RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00295
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030517

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve O2, Engineer Officer, medically separated for “mechanical low back pain,” “chronic left shoulder pain,” and “chronic bilateral plantar fasciitis/heels syndrome in a flexible pes planus,” rated 10%, 0%, and 0%, respectively, with a combined disability rating of 10%.  

CI CONTENTION:  The CI contends that he was given a higher rating for his conditions by the VA and the Army didn’t consider his post-traumatic stress disorder (PTSD).   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 - 20030124	VARD - 20030527	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mechanical Low Back Pain	5295	10%	Lumbar Strain	5295	10%	20030205	
Chronic Left Shoulder Pain	5009-5003	0%	Residuals, Arthroscopic Procedure of the Left Shoulder	5301	10%	20030205	
Chronic Bilateral Plantar Fasciitis/Heel Spur Syndrome in a Flexible Pes Planus	5009-5003	0%	Plantar Fasciitis Left Foot with Left Achilles Spur	5299-5020	10%	20030205	
			Right Foot Plantar Fasciitis	5299-5020	10%	20030205	
			Bilateral Pes Planus	5276	10%	20030205	
Migraine Without Aura	Not Unfitting	Vascular Headaches	8199-8100	10%	20030205	
Left Knee Pain	Not Unfitting	Left Leg Periostitis	5299-5022	10%	20030205	
Season and Perennial Allergic Rhinitis, Moderate	Not Unfitting	Perennial Allergic Rhinitis 	6522	0%	20030205	
Major Depressive Disorder, Recurrent, Moderate	Not Unfitting	Post-Traumatic Stress Disorder	9411	30%	20030204	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  80%	
ANALYSIS SUMMARY:  

Mechanical Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back condition began sometime in 1995.  The CI’s pain started in his mid-to-lower back pain.  No injury or trauma reported.  Radiographic (X-rays) studies in September 2001 showed a negative lumbosacral spine, with X-rays in November 2002 showing mild anterior vertebral lipping (early degenerative changes) with vertebral body height and disc space within normal.  Despite physical therapy and prescribed medications, the CI continued to have low back pain.  The MEB forwarded “low back pain” for PEB adjudication.  

The MEB NARSUM examination on 18 December 2002, 5 months prior to separation, noted complaints of constant pain.  No improvement was reported with physical therapy or prescription medications.  There was no reported numbness, tingling or weakness in the legs.  No bowel or bladder dysfunction.  The pain was 95% in his back and 5% in his legs.  Physical examination showed no tenderness to palpation, no step-off, and no crepitus.  Lumbar flexion was noted at 20 degrees (normal 90), extension 22 degrees (normal 30), side bend left at 35 degrees and side bend right 13 degrees (normal 30).  Provocative testing for radicular signs was negative.  Muscle strength, reflexes, and sensory testing were normal.  

At the 4 February 2003 VA Compensation and Pension (C&P) evaluation, performed 3 months before separation, the CI reported no particular injuries, but a history of 45 parachute jumps. X-ray studies were normal.  The CI reported daily low back pain which was aggravated by standing or sitting for more than 15 minutes.  No radicular symptoms reported.  Range of motion (ROM) reduction was reported due to pain with flare-ups due to repetitive motion.  Episodic spasms were reported.  No weakness was reported.  Physical examination showed ROM decreased by 25%.  No medications were reported.  Gait was normal, curvature of the spine was normal.  Some tenderness to percussion was noted over the lower lumbar area.  No muscular spasms were appreciated.  ROM measurement showed a flexion of 85 degrees, and a combined ROM of 235 degrees (normal 240). All motions were noted to cause discomfort in the lower lumbar area.  Neurologic examination of the lower extremity was unremarkable.  

The Board directed attention to its rating recommendation based on the above evidence.  In accordance with DoDI 6040.44, the Board is required to recommend a rating IAW the VASRD in effect at the time of separation.  The Board noted that the 2003 Veteran Administration Schedule for Rating Disabilities (VASRD) standards for the spine, which were in effect at the time of separation, were changed to the current §4.71a rating standards effective 26 September 2003.  The Board correlated the above clinical data with the 2003 rating schedule; applicable diagnostic codes include:  5292 (limitation of lumbar spine motion); and 5295 (Lumbosacral strain).  

The PEB rated the back condition 10%, coded 5295 (lumbosacral strain), citing moderate limitation of motion by pain, no radiculopathy, and rated as characteristic pain on motion.  The VA rated the back condition 10%, coded 5295, based on the VA C&P examination 3 months before separation, citing characteristic painful or limited motion.  The Board adjudged that the VA examination was closest to separation and had the greatest probative value for rating.  

The record did not support greater than slight limitation of lumbar motion (under code 5292 – lumbar spine limitation of motion); or, muscle spasm on extreme forward bending, loss of lateral spine motion; or periods of incapacitation requiring physician prescribed bed rest for any higher rating than that awarded by the PEB.  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 condition.  

Left Shoulder Pain.  The CI was right-handed.  According to STRs and the MEB NARSUM, the CI’s left shoulder pain condition began in 1992-1993, as a tendonitis without specific history of trauma or injury reported.  X-rays showed a normal left shoulder, with increased tracer uptake on bone scan of both shoulders.  At the 4 June 2001 orthopedic evaluation, the CI complained of left shoulder weakness and pain.  He related a history of a soccer injury in 1998 with arthroscopic surgery of the left shoulder with drilling of an osteochondral defect to improve the cartilage coverage.  Physical examination showed positive impingement signs without instability.  Despite treatment, the left shoulder 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 “left shoulder musculoskeletal pain” for PEB adjudication.  

Physical therapy (PT) ROM measurement dated 10 October 2002 showed left shoulder flexion of 150 degrees (normal 180) and abduction of 145 degrees (normal 180).  The MEB NARSUM examination on 12 December 2002, 5 months prior to separation, noted complaints of left shoulder pain over the anterior and posterior side of the left shoulder, with weakness and decreased ROM of the left arm.  Pain was rated at 5-8/10.  No relief of pain was found despite activity modification, PT and injections.  Physical examination showed positive tenderness to palpation over the anterior and posterior acromion.  ROM demonstrated 180 degree abduction and flexion, with 90 degrees internal and external rotation.  There was painful cross-arm abduction and a positive apprehension test.  There were no signs of instability.  Muscle strength was normal (5/5) and there was no sensory or vascular deficit.  

At the 4 February 2003 VA C&P evaluation, performed 3 months before separation, the CI reported continued discomfort in both shoulder, especially with raising the elbow above the head.  Repetitive motion aggravated the discomfort in both shoulders, greater on the left than the right.  Flare-ups were only associated with repetitive motion.  Strength was unchanged, but speed was reduced.  X-ray studies were negative.  Physical examination showed a non-tender scars on the left shoulder consistent with history of arthroscopic procedure.  ROM showed anterior flexion and abduction of 160 degrees, external rotation to 75 degrees, internal and external rotation to 85 degrees, and all motions produced discomfort.  Repetitive motion increased pain without further decrease in ROM.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 0%, analogously coded 5003 (arthritis, degenerative), citing full range of motion.  The VA rated the left shoulder condition 10%, coded 5301 (shoulder function, Group I muscle), based on the VA C&P examination 3 months before separation, citing discomfort with ROM testing and slightly limited motion rated as a moderate muscle disability.  

The VASRD §4.71a threshold for rating for ROM impairment (code 5201, arm limitation of motion) is “at shoulder level” (approximately 90 degrees from the side), and the examinations in evidence demonstrated motion above this level.  Although there was insufficient limitation of motion as recorded in the MEB NARSUM and VA examinations to support a rating under the 5201 code, 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); and no nonunion with loose movement of the clavicle to warrant the next higher 20% rating under the 5203 code (clavicle or scapula, impairment of).  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 shoulder condition, coded 5099-5003.  

Chronic Bilateral Plantar Fasciitis/Heel Spur Syndrome in a Flexible Pes Planus.  According to STRs and the MEB NARSUM, the CI had a long history of recalcitrant bilateral plantar fasciitis treated with custom shoe inserts (orthotics).  The commander’s statement indicated onset of bilateral foot and shin problems in 1992 during train-up for airborne school, with significant worsening in 2001.  The 29 April 2002 Podiatry evaluation indicated the CI complained of increased bilateral foot pain and that he could no longer run.  Examination showed tenderness bilaterally at the insertion of the plantar fascia and medial ankle.  There was bilateral pes planus with moderate pronation throughout stance.  The diagnosis was over pronation and plantar fasciitis.  X-ray studies showed bilateral pes planus, small right Achilles spur, bilateral os trigonum (extra bone by ankle/tendon), and positive left talar beak (degenerative change).  Despite treatment, the bilateral foot 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 “flexible pes planus deformity of bilateral feet” and “plantar fasciitis / heel spur syndrome of bilateral feet” for PEB adjudication.  

The NARSUM referenced the MEB Podiatry consultation examination dated 12 December 2002, 5 months prior to separation, indicating the MEB diagnoses and inability for the CI to do running, jumping, marching, prolonged walking or standing activities without significant pain in bilateral feet.  The Podiatry consultant include history of multiple injections and a complaint of swelling along the "ligament" on the plantar aspect of both feet.  

Physical examination showed bilateral findings of: flexible pes planus deformity, a positive "too many toes sign," tenderness to palpation of the proximal 1/3 of the plantar fascia bilateral and plantar medial heel.  Ankle ROM was dorsiflexion of 5 degrees (normal 20) and full subtalar joint ROM without pain or crepitus.  There was mild non-pitting edema on the plantar aspect of the medial arch of both feet.  Radiographs showed bilateral talonavicular spurring and right retrocalcaneal spurring.  

At the 2 February 2003 VA C&P evaluation, performed 3 months before separation, the CI reported bilateral foot pain with use of prescribed orthotics on a daily basis.  The CI underwent injections for plantar fasciitis.  The CI had easy fatigue with increased pain throughout the day, with no weakness or instability.  X-ray studies showed bilateral pes planus with mid near complete deformation of the mid foot and complete reformation upon unloading.  Physical examination showed pes planus bilaterally with near complete deformation of the mid foot and complete reformation with unloading, otherwise, the fore and hind foot architecture was within normal limits.  Both feet were flexible with pain and tenderness.  Ankle dorsiflexion was 15 degrees (normal 20) with plantar flexion to 35 degrees (normal 45) without instability.  There was mid tibial tenderness bilaterally.  The diagnoses were bilateral plantar fasciitis, bilateral pes planus, and left Achilles spur.  

The PEB bundled the two MEB conditions of “flexible pes planus deformity of bilateral feet” and “plantar fasciitis / heel spur syndrome of bilateral feet” as “chronic bilateral plantar fasciitis/heel spur syndrome in a flexible pes planus” with a single rating of 0%, coded 5099-5003 (analogous to arthritis, degenerative).  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.  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 for each foot and condition.  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 Disability Evaluation System (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 VA separately rated the left foot at 10% and the right foot at 10%; each coded 5299-5020 (synovitis), citing painful motion of a group of minor joints for each foot; and additionally rated the bilateral pes planus condition at 10% coded 5276 (flatfoot, acquired), citing pain on manipulation and use of the feet; all ratings based on the VA C&P examination 3 months before separation.  

In this case, both feet were considered to fail retention standards, both were implicated by the NARSUM and in the commander’s statement, and both were profiled.  The Board adjudged that each foot was separately unfitting.  The Board next considered if the bilateral flexible pes planus was separately unfit and ratable from the plantar fasciitis/heel spur syndrome for each foot.  Given the significant overlap of symptoms of foot tenderness and pain on manipulation of the foot for each condition, and the tenants of VASRD §4.14 (avoidance of pyramiding) the Board did not consider the flexible pes planus additionally ratable.  

The Board adjudged that the VA C&P examination was closer to separation and had the highest probative value for rating at separation.  The Board adjudged that a 10% rating was supported for each foot based on functional loss (§4.40 and §4.45) and painful motion (§4.59) of the collection of joints in each foot.  Only the more remote MEB examination indicated limitation of motion of the ankle joint to support a potential rating under diagnostic code 5271 (limitation of motion) and no examinations noted the presence of painful ankle motion.  Alternatively rating each foot analogously to 5276 (flatfoot, acquired) would rate no higher than 10% for both feet together, as there was no evidence of severe pes planus.  Coding alternatives for each foot at 10% either analogous to 5020 (synovitis), or analogous to 5003, were considered equivalent.  

In the matter of the bilateral foot condition (bilateral plantar fasciitis/heel spur syndrome in a flexible pes planus), the Board unanimously recommends that each foot be separately adjudicated as follows:  an unfitting right foot condition coded 5299-5003 and rated 10%, and an unfitting left foot condition, coded 5299-5003 and rated 10%, both IAW VASRD §4.71a.  

Contended PEB Conditions.  

Migraine without Aura.  The migraine condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  The CI was able to function well despite his headaches.  There was no performance-based evidence from the record that the migraine without aura condition significantly interfered with satisfactory duty performance at separation.  

Left Knee Pain.  The left knee condition was not specifically profiled, but may have been overshadowed by the profile for bilateral shin splints.  The commander’s statement indicated general difficulties with pain and swelling in the feet and legs, without specifically mentioning the knees.  The CI’s knee pain was without specific trauma and had existed since 1992 with running.  There were no symptoms of instability.  There were scant treatment records for the left knee condition and insufficient performance-based evidence from the record that the left knee condition significantly interfered with satisfactory duty performance before referral into the DES or at separation.  

Season and Perennial Allergic Rhinitis, Moderate.  The allergic rhinitis was not profiled, implicated in the commander’s statement and was not judged to fail retention standards.  The CI was determined to have “excellent” functional status that did not interfere with the CI’s ability to perform his military duties.  There was no performance-based evidence from the record that the season and perennial allergic rhinitis condition significantly interfered with satisfactory duty performance at separation.  

Major Depressive Disorder, Recurrent, Moderate.  The major depressive disorder was profiled (S3), and judged to fail retention standards.  However, the Commander detailed the CI remained a motivated officer, had been an asset, and was “a solid performer despite his diminished physical capabilities.”  The CI was referred for a psychiatric consultation during his MEB processing for depression requiring medication, and possible PTSD and Gulf War experience.  The psychiatric evaluation completed on 30 October 2002, detailed onset of mental health symptoms in 1993, a diagnosis of depression in 1996, and use of antidepressant medications beginning in 1996.  The mental status examination was unremarkable with the exception of a mood described as “mildly depressed and physically uncomfortable,” and being concrete in interpreting proverbs with difficulty expressing emotions.  The psychiatrist diagnosed major depressive disorder, recurrent, moderate and assigned a global assessment of functioning (GAF) of 55 (in the moderate symptom range) indicating stressors as “occupational, financial, care of children, concern about future employability.”  Summary indicated that the CI required antidepressant medications to allow him to meet the expectations of his supervisors.  The CI was on medication and engaged in therapy, and if retained, he would require weekly access to continued psychiatric care.  The Board noted that the pre-separation VA examination diagnosed PTSD with a GAF of 75 (If symptoms are present they are transient and expectable reactions to psychosocial stressors; no more than slight impairment in social, occupational, or school functioning).  The Board adjudged that there was scant evidence from the record that the major depressive disorder significantly interfered with satisfactory duty performance before referral into the DES or 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 low back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic left shoulder pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the “chronic bilateral plantar fasciitis/heel spur syndrome in a flexible pes planus” condition, the Board unanimously recommends an unfitting left foot condition with a disability rating of 10%, coded 5299-5003; and an unfitting right foot condition with a disability rating of 10%, coded 5299-5003; both IAW VASRD §4.71a.  In the matter of the contended migraine without aura; left knee pain; season and perennial allergic rhinitis, moderate; and major depressive disorder, recurrent, moderate 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 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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Mechanical Low Back Pain	5295	10%	
Chronic Left Shoulder Pain	5009-5003	10%	
Chronic Bilateral Plantar Fasciitis/Heel Spur Syndrome in a Flexible Pes Planus	Left	5299-5003	10%	
	Right	5299-5003	10%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150419, w/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

06 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170000667 (PD201500295)

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 40% 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 40% 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