RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01737
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050801

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Health Care Specialist, medically separated for “chronic right shoulder pain” and “bilateral ankle pain” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  The CI believes he should have been rated higher. His conditions continue to worsen and impact his daily life.  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 - 20050504	VARD - 20060518	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Shoulder Pain	5003	10%	Right Shoulder Strain, Status Post Right Shoulder Surgery	5024-5201	10%	20060405	
Bilateral Ankle Pain	5099-5003	0%	Right Heel Spur	5273	0%		
			Left Heel Spur	5273	0%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Right Shoulder Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-hand dominant to write, and left-hand dominant to shoot, CI injured his right shoulder in November 2003 while during a log physical training event for a Special Forces assessment evaluation.  X-rays on 5 December 2003 showed degenerative changes, cortical irregularity, erosive change of the distal clavicle, and subchondral cystic change of anteromedial right humeral head.  The glenohumeral joint space was preserved and bone mineralization was normal.  Another X-ray on 16 August 2004 showed degenerative changes. Arthroscopic surgery with type II SLAP repair of the right shoulder along with an open Mumford was performed in October 2004. Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty. 
 
During the 17 April 2005 MEB examination, 4 months prior to separation, the CI reported intermittent right shoulder pain especially noted with overhead work and repetitive lifting.  Physical examination showed surgical changes associated with prior Mumford surgery.  The range of motion (ROM) was mildly limited to 130 (normal 180) by pain in abduction.  

At the 5 April 2006 VA Compensation and Pension (C&P) examination, 8 months after separation, the CI reported 1.5 months prior he had a hard sneeze that caused a sharp pain in his shoulder which caused the shoulder to feel like “a rubber band will give way.”  The pain was described as achy, causing decreased ROM, and a tingly sensation that would get hot.  The pain was aggravated by lifting his baby, throwing a ball, and performing daily activities.  The pain was relieved by medication and re-adjusting his position.  Physical examination showed the right shoulder was non-tender and the ROM was mildly limited in flexion of 130 (normal 180) and abduction of 130 (normal 180). X-ray studies 5 April 2006 showed a 1 to 2 cm gap between the distal aspect of the clavicle and the acromion, noted by the examiner as “suggesting a Mumford procedure,” however, the alignment appeared to be grossly normal.  There were slight marginal osteophytes and degenerative changes at the inferior of the right humeral head.  
 
The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the analogous 5003 code (arthritis, degenerative [hypertrophic or osteoarthritis]), citing a major joint with radiographic evidence of degenerative joint disease (DJD) and slight limitation of motion.   The VA also assigned a 10% rating using the 5024-5201 code (arm, limitation of motion) for painful or limited motion of a major joint or group of minor joints.  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.  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 shoulder condition.

Bilateral Ankle Pain.  The PEB combined the left and right ankle conditions as a single unfitting condition coded 5099-5003 and rated 0% citing DJD with normal motion.  This 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 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 and right ankle conditions is presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

Left and Right Ankle Pain.  According to the STR and the MEB NARSUM, the CI’s left ankle condition began in June 2004 after falling and twisting his ankle during a run.  X-ray studies 14 June 2004 showed findings that the examiner noted as suggesting prior injury to the left ankle and possible instability.  There was swelling noted as possibly being associated with chronic injury, but which may have been associated with an acute injury that had occurred within the past 3 weeks.  There were no displaced fractures.  X-ray studies 15 August 2004 indicated irregular ossification in the distal interosseous ligament that the examiner noted as suggesting previous injury.  There was no acute fracture, dislocation or osteochondral abnormality.  There was no effusion or soft tissue swelling.  The ankle mortise was maintained bilaterally.  X-ray studies 16 August 2004 showed left ankle greater than right ligamentous abnormality.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  

During the 17 April 2005 MEB examination, 4 months prior to separation, the CI reported intermittent bilateral ankle pain over the past 2 years, noted to worsen after a left ankle sprain in June 2004.  Physical examination showed no edema, erythema, or crepitus of the ankle, and normal strength.  There was ligamentous instability on examination.  There was full ROM.  At the 5 April 2006 VA Compensation and Pension (C&P) examination, 8 months after separation, the CI reported bilateral ankle pain described as edema and always aching.  The pain was aggravated by “anything and everything, walking and standing” and was relieved by medication.  The CI reported wearing ankle braces but they caused him to shift position in bed due to the braces bothering him.  Physical examination showed a smooth and steady gait.  There was no tenderness or angulation and the ankle was stable.  The ROM was normal.  X-ray studies 5 April 2006 of the left ankle showed calcific changes in the region of the distal interosseous ligament.  The talus was well aligned within the ankle mortise.  There was no foreign body, but there was a 3 to 4 mm calcification at the base of the calcaneus.  X-ray studies of the right ankle on the same day showed no fracture, misalignment or foreign bodies.  The subtalar joint appeared unremarkable.  There was a 1 to 2 mm calcific change at the plantar surface of the calcaneus which the examiner noted was suggestive of an early plantar heel spur.

The PEB rated the left and right ankles combined at 0%, respectively, coded 5099-5003 (arthritis, degenerative [hypertrophic or osteoarthritis]), citing DJD with normal motion.  The VA rated the left and right heel spurs independently at 0% each, coded 5273 (os calcis or astragalus (talus), malunion of), citing the absence of moderate deformity of the os calcis or astragalus.  

The Board considered if the left and right ankle conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above. There was no limitation of motion of the ankle joints to support a rating under diagnostic code 5271 (limitation of motion) and the MEB and VA C&P examinations did not note the presence of painful joint motion.  The gait was normal and there was no evidence of functional loss that would impact functioning in the average civil occupation.  The Board considered alternative VASRD ankle and analogous codes, but all were less applicable and not advantageous to rating.  The Board members concluded that the preponderance of evidence showed that the left and right ankle conditions would not reasonably have caused the CI to be referred into the DES or be found unfit due to the ankle condition.

BOARD FINDINGS:  In the matter of the chronic right shoulder pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral ankle pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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 20150701, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170005124, XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

A copy of this decision has been provided to the counsel you listed on your application, XXXXXXXXXXXXXXXXXXXXX.

Sincerely,					      
						      					
Enclosure