB).  The narrative summary (NARSUM) noted was dated 19 January 2005, 4 months prior to separation and 4 months after arthroscopy.  It recorded that he could not lift or move heavy objects, but his range of motion (ROM) was slowly improving.  On examination, the shoulder was non-tender and instability was not recorded.  Testing showed signs of impingement and a rotator cuff injury.  The examining orthopedist noted that the CI was unlikely to recover as long as he continued the heavy demands of his military speciality and that he was at maximum medical improvement.  

At the VA Compensation and Pension (C&P) examination performed on 5 May 2005, 20 days before separation, the CI reported that he exercised by riding a bike and swimming.  On examination, the motor function was normal and muscle bulk equal bilaterally.  Tenderness was absent.  No comment was made on stability.  The ROM was reduced as charted below.  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.  

Left Shoulder ROM
(Degrees)	MEB ~4 Mo. Pre-Sep	PT ~2 Mo. Post-Sep	VA C&P 20 Days Pre-Sep	
Flexion (180 Normal)	145	160 160 160	148 151 146	
Abduction (180)	155	140 140 140	180 180 180	
Comments	Positive impingement test		Limited by pain	
§4.71a Rating	0%	0%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the shoulder condition at 0%, coded 5099-5003 (analogous to degenerative arthritis).  The VA rated the shoulder at 10%, coded 5203 (impairment of the clavicle [collar bone] or scapula [shoulder-blade]).  The evidence supports both the presence of painful motion and functional loss, supporting a 10% IAW VASRD §4.59 (painful motion) and §4.40 (functional loss).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommended a disability rating of 10% for the left shoulder pain condition, coded 5003.  

Right Ankle.  The record showed that the CI fractured his left ankle in 2001 and was treated surgically.  He recovered and was deployed, but then twisted his right ankle.  He had surgery for ankle stabilization and peroneal subluxation (abnormal slippage of the foot tendons in the foot from the normal position) on 16 June 2004.  Following surgery, he was noted to have a stable ankle, but persistent snapping (a sign of subluxation).  In podiatry on 7 December 2004, he had a normal gait but dorsiflexion (toes up) was limited to neutral (normal is 20 degrees); in orthopedics, the same day, dorsiflexion of 7 degrees was recorded.  In PT on 10 January 2005, he reported difficulty with walking long distances (2 miles).  Plantar flexion (toes down) was normal at 45 degrees, but dorsiflexion was recorded as 5/5, an indication of normal motor function, but not a measurement of motion.  The NARSUM was dated 13 January 2005 and accomplished by the podiatrist.  The CI reported that he was unable to march over a quarter mile or pass the physical fitness test.  On examination, the gait was guarded due to pain on the left.  Motor strength was normal, but dorsiflexion limited to 7 degrees.  Subluxation of the peroneal tendons was present.  

At the VA C&P examination, performed 20 days before separation, the CI reported that he could ride a bike for an hour and also swam for exercise.  He could walk a mile before the onset of pain.  On examination, he was noted to be overweight, but to have a normal posture and gait.  Strong foot dorsiflexion was noted on the motor examination.  He could walk on his toes and heels as well as tandem walk.  Snapping of his peroneal tendons was present on the right.  There was no localized tenderness, swelling, or pain.  The ROM is charted below.  The Board observed that the CI was limited in dorsiflexion to less than neutral at 5 degree of plantar flexion, but able to walk on his heels implying functional dorsiflexion.  Also, foot drop, seen when the foot cannot be dorsiflexed, was not recorded.  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.  

Ankle ROM
(Degrees)	PT 4 Mo. Pre-Sep	PT ~3 Mo. Pre-Sep	VA C&P 20 Days Pre-Sep	
	Right	Right	Right	
Dorsiflexion (20 Normal)	5/5	0 0 0	-5	
Plantar Flexion (45)	45	50 50 50	62	
Comment	Eversion 4/5.  Nml motor otherwise		Nml posture and gait, toe and heel walk.  Limited by stiffness	
§4.71a Rating	10%	10%	20%	

The PEB rated the CI for unfitting bilateral ankle pain.  The Board first considered if the right ankle condition was separately unfitting.  The CI had a history of both surgery with persistent limitation in motion and peroneal subluxation on the right.  The right and left ankle were each noted to be medically unacceptable by the MEB and the profile noted pain and instability in each ankle.  The evidence supports a finding that the right ankle was separately unfitting.  

The Board then directed attention to its rating recommendation based on the above evidence.  The PEB rated bilateral ankle pain at 10%, coded 5099-5003 (analogous to degenerative arthritis).  The VA separately rated the right ankle at 10%, coded 5271 (limitation of motion) at the moderate level.  The Board considered the evidence.  While there was a significant limitation in dorsiflexion when measured, the functional impact was not beyond the moderate level.  Foot drop was not documented, the CI could heel walk, and noted that he could walk 2 miles at one examination and could walk a mile (before the onset of pain) on another.  His gait was normal on the VA C&P examination, 3 weeks prior to separation.  The evidence supported a separate 10% rating at the moderate level of impairment, coded 5271.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommended a disability rating of 10% for the right ankle condition, coded 5271.  

Left Ankle.  The CI had a left ankle fracture on 4 October 2001 which was treated surgically.  He did well initially, but then had painful hardware, following several sprains, which lead to removal on 16 April 2004.  On 7 December 2007, he was noted to have 5 degrees of dorsiflexion, but a normal gait.  In PT on 10 January 2005, he reported difficulty with walking long distances (2 miles).  Plantar flexion (toes down) was normal at 45 degrees.  Dorsiflexion was recorded as 5/5, an indication of normal motor function, but not a measurement of motion.  The NARSUM was dated 13 January 2005 and accomplished by the podiatrist.  The CI reported chronic pain in the left ankle.  On examination, the gait was guarded due to pain on the left.  Motor strength was normal, but dorsiflexion limited to neutral.  Crepitus (abnormal sensation or noise on movement) was present.  X-rays showed degenerative changes.  

At the VA C&P examination, performed 20 days before separation, the CI reported that he could ride a bike for an hour and also swam for exercise.  He could walk a mile before the onset of pain.  On examination, he was noted to be overweight, but to have a normal posture and gait.  Strong foot dorsiflexion was noted on the motor examination.  He could walk on his toes and heels as well as tandem walk.  There was no localized tenderness, swelling, or pain.  The ROM is charted below.  The Board observed that the CI was limited in dorsiflexion to less than neutral at 13 degree of plantar flexion, but able to walk on his heels implying functional dorsiflexion.  Also, foot drop, seen when the foot cannot be dorsiflexed, was not recorded.  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.

Ankle ROM
(Degrees)	MEB ~4 Mo. Pre-Sep	PT ~2 Mo. Pre-Sep	VA C&P 20 Days Pre-Sep	
	Left	Left	Left	
Dorsiflexion (20 Normal)	0	-5 -5 -5	-13	
Plantar Flexion (45)	Neutral	55 55 55	52	
Comment			Nml posture and gait	
§4.71a Rating	20%	20%	20%	

The Board first considered if the left ankle condition was separately unfitting.  The CI had a history of surgery with persistent limitation in motion.  The right and left ankle were each noted to be medically unacceptable by the MEB and the profile noted pain and instability in each ankle.  The evidence supports a finding that the left ankle was separately unfitting.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated bilateral ankle pain at 10%, coded 5099-5003 (analogous to degenerative arthritis).  The VA separately rated the left ankle at 10%, coded 5271 (limitation of motion) at the moderate level.  The Board considered the evidence.  While there was a significant limitation in dorsiflexion when measured, the functional impact was not beyond the moderate level.  Foot drop was not documented, the Ci could heel walk, and noted that he could walk 2 miles at one examination and could walk a mile (before the onset of pain) on another.  His gait was normal on the VA C&P examination, 3 weeks prior to separation.  The evidence supported a separate 10% rating at the moderate level of impairment, coded 5271.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommended a disability rating of 10% for the left ankle condition coded 5271.  

BOARD FINDINGS:  In the matter of the left shoulder condition, the Board unanimously recommends a disability rating of 10%, coded 5003 IAW VASRD §4.71a.  In the matter of the right ankle condition, the Board unanimously recommends a disability rating of 10%, coded 5271 IAW VASRD §4.71a.  In the matter of the left ankle condition, the Board unanimously recommends a disability rating of 10%, coded 5271 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  The Board 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 his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Left Shoulder Pain	5003	10%	
Right Ankle Pain	5271	10%	
Left Ankle Pain	5271	10%	
RATING (w/ BLF)	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140619, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20160008651, 

Dear 

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board's recommendation and record of proceedings for your information.

The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.

The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXXX.

A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,

Enclosure