RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03563
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20050310

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Air National Guard E6, Aircraft Structural Maintenance, medically separated for “degenerative joint disease status post fusion” and “degenerative disk disease, lumbar spine,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  “Consider 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 - 20041207	VARD - 20050813	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Degenerative Joint Disease (DJD) Right Foot Status Post Fusion	5271	10%	Traumatic Degenerative Joint Disease, Right Foot S/P Subtalar Joint Fusion	5003-5271	10%	20050324	
			Residual Scar, Right Foot	7804	10%	20050324	
Degenerative Disk Disease Lumbar Spine	5243	10%	Degenerative Joint Disease and Disc Disease, Lumbar Spine with Chronic Strain 	5242	10%	20050324	
Degenerative Joint Disease Left Knee	Cat II	Residuals of Meniscal Surgery with Mild Degenerative Arthritis, Left Knee	5003	10%	20050324	
Ulnar Nerve Entrapment Syndrome	Cat II	Residuals s/p Ulnar and Median Nerve Release, Left Upper Extremity (Minor) 	8516	10%	20050324	
		Residual Scar, Left Medial Elbow	7804	10%	20050324	
Hypertension	Cat II	Hypertension	7101	10%	20050324	
Gastroesophageal Reflux Disease (GERD)	Cat II	Gastroesophageal Reflux Disease	7346	0%	20050324	
History of Depression associated with Insomnia and Erectile Dysfunction	Cat II	Depression with Insomnia	9435	10%	20050324	
Tobacco Abuse	Cat III	No VA Placement	
Overweight 	Cat III	No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS: 60%	
ANALYSIS SUMMARY:  

Degenerative Joint Disease (DJD) Right Foot.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent subtalar joint right foot fusion surgery in July 2003 for severe degenerative joint disease.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “degenerative joint disease of the right foot, status post subtalar joint fusion” for PEB adjudication.  A physical examination on 22 July 2004 (8 months before separation) noted full range of motion (ROM) of the ankle.  At the NARSUM examination on 17 September 2004 (6 months before separation) the CI reported pain and discomfort with walking and prolonged standing.  Physical examination showed decreased but unmeasured ROM of the right ankle, and no tenderness.  

At the 18 February 2005 VA Compensation and Pension (C&P) examination, performed 1 month before separation, the CI reported that he could walk no more than 3 miles, but could not run.  He could stand for no more than 1 hour at a time.  Examination showed a limp that was not due to the right foot condition.  A physical examination on 23 February 2005 showed a normal gait and normal lower extremity muscle strength.  At a second VA C&P examination on 24 March 2005 (2 weeks after separation), the CI complained of constant right foot pain that caused him to limp.  Examination showed a limping gait that placed more weight on the right lower extremity.  Right ankle dorsiflexion was 5 degrees (normal 20 degrees) and plantar flexion was 35 degrees (normal 45 degrees).  There was no painful motion and no evidence on the feet of abnormal weight-bearing.  A 2.5 inch tender scar over the lateral ankle was present.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right foot condition 10%, coded 5271 (ankle, limited motion of).  The VA also rated the right foot condition 10%, coded 5003-5271 (arthritis, degenerative-ankle, limited motion of), citing moderate limitation of ankle motion as the rationale.  All Board members agreed the limitation of motion was no more than moderate, therefore supporting the 10% rating adjudicated by the PEB.  A higher rating of 20% was not indicated in the absence of marked limited ROM of the ankle.  Although the fusion surgery created a sub-talar joint that was equivalent to ankylosis, the resulting weight-bearing position was not “poor,” and therefore a 20% rating was not justified under the 5272 code (subastragalar or tarsal joint, ankylosis of).  

The Board also considered whether ratings under the VASRD code for other foot injuries (5284) provided for a higher rating; however, all Board members agreed that the impairment did not more nearly approximate moderately severe to support a higher rating.  The VA also assigned a separate 10% rating for painful scar.  The Board does not recommend separation rating for scars unless their presence imposes a direct limitation on fitness.  The Board reviewed the STR and did not find evidence that a tender or painful scar separately interfered with duty and therefore a separate rating was not recommended.  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 foot condition.  

Degenerative Disk Disease (DDD) Lumbar Spine.  According to the STR and the NARSUM, the CI’s back condition began gradually over a number of years of heavy lifting associated with his duties.  Radiographic imaging studies showed degenerative disc changes, a disc bulge at L4-5 and a small disc herniation at L4-S5 without spinal canal narrowing or nerve impingement.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty. The MEB forwarded “degenerative disc and joint disease of the lumbar spine” for PEB adjudication.

At the time of a surgical assessment on 6 May 2004 (10 months before separation), the CI reported back pain, but no sensory or muscle strength problems except numbness in the right buttock area.  Physical examination showed “normal ROM of the lumbar spine without reproduction of (his) typical pain.”  Tenderness was present.  There was no evidence of nerve root irritation, and lower extremity neurologic findings were normal.  An examination on 22 July 2004 (8 months before separation) showed full ROM of the back, normal alignment and no tenderness.  The MEB NARSUM examination 6 months prior to separation noted complaints of low back pain with numbness to his low back and right buttocks region.  On examination there was no scoliosis, tenderness or malalignment of his back.

At the 18 February 2005 VA C&P evaluation performed 1 month before separation, the CI reported that he limited lifting to no more than 25 pounds due to his back; he also limited his walking to no more than 3 miles.  Flare-ups of pain occurred from bending, twisting or sitting for prolonged periods, and lasted for 15-20 minutes.  He denied incapacitating episodes.  Physical examination showed difficulty rising from a sitting position and from a lying-down position due to back pain.  A limping gait was present, but it was not due to the spine condition.  Spine ROM measurements showed flexion of 75 degrees (normal 90 degrees) and combined ROM of 165 degrees (normal 240 degrees).  Painful motion was present.  Back muscle spasms were also present, but spinal contour was not mentioned.  A sign of possible nerve root impingement was negative.  There was no evidence that repetitive motion caused additional limitation.  Lower extremity neurologic findings were normal.  A second C&P examination on 24 March 2005 (2 weeks after separation) noted full ROM of the lumbar spine, but measurements were not provided.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the lumbar spine condition 10%, coded 5243 (intervertebral disc syndrome).  The VA also rated the lumbar spine condition 10%, coded 5242 (degenerative arthritis of the spine), citing limitation of motion as the rationale.  The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the VA C&P examination prior to separation.  The presence of tenderness, painful motion and muscle spasm were also routes to a 10% rating.  The muscle spasm noted by the C&P examiner was not severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no evidence of intervertebral disc syndrome (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula (for IVDS).  Finally, there was no evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve rating.  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 “degenerative disc disease of the lumbar spine” condition.  

Contended PEB Conditions:  Degenerative joint disease (DJD) Left Knee, Ulnar Nerve Entrapment Syndrome, Hypertension, Gastroesophageal Reflux Disease, History of Depression Associated with Insomnia and Erectile Dysfunction, Tobacco Abuse, and Overweight. The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting. 

Degenerative Joint Disease Left Knee.  In February 2003 the CI underwent arthroscopic debridement of a left knee medial meniscal tear and mild patellar chondromalacia.  The VA on 19 November 2003 rated the left knee condition 0% effective 21 September 2003 (18 months prior to separation). The NARSUM examiner 6 months prior to separation reported that the left knee improved after surgery, but the CI continued to experience pain and discomfort with prolonged standing and running.  The NARSUM identified left knee DJD as one of 3 final diagnoses (including the right foot and lumbar spine conditions).  The commander’s statement on 21 October 2004 (5 months prior to separation) did not specify the left knee as an impediment to performance of duties.  L4 profiles in May, June and September 2004 were for the low back and ankle conditions only.  The final L4 profile in December 2004 did not indicate if restrictions were a consequence of the left knee in addition to the lumbar spine and ankle conditions.  The MEB submission listed left knee DJD.  At the C&P evaluation 1 month before separation, the CI reported that his knee pain would “come and go” and was 3-5/10 in severity.  He limited walking to no more than 3 miles.  Although the C&P examiner noted a limp due to left knee pain, another examiner 5 days later observed a normal gait.  The Board concluded there was not a preponderance of evidence that the left knee DJD separately interfered with performance of duty sufficiently to be considered unfitting.

Ulnar Nerve Entrapment Syndrome. At a 14 November 2004 follow-up appointment with the NARSUM examiner, the CI reported a history of intermittent left little finger numbness.  In November 2004 (after the NARSUM and the MEB), ulnar nerve release surgery was performed.  The Board notes that fitness determinations are subject to DoDI 1332.38 (E3.P3.3.3 - Adequate Performance Until Referral) which states: “If the evidence establishes that the Service member adequately performed his or her duties until the time the Service member was referred for physical evaluation, the member may be considered fit for duty even though medical evidence indicates questionable physical ability to continue to perform duty.”  The Board members agreed that at the time of the MEB referral, there was no evidence of inadequate performance of duty as a consequence of the ulnar nerve entrapment condition.

Tobacco Abuse and Overweight.  Tobacco abuse and overweight are conditions that do not constitute a physical disability.  The Board therefore has no reasonable basis for recommending these conditions as additionally unfitting for separation rating.    

Hypertension, Gastroesophageal Reflux Disease, and History of Depression:  were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  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, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of these conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the degenerative joint disease right foot status post fusion condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the degenerative disk disease lumbar spine condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended degenerative joint disease left knee, ulnar nerve entrapment syndrome, hypertension, gastroesophageal reflux disease, history of depression associated with insomnia and erectile dysfunction, tobacco abuse, and overweight 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.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140725, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-03563.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings