RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04123
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070313

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Psychological Operations Specialist, medically separated for “chronic left shoulder and left ankle pain,” with a disability rating of 10%.  

CI CONTENTION:  He was not given a rating for his PTSD condition.  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 on 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 - 20061208	VARD - 20070822	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Shoulder and 
Left Ankle Pain	5099-5003	10%	Left Shoulder Instability with Surgical Repair	5203	10%	STR	
			Surgical Scar Left Shoulder	7805	0%		
			Left Ankle Instability	5271	10%		
Adjustment Disorder with Depressed Mood	Not Unfitting	Post-Traumatic Stress Disorder	9411	30%	20070605	
		Depression	9434	NSC		
		Anxiety	9400	NSC		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  The PEB combined the chronic left shoulder and left ankle pain conditions as a single unfitting condition rated 10% using the analogous 5099-5003 code and applied the US Army Physical Disability Agency (USAPDA) pain policy.  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, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  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 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 left shoulder and left ankle pain conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

Chronic Left Shoulder Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-hand dominant CI injured his left shoulder in August 2003 after a bad parachute landing during airborne school.  He reinjured his left shoulder in March 2005 during physical training.  Ongoing pain led to a Bankart repair and capsular shift surgery in October 2005.  The CI had a reinjury in February 2006 with diagnostic imaging in March 2006 showing a moderate small focal bone bruise of the supralateral humeral head with post-surgical changes of the anteroinferior labrum consistent with capsular shift and Bankart repair; however, a superimposed acute injury could not be excluded.  The CI had a continued feeling of a “loose” shoulder with pain and received trigger point injections of his left shoulder on 28 April 2006.  No additional surgery was indicated and further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic left shoulder multidirectional instability” for PEB adjudication.  

At the MEB examination dated 12 October 2006, 5 months prior to separation, the CI reported constant left shoulder pain and instability, rated at 3-4/10, which worsened to  10/10 with lifting or carrying weight, driving, overhead activity and impact activities.  Surgery improved the condition temporarily, but pain returned to pre-surgery levels with instability following an additional injury.  The pain was relieved by physical medicine treatments, but did not affect the instability.  Further surgical treatment was not recommended.  The pain prevented the CI from running, jumping, or prolonged marching.  He could not perform military specialty duties except for wearing chemical protective equipment.  He could not lift or carry weight or perform strenuous or continuous overhead activity with his left arm.  The examiner noted tenderness to palpation greatest over the lateral and anterior aspects.  Evaluation for ligamentous instability (apprehension test) was positive.  The range of motion (ROM) was limited by pain and instability to 140 degrees (normal 180) of flexion and 153 degrees (normal 180) of abduction.

There was no VA Compensation and Pension (C&P) examination that addressed the shoulder proximate to separation and the VARD indicated the CI failed to report for a scheduled VA examination.  

The Board directed attention to its rating recommendation based on the above evidence.  As noted, the PEB bundled the left shoulder and left ankle pain conditions and applied a single 10% rating under the analogous code 5099-5003 (arthritis, degenerative), citing constant and slight pain IAW the USAPDA pain policy.  The VA assigned a 10% rating using code 5203 (clavicle or scapula, impairment of) for malunion or nonunion of the clavicle or scapula, citing the service medical records (the separate VA rating for the ankle is discussed below).  The Board first considered if the chronic left shoulder pain condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The left shoulder was profiled, implicated in the commander’s statement and was judged to fail retention standards.  Board members agreed that the evidence reasonably justified that the functional limitations of the left shoulder condition contributed to the CI’s inability to perform his military duties, and accordingly a separate disability rating is recommended.  

The VASRD §4.71a (code 5201, arm limitation of motion) threshold for a rating for ROM impairment is “at shoulder level” (approximately 90 degrees from the side), and the ROM in evidence demonstrated motion above this level.  Although there was insufficient limitation of motion to support a rating under 5201, Board members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion).  There was no malunion or recurrent dislocation of the humerus to justify a rating under the 5202 code (humerus, other impairment of).  Although an alternative rating of 10% could be justified under the 5203 code (clavicle or scapula, impairment of) for instability, there was no loose movement of the clavicle to warrant the next higher 20% rating under that code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a separately unfit determination with a disability rating of 10% for the left shoulder condition, coded 5099-5003.

Chronic Left Ankle Pain.  According to the STR and MEB NARSUM, the CI’s left ankle condition began in August 2003 after a bad parachute landing during airborne school.  He reinjured his left ankle after falling in a pothole while running in January 2005. Diagnostic imaging supported findings of posterior talofibular ligament sprain and slight widening of the ankle joint.  The CI was scheduled to undergo a left lateral ankle stabilization procedure, but reasonably declined due to the outcome of his shoulder surgery and chances of continued ankle problems after surgery.  Conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic left ankle instability” for PEB adjudication.  

At the physical medicine examination dated 22 September 2006 (administered for MEB addendum), 6 months prior to separation, the CI reported constant pain rated at 2/10 increasing to 8/10 when climbing stairs or with prolonged walking or standing.  The pain was relieved by using an ankle brace and medication, and prevented him from running, marching or participating in any field activity that involved walking on uneven surfaces.  Physical examination showed no swelling or erythema; strength was normal and neurovascular status intact.  There was tenderness to palpation at the distal fibula along the lateral ankle ligaments and normal ROM in all planes with painful motion on inversion and eversion.  Anterior drawer tests for instability were positive.  

At the MEB examination dated 12 October 2006, 5 months prior to separation, the CI reported constant left ankle pain and instability rated at 2/10.  The pain worsened to 7/10 with prolonged standing or walking, climbing stairs, repetitive flexing of the ankle while bearing weight, impact activities, and physical activities related to military duties.  Rest, physical therapy, or medical treatment did not relieve the pain but he was able to perform activities of daily life.  Physical examination showed tenderness to palpation about the lateral aspect of the joint and distal fibula.  Tests for instability were positive and there was painful motion.  Physical therapy ROMs for the ankle (performed in October 2006) documented dorsiflexion to 5 degrees (normal 20) and plantar flexion to 45 degrees (normal).  

The Board directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB bundled the left shoulder and left ankle pain conditions and applied a single 10% rating under the analogous codes 5099-5003 citing constant and slight pain IAW the USAPDA pain policy.  The VA assigned at 10% rating for the left ankle using the 5271 code (ankle, limited motion of), citing moderate limited motion of the ankle based on service medical records. The Board first considered if the chronic left ankle pain condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The left ankle condition was profiled, implicated in the commander’s statement and was judged to fail retention standards.  Board members agreed that the evidence reasonably justified that the functional limitations of the condition contributed to the CI’s inability to perform his military duties, and accordingly a separate disability rating is recommended.  

The Board considered if the limitation of motion was moderate or marked when applying the 5271 code.  Members agreed that the MEB ROM examination proximate to separation was consistent with a moderate limitation of motion (limited by pain), for the 10% rating under this code.  A higher rating of 20% was not indicated in the absence of marked limited ROM of the left ankle.  The Board considered alternative VASRD ankle and analogous codes, but all were less applicable and not advantageous to rating.  Because there was no ankylosis, nonunion or malunion, VASRD §4.71a offers no applicable joint code which would yield a rating higher than a 10% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a separately unfit determination with a disability rating of 10% for the left ankle condition, coded 5271.  

Contended PEB Condition:  Adjustment Disorder with Depressed Mood.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  Adjustment disorder is a condition not constituting a physical disability IAW DoDI 1332.38 in effect at the time.  Therefore, the Board has no basis for recommending it as unfitting/compensable.   After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the left shoulder condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 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.  In the matter of the contended adjustment disorder with depressed mood condition, the Board unanimously agrees that it cannot recommend it for additional disability rating.  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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Left Shoulder Pain	5099-5003	10%	
Chronic Left Ankle Pain	5271	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated, 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 AR20160011992 (PD201404123)

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