RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	      CASE:  PD-2014-03346
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070119

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an National Guard E4, Infantryman, medically separated for chronic low back pain, chronic right knee pain and bilateral plantar fasciitis, rated 10%, 10% and 0%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI requested consideration of all conditions. 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 based upon a 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 –20061215	VARD - 20070530	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain…	5243	10%	Degenerative Disc Disease, Lumbar Spine	5242	20%	20070327	
Chronic Right Knee Pain	5099-5003	10%	Degenerative and Traumatic Arthritis, Right Knee	5260	0%	20070327	
Bilateral Plantar Fasciitis	5399-5310	0%	Bilateral Plantar Fasciitis	5276	0%	20070327	
Substance Induced Mood Disorder …	Not Unfitting	Posttraumatic Stress Disorder	9411	30%	20070412	
Chronic Right Wrist Pain	Not Unfitting	Right Wrist Sprain	5215	0%	20070327	
Left Knee	Not Unfitting	Degenerative and Traumatic Arthritis, Left Knee	5260	0%	20070327	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY

Chronic Low Back Pain. According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) addendum, the CI’s back pain begun when he was deployed to Iraq.  His back pain was treated conservatively without significant improvement.  Lumbar spine MRI demonstrated degenerative disk disease at L4-5 with disc herniation at L4-5 and L5-S1.  He was not a surgical candidate.  The CI’s condition did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded back pain-lumbar disc herniation for PEB adjudication.

At the MEB examination dated June 2006, 7 months prior to separation, physical examination recorded tenderness to palpation of the lumbar spine, and decrease range of motion (ROM) with pain on motion.  The MEB NARSUM addendum examination on 5 August 2006, 5 months prior to separation, noted complaints of constant back pain which he rated 7/10.  He had not found anything that alleviated his pain.  His symptoms were worse with running, walking, high impact activities, repetitive bending and wearing or carrying military equipment.  Physical examination showed there was tenderness to palpation bilaterally over lumbar muscles.  Muscle strength was normal and evidence of neuropathy was absent.  ROM was not recorded.  PT ROM for the MEB was conducted 5 weeks before separation, and documented forward flexion to 30 degrees (NL=90), extension of 7 degrees (30), and combined ROM between 105-115 (240) with the notation of pain limiting motion.

At the 27 March 2007 VA Compensation and Pension (C&P) evaluation, performed 2 months after separation, the CI reported he injured his back after he was “blown into the air and fell on his back.”  His back pain was 6/10 at rest and increased to 9/10 with activity.  There was no radiation of pain and he did not wear a brace.  His only medication was a non-steroidal anti-inflammatory.  Physical examination recorded ROM flexion to 40 degrees and extension of 25 with pain on motion.
 
The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the back condition 10%, coded 5243 (Intervertebral disc syndrome), citing, limitation of motion.  The VA rated the back condition 20% coded 5242, based on the VA C&P examination ROM recordings.  The Board noted although the CI had ROM flexion averaging 30 degrees at the PT examination, the combined ROM of the thoracolumbar spine was less than 120 degrees, and therefore, justified the 20% rating, consistent with the C&P examination.  The Board reviewed the STR and was unable to find any entry supporting the 10% back rating.  Therefore, the Board agreed that a 20% rating, but no higher, was justified for limitation of flexion (thoracolumbar flexion greater than 30 degrees or combined ROM not greater than 120 degrees), reported on the MEB NARSUM and the C&P examinations.  

The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The NARSUM examination revealed no objective findings of radiculopathy that would impact duty performance.  Motor strength was recorded as normal at both the NARSUM and C&P examinations.  The Board therefore concluded that an additional disability rating was not justified.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the back condition.  

Right Knee Pain.   According to STR and the MEB NARSUM, the CI sustained a twisting injury to his right knee in September 2004, and despite pain, he was able to deploy to Iraq in January 2005.  The CI had complained of popping and giving way, so he was provided a trial of physical therapy and medication without any improvement.  Failing conservative care, the CI underwent right knee diagnostic arthroscopy without complication.  However, he continued to report pain and locking in the knee.  He was offered a repeat surgery but declined.  Despite treatment, the right knee pain condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “chronic right knee pain” for PEB adjudication.  

The MEB NARSUM was accomplished in July 2006, 6 months before separation.  The CI reported he had occasional pain in the knee, but otherwise improved.  Physical examination showed no effusion or signs of inflammation.  There was a well-healed surgical scar from the procedure, and mild diffuse tenderness anteriorly.  The examiner recorded “full” ROM in the knee with crepitus, and evidence of knee instability was absent.  Motor strength was normal and there was no evidence of neurovascular compromise.  Physical therapy range of motion (ROM), 6 months before separation recorded “full” ROM.  An addendum to the MEB was conducted by orthopedic staff in December 2006, 6 weeks before separation.  Physical examination documented he had 160 degrees (140) of motion with no effusions.  Crepitus was present through ROM, and there was no evidence of knee instability.

At the VA Compensation and Pension (C&P) examination 2 months after separation, the CI reported he had pain in the right knee at 5/10 at rest with increase to 8/10 during activity.  He was not wearing a brace.  ROM recorded flexion to 130 degrees, with tenderness present all the way around the knee.  There was slight crepitus with flexion and no laxity.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10% coded 5099-5003 (arthritis, degenerative) rated for pain, slight/constant.  The VA rated the right knee condition 0% coded 5260 (limitation of flexion) based on absence of compensable ROM and absence of painful motion.  The Board found no evidence to support a rating based on ROM.  There were no additional codes to consider.  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 knee condition.  

Bilateral Plantar Fasciitis.  According to STR and the MEB narrative summary (NARSUM) podiatry addendum, the CI’s bilateral left greater than right, heel pain had been present since May 2005.  Radiographs of both foot were normal. He was prescribed insert supports.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty. The MEB forwarded “bilateral plantar fasciitis” for PEB adjudication.  At the MEB examination dated June 2006, 7 months before separation, the CI did not report any foot symptoms but noted that he had been prescribed foot sole support for his fasciitis.  Physical examination recorded tenderness to palpation of the left heel and normal gait.  It was noted that the CI could not perform toe walk.  No findings were recorded for the right foot.

The podiatry addendum dated 27 July 2006, 6 months before separation, noted that the condition had been treated with rest, medications, inserts, night splints and injection therapy with little improvement.  The CI reported that he was limited to less than 20 minutes of use and was unable to walk greater than half a mile without significant limiting symptoms.  Physical examination focused on the lower extremity and recorded normal neurovascular examination, including normal pulses and sensation.  There was pain elicited in the left heel greater than the right and ankle and foot ROM were recorded as “full” with absence of crepitus.  The examiner opined that the heel pain had the chance of improving with less demanding occupational stresses and with comfortable shoes.

At the VA Compensation and Pension (C&P) examination on 27 March 2007, 2 months after separation, the CI reported his foot pain increased with activity.  He wore inserts in his shoes.  Physical examination of the bilateral foot documented no abnormal shoe wear pattern, absence of calluses, grade II pes planus bilaterally, and a slight limp of the left leg opined to be secondary to foot pain.  The examiner documented absence of painful motion, edema, weakness, instability and tenderness.  There was no pain on manipulation of either foot.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral plantar fasciitis condition 0% (coded analogously 5399-5310 (group X) citing slight pain, IAW US Army Physical Disability Agency (USAPDA) policy/guidance memorandum #12, table of analogous codes.  Likewise, 2 months after separation, the VA combined the condition and used the 5276 (flatfoot, acquired) code for a 0% rating, citing mild symptoms relieved by built-up shoe or arch support.  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  IAW DoDI 6040.44 the Board must follow suit if the PEB combined adjudication is not compliant with the latter stipulation, provided that each ‘unbundled’ condition can be reasonably justified as separately unfitting in order to remain eligible for rating.  If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  

The commander’s statement (CS), was written 6 months before separation, and documented that the CI was unable to move with a fighting load, run, jump or kneel; however, did not directly implicate the foot condition.  The commander also noted that the CI was capable of performing the duties of his primary MOS provided his duties did not violate his profile.

The Board then proceeded to the rating of the right foot condition.  The MEB physical examination did not record any right foot symptoms.  The podiatry addendum noted that the left foot was more symptomatic than the right.  The C&P examination documented absence of painful motion or on manipulation of either foot.  Although pain was documented at the podiatry examination, the C&P examination was most proximate to separation and considered by the Board as representing the condition closest to separation.  That examination recorded absence of painful motion, weakness, instability or tenderness in either foot.

The Board agreed that the record sufficiently documented pain; however, preponderance of evidence did not support a compensable rating under codes 5310 or 5276.  The Board agreed that the condition was not compensable under any other applicable VASRD code.  The Board next proceeded in rating of the left foot condition.  The podiatry addendum, 6 months before separation concluded that the left foot was worse than the right; however, the C&P examination closer to separation did not comment on one foot being better or worse than the other, but did record the limping of the slight left leg due to foot pain.  The examiner also noted that the bilateral foot condition had minimal impact on his functioning.  The record documented no decrease in ROM, no evidence of instability, or functional loss.  There were no abnormal radiographic findings in either foot.

After deliberation, the Board concluded the record in evidence did not support the minimal compensable rating for left foot pain under any coding scheme.  The Board agreed neither the left foot nor the right foot condition rose to a level of compensability under §4.59, §4.45 or §4.40.  Thereupon, after due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 0% for the right foot condition and 0% for the left foot condition.  As this result in no rating benefit to the CI, the Board recommends no change in the PEB adjudication for the bilateral plantar fasciitis condition. 

Contended PEB Conditions: Substance Induced Mood Disorder, Right Wrist Pain and Left Knee Pain.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, 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:  In the matter of the chronic low back pain condition, the Board recommends a disability rating of 20%, coded 5243 IAW VASRD §4.71a.  In the matter of the chronic right knee pain condition and IAW VASRD §4.71a, the Board recommends no change in the PEB adjudication.  In the matter of the bilateral plantar fasciitis condition and IAW VASRD §4.71a, the Board recommends no change in the PEB adjudication.  In the matter of the contended substance induced mood disorder and alcohol abuse, chronic right wrist pain, and left knee conditions, the Board recommends no change from the PEB determinations as not unfitting.  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	PERMANENT RATING	
Chronic Low Back Pain	5243	20%	
Chronic Right Knee Pain	5099-5003	10%	
Bilateral Plantar Fasciitis	5399-5310	0%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140630, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXX AR20160017176 (PD201403346)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.  

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:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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:

						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA