RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02118
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20071024

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Human Resources Specialist, medically separated for “lumbosacral strain” and “chronic pain of the left ankle, right wrist secondary to DeQuervain’s tendonitis and bilateral knee pain,” rated 10% and 0%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI contended his wrist, back and ankle.  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination 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(s) at the time of separation.  The panel 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 panel 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 - 20070711	VARD - 20071205	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbosacral Strain	5237	10%	Strain, Thoracolumbar Spine	5237	20%	20070821	
Chronic Pain of the Left Ankle, Right Wrist…and Bilateral Knee Pain	5099-5003	10%	Post Traumatic Changes of the Left Lateral Malleous, Left Ankle	5010	0%		
			Strain, Right Knee	5299-5014	0%		
			Strain, Left Knee	5299-5014	0%		
			Right Wrist DeQuervain’s Tenosynovitis (Dominant)	5024	0%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

Lumbosacral Strain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in April 2003 after being involved in a motor vehicle accident while 2 months pregnant.  She developed low back pain and coccygeal pain which began after an epidural for the birth of her daughter in April 2006.  Back spasm and pain recurred during a subsequent pregnancy, requiring a back brace.  She noted she had symptoms for many years with increased activity, especially physical training.  She reported she has had pain and spasm lasting up to one week and then symptom-free for about 4 weeks.  Imaging May 2006 was normal except for a small left central focal disc protrusion at L5-S1 which did not affect either S1 nerve root.  The MEB forwarded chronic lumbar pain/spasm for PEB adjudication.  

The MEB NARSUM examination on 8 June 2007, 5 months prior to separation, noted complaints of Pain was worse during sit-ups and crunches, at night, and during daily activities and physical therapy.  She had no sensory or motor problems in her lower extremities.  Physical examination conducted by physical therapy (PT), dated 1 March 2007, revealed no bowel or bladder dysfunction, no muscle wasting and muscle strength 5/5 in lower extremities.  .  Range of motion (ROM) showed severe pain with flexion at the waist with spasm and exquisite tenderness mid-thoracic and lumbar area.  There was moderate pain with rotation and side-to-side lean.  She had negative straight leg raise from the seated and supine position.  Motor strength in the lower extremities was normal.  

At the 27 March 2007 orthopedics examination, the CI revealed pain at night unless she padded her back with pillows and put pillows between her legs.  On examination, there was marked tenderness over the lumbar spine and tenderness over the low back.  She had low back pressure sensations with pressure without distraction changes to her pain.  She had no discomfort with rotation or full lateral bending to both left and right.  She had marked discomfort with extension.  She could forward flex with her hands to about the level of the mid tibia.  She had negative straight leg raise from both seated and supine positions with normal motor strength and reflexes.  

At the 21 August 2007 VA Compensation and Pension (C&P) evaluation, performed 2 months before separation, the CI reported constant crushing pain in the mid to lower back for 4 years.  It radiates to the buttocks.  The pain level is 10 and can occur with physical activity and stress.  Rest and medications relieve the pain.  She reports no incapacitation and no limitation.  Physical examination showed no evidence of radiating pain, muscle spasm or tenderness.  There was positive straight leg raising bilaterally.  ROM showed flexion of 40/90 degrees and extension of 20/30 degrees with motion limited by pain.  Pain had the major functional impact and spinal function was additionally limited by 0 degrees after repetitive use.  The spine had normal curvature and gait was within normal limits.  CI reported constant pain in the mid to lower back that travels to buttocks.  Pain was at 10/10 and could be elicited by physical activity and stress, relieved by rest and medication.  At the time of pain, she could function with medication.  It did not cause incapacitation or limitation.  She required a brace to walk for bilateral knee support.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the lumbosacral strain condition 10%, coded 5237 (lumbosacral strain), citing pain limited motion.  The VA rated the thoracolumbar strain condition 20% coded 5237, based on the C&P examination 2 months before separation, citing limitation of forward flexion.  The panel agreed that a 10% rating, but no higher, was justified for motion limited by pain reported on the VA examination.  The panel agreed that the findings were isolated and inconsistent with findings from previous examinations and pathology was minimal.  The CI reported no incapacitation or limitation.  The documentation suggests the ROM was documented according to the level of occurrence of pain and not according to the level of movement.  The panel agreed that findings were not consistent with preponderance of evidence, therefore the panel attributed less probative value to the VA examination.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the lumbosacral strain condition.  

Chronic Pain of the Left Ankle, Right Wrist and Bilateral Knee Pain.  The MEB forwarded chronic left ankle pain and swelling, chronic right wrist pain and bilateral knee pain for PEB adjudication.  The PEB combined chronic left ankle pain and swelling, chronic right wrist pain and bilateral knee pain potentially separate conditions under a single disability rating, coded analogously to 5003.  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  IAW DoDI 6040.44 the panel must follow suit if the PEB combined adjudication is not compliant with the latter stipulation, provided that each ‘unbundled’ condition can be reasonably justified as separately unfitting in order to remain eligible for rating.  If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB.  The panel’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  To that end, the evidence for bilateral knee, right ankle and chronic right wrist pain conditions are presented separately; with attendant recommendations regarding separate unfitness, and separate rating if indicated.

Chronic Pain of the Left Ankle.  The ankle condition began in April 2003 during the same motor vehicle accident where the CI suffered her back injury.  She was 2 months pregnant and developed left medial ankle pain and was placed on 72 hours of quarters.  Bone scan showed moderate posttraumatic changes of the left lateral malleolus.  She received conservative treatment for pain and swelling with no improvement.  She was given an ankle brace.  She was placed on profile during pregnancy in October 2004.  Left ankle pain 5/10 and swelling persisted.  X-rays of the left ankle revealed some soft tissue swelling around the left ankle.  She reported she wore soft shoes because she could not tolerate an Army boot and took over the counter medication for pain and swelling as needed.  She was able to perform her office job but was unable to perform in a field environment due to her inability to tolerate boots, road march or run.  Physical examination of the left ankle conducted by physical therapy (PT), dated 1 March 2007, showed no swelling, but exquisite tenderness medially, full ROM and pain with inversion.  Heel raise increased medial ankle pain significantly but joint was stable.  

The orthopedics examination on 27 March 2007, showed a slight swelling on the medial aspect when compared to the right ankle. She was very tender over the medial malleolus of the left ankle and there was pain with any movement.  There was no instability.  At the 21 August 2007 VA Compensation and Pension (C&P) evaluation, 2 months prior to separation, the CI reported constant, localized pain for 4 years.  Pain was 9/10 and elicited by physical activity and stress.  Rest and medication relieved the pain.  At the time of pain she could function with over-the-counter (OTC) medication.  The pain was not incapacitating or limiting.  Physical examination showed no deformities, swelling, effusion, weakness, tenderness, heat, subluxation or guarding.  ROM was dorsiflexion 20 degrees (normal) and plantar flexion 45 degrees (normal.)  There was no painful motion.  There was no evidence of other limiting factors.  The VA examination, the examination most proximate to separation, documented the presence of a full ROM and the absence of painful motion.  The panel agreed that there was no evidence of painful motion to warrant a 10% rating IAW VASRD §4.59 (painful motion), ankylosis (5270) or limited range of motion (5271.)  Therefore the panel concluded there was not sufficient evidence to support a rating higher than the 0%.  

Chronic Pain of the Right Wrist.  The CI’s right wrist (dominant) condition began in November 2004 after experiencing pain with use.  She developed bilateral de Quervain’s tenosynovitis but left wrist symptoms resolved by March 2005.  The right wrist pain persisted despite treatment.  She was referred to orthopedics who treated her in June 2005 with a steroid injection and placed her in a cast for three week.  The wrist was initially pain free but pain returned to 7/10 daily and persisted with use of a splint to the present.  X-ray was within normal limits.  Physical examination of the right wrist conducted by PT, dated 1 March 2007, showed a full ROM, no swelling, grip strength 5/5, and severe pain with palpation.  

At the 27 March 2007 orthopedics consultation, CI reported pain with most activities involving the right hand and wrist, including typing and lifting anything more than 15 lbs.  She reported no numbness, tingling or weakness except as related to pain.  Examination showed a full ROM with marked tenderness over the first dorsum compartment of the wrist and a positive Finklestein’s (flexion of the fingers overlying the thumb and pain with flexion of the wrist.)  She had pain with resisted extension of the thumb.  

At the C&P evaluation the CI reported bilateral wrist pain for 5 years, occurring 5 times per week and each time lasting for 2 hours.  She reported no limitation due to this condition; no painful motion, no weakness, and no prosthetic implants.  She reported she was able to function with medication at the time of the pain.  Examination revealed no swelling, weakness, tenderness, redness, heat, subluxation or guarding.  The ROM showed dorsiflexion 70 degrees (normal); palmar flexion 80 degrees (normal), radial deviation 20 degrees and ulnar deviation 45 degrees.  The panel agreed there was no evidence of limited motion (5206, 5207), painful motion (4.59), ankylosis (5214 or 5215) or other impairment involving the wrist  The panel agreed there was no VASRD §4.71a route to a rating higher than the 0% under any applicable code.  

Bilateral Knee Pain.  According to STR and the MEB NARSUM, the CI’s bilateral knee condition began in 2001 while running and ruck marching.  She was treated with physical therapy and had deep heat treatment and pain improved.  Pain resolved in March 2002 with conservative treatment.  Pain recurred during pregnancy in August 2004 but resolved 3 months post-partum.  Pain recurred during the second pregnancy in November 2005.  X-rays of the knees showed no significant abnormalities.  

The 8 June 2007 MEB NARSUM examination, 5 months prior to separation, noted complaints of bilateral medial joint pain 8/10.  OTC medication reduced the pain temporarily but it increased markedly with high impact activity despite the OTC medication.  Physical examination conducted by PT, showed no swelling and no crepitus with full ROM, no instability but pain with pressure and with deep knee bends.  

At 27 March 2007 orthopedics consultation, CI reported no swelling, locking or catching of either knee.  She denied numbness, tingling or weakness in her lower extremities.  Examination showed minimal crepitus, no effusion, and tenderness over the medial aspect of the knee.  She had bilateral ROM to 150 degrees, and no instability.  There was some diffuse discomfort about both knees with McMurray testing.  At the C&P evaluation, performed 2 months before separation, there was no evidence of pathology in either knee.  She reported no limitation, painful motion or weakness due to this condition.  ROM bilaterally was flexion 140 degrees (normal) and extension 0 degrees (normal) with no evidence of instability, guarding, weakness, tenderness, subluxation or abnormality of the meniscus.  

There was no evidence of painful motion with functional loss to support a 10% rating for either knee.  Neither knee had ligamentous instability or laxity (5257), no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  There was no fracture, non-union, or mal union of the femur or tibia of either leg to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  The panel agreed there was no VASRD §4.71a route to a rating higher than the 0% under any applicable code.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic pain of the left ankle, right wrist and bilateral knee pain condition 10%, coded 5099-5003 (analogous to degenerative arthritis), citing the US Army Physical Disability Agency (USAPDA) pain policy rating of slight and constant.  

The VA separated rated each condition based on the C&P examination 2 months before separation.  The posttraumatic changes of the left lateral malleolus (ankle) condition was rated 0%, coded 5010 (arthritis due to trauma and substantiated by X-ray findings), citing no objective evidence of painful or limited motion of the ankle.  The left and right knee strains were rated 0% and 0% each, coded 5299-5014 (analogous to osteomalacia), citing no objective evidence of painful or limited motion of either knee.  The right wrist DeQuervain’s tenosynovitis was rated 0%, coded 5024 (tenosynovitis), citing no objective evidence of painful or limited motion of the wrist.

The left ankle, right wrist and bilateral knee pain, condition was determined to fail retention standards and were profiled.  Each were reasonably determined to be unfit for service.  However, none individually met a disability rating higher than 0%.  Therefore, the panel concluded a combined individual rating would not have resulted in a higher rating than the 10% adjudicated by the PEB.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic pain of the left ankle, right wrist and bilateral knee pain condition.  

BOARD FINDINGS:  In the matter of the lumbosacral strain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the chronic pain of the left ankle, right wrist and bilateral knee condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There were no other conditions within the panel’s scope of review for consideration.  The panel, 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 20150729, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170011090, XXXXXXXXXXXXXXXXXX

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Dear XXXXXXXXXXXXXXXXXX

	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.

Sincerely,