RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00048
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060113

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a mobilized Army National Guard E5, Administrative Specialist, medically separated for “chronic low back pain” and “bilateral ankle pain and instability,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI was given a higher rating for his conditions by the VA.  The 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 - 20051122	VARD – 20070306	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Mechanical Low Back Pain	5237	10%	STR	
Bilateral Ankle Pain and Instability	5099-5003	10%	Left Ankle Instability with Chronic Stress Changes	5271	10%		
			Bilateral Ankle Instability	5271	10%		
Depressive Disorder	Not Unfitting	Posttraumatic Stress Disorder	9411	70%		
Chronic Left Wrist Pain	Not Unfitting	Chronic Left Wrist Pain	5215	0%		
Dorsal Wrist Ganglion, Right	Not Unfitting	Dorsal Wrist Ganglion, Right	5215	0%		
Hiatal Hernia	Not Unfitting	Hiatal Hernia	7346	0%		
Chronic Right Wrist Pain	Not Unfitting	No VA Placement		
Bilateral Knee Stress Reactions	Not Unfitting	Left Knee Stress Reaction	5257	0%		
		Right Knee Stress Reaction	5257	0%		
History of Bright Red Blood Per Rectum	Not Unfitting	Rectal Bleeding	7399-7336	NSC		
Hearing Loss Bilaterally	Not Unfitting	Bilateral Hearing Loss	6100	0%		
Gastroesophageal Reflux Disease (GERD)	Not Unfitting	No VA Placement		
Alcohol Abuse in Partial Remission	Not Unfitting	No VA Placement		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	
ANALYSIS SUMMARY:  

Low Back Pain.  The PEB combined the bilateral ankle condition as a single unfitting condition, coded analogously to 5003 and rated 10%.  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.  The Board must apply separate codes and ratings in its recommendations if compensable ratings for each condition are achieved IAW applicable VASRD sections.  If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the reasonable requirement that each ‘unbundled’ condition was unfitting in and of itself or at least an indispensable element of a combined effect rating.  Thus the Board must maintain the prerogative of separate fitness recommendations in this circumstance, with the caveat that its recommendations may not produce a lower combined rating than that of the PEB.  

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain began in August 2004 after seeking cover in a ditch during an indirect fire attack in Iraq.  There was no surgical indication and despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty.  The MEB forwarded “mechanical low back pain” for PEB adjudication.  

At the MEB examination dated 30 March 2005, 9 months prior to separation, the CI reported chronic back pain that prevented him from sitting on the floor or standing in a crouched position for any extended length of time.  Physical examination showed the CI could walk heel to toe, with negative straight leg bend and axial load tests. 

The MEB NARSUM examination on 16 May 2005, 7 months prior to separation, noted complaints of chronic low back pain.  Physical examination showed full range of motion of the thoracolumbar spine with intact neurovascular, motor and strength bilaterally. The low back was tender to palpation over the lumbar paraspinal muscles.  The CI did not present for a VA Compensation and Pension (C&P) evaluation. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain), citing normal imaging studies, no radiculopathy, no significant loss of spinal motion or muscle spasms.  Tenderness to palpation of the paraspinal muscles was noted.  The VA also  rated the low back condition 10%, coded 5237 (lumbosacral strain), stating “there is evidence of some impairment: however, Mr. Haskins did not report for the examination that was scheduled for February 6, 2006 to more fully evaluate the condition.”

Although there was insufficient limitation of motion to support a minimum rating, the Board agreed a 10% rating was justified for the presence of tenderness.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  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 low back pain.  

Bilateral Ankle Pain and Instability.   According to STR and the MEB NARSUM, the CI’s bilateral ankle pain began in 1987. The CI reinjured his right ankle in Iraq in 2004 and experienced recurrent ankle sprains every 2 months thereafter.  

At the MEB examination the CI reported the right ankle “pops loudly when turned a certain way.” Physical examination showed the CI was able to heel and toe walk without abnormality.  The examiner recorded a diagnosis of “history of recurrent left ankle sprain with instability” and made no mention of the right ankle.    

The MEB NARSUM examination noted complaints of recurrent ankle sprains approximately every 2 months.  Physical examination showed negative anterior ankle drawer and negative talar tilt bilaterally and both feet and ankles were intact to light touch neurologically.  The examiner recorded tenderness to palpation of the ankle tendons, left greater than right.  Painful motion was not documented.  At the 6 September 2005 clinic appointment, 4 months prior to separation, the CI’s gait was normal. Bilateral ankles show no swelling.  There was no tenderness to palpation over either ankle mortise.  Inversion and eversion was normal and anterior drawer was negative.  The assessment was “sprained ankles, resolved.”  The CI did not present for a VA Compensation and Pension (C&P) evaluation.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral ankle condition 10%, coded 5003 (arthritis, degenerative), citing degenerative arthritis with radiological evidence and no loss of joint motion.  The VA rated the bilateral ankle condition 10%, and left ankle instability with chronic stress, 10% analogously coded 5271 (ankle, limited motion of), based on service treatment records citing there was no indication of loss of motion of the ankle: however, the disabling effects warrant a compensable rating.  

The Board undertook an evaluation of each condition separately for rating purposes, and first considered the left ankle.  The NARSUM recorded normal physical examination of both ankles with the exception of tenderness to palpation over the ligaments, left greater than right.  The PEB noted the bone scan showed degenerative changes in both ankles.  However, the NARSUM documented bone scan of the left ankle showed evidence of stress changes, without reference to the right ankle.  It was noted that podiatry had diagnosed chronic bilateral ankle instability, left greater than right.   STR was silent regarding treatment of the ankles.  The MEB examination only referenced an issue with the left ankle.  The evidence demonstrated the left ankle was compensable at 10% under the 5003 code; however, there was insufficient evidence to support a higher than minimal compensable rating under any applicable VARSD code. 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 left ankle condition.  The Board next proceeded with the rating of the right ankle condition.  The PEB determined that the right ankle was unfitting.  The NARSUM noted that the left ankle was worse than the right and the examiner made no reference to any radiographic abnormality of the right ankle.  The record clearly documented that the left ankle condition was worse than the right.  Therefore, Board members concluded, there was insufficient evidence to support a compensable rating for the right ankle.  

Thereupon, 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 left ankle condition and 0% for the right ankle condition.  As this results in no rating benefit to the CI, the Board recommends no re-characterization of the PEB adjudication for the bilateral ankle condition. 

Contended PEB Conditions. Chronic left wrist pain, dorsal wrist ganglion, right hiatal hernia, chronic right wrist pain, bilateral knee stress reactions, history of bright red blood per rectum, hearing loss bilaterally, gastroesophageal reflux disease (GERD), depressive disorder, and alcohol abuse in partial remission.  With the exception of the left wrist condition mentioned in the commander’s statement, the remaining conditions were not profiled, otherwise implicated in the commander’s statement and not judged to fail retention standards.  There was no performance based evidence from the record that 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 the chronic left wrist pain, dorsal wrist ganglion, right hiatal hernia, chronic right wrist pain, bilateral knee stress reactions, history of bright red blood per rectum, hearing loss bilaterally, gastroesophageal reflux disease (GERD), and alcohol abuse in partial remission” conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS: In the matter of the chronic low back pain and IAW VASRD §4.71a, the Board recommends no change in the PEB adjudication.  In the matter of the bilateral ankle pain and instability and IAW VASRD §4.71a, the Board recommends no change in the PEB adjudication.  In the matter of the contended chronic left wrist pain, dorsal wrist ganglion, right hiatal hernia, chronic right wrist pain, bilateral knee stress reactions, history of bright red blood per rectum, hearing loss bilaterally, gastroesophageal reflux disease (GERD), depressive disorder, and alcohol abuse in partial remission 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, 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 20140119, with attachments
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 XXXXXXXXXXXXXXXXXXXXX, AR20160018803 (PD201500048)

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, I accept the Board’s recommendation and hereby deny the individual’s application.
This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF:
(  ) DoD PDBR (  ) DVA