RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX.	CASE:  PD-2016-00245
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20080721

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Chemical Operations Specialist, medically separated for “right ankle pain” and “chronic low back pain” rated 10% and 0%, with a combined disability rating of 20%.  

CI CONTENTION:  “Review all conditions.”  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 - 20080317	VARD - 20150925	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Ankle Pain	5024-5271	10%	Right Lateral Collateral Ligament Sprain 	5271	10%	20150912	
			Painful Scar	7804	10%		
			Surgical Scar	7805	0%		
Chronic Low Back Pain	5299-5237	10%	Lumbosacral Sprain with Bilateral T10-S1 Facet Joint Syndrome, and Bilateral Sacroiliac Joint	5243	10%		
Headache Syndrome	Not Unfitting	Migraines	8100	30%		
Adjustment Disorder with Depressed Mood		No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Right Ankle Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent surgery for right ankle os trigonum (accessory bone behind the ankle – normal variant) excision and peroneal tendon debridement in January 2007.  Follow-up right ankle X-rays in April and November 2007 were normal, except for the absence of the os trigonum, without evidence of arthritis.  

The 12 December 2007 MEB NARSUM examination, 7 months prior to separation, noted complaints of right ankle pain and that the CI was unable to squat because of ankle pain.  There was marked tenderness to palpation (TTP) over the incisional scar and over the posterior aspect of the right ankle without swelling.  There was pain with resisted range of motion (ROM) and the CI wore a laced ankle support.  Ankle ROM measurements showed dorsiflexion 15 degrees (normal 20) and plantar flexion 45 degrees (normal 45).   

At the February 2008 family practice clinic and physical medicine & rehabilitation (PM&R) visits, both 5 months before separation, the physical examinations showed that the CI had a normal gait.  

At the 6 March 2008 MEB NARSUM PM&R addendum examination, 5 months before separation, performed for low back examination, physical examination showed a normal gait, with normal strength and reflexes, with full active ROM.  

There was no VA Compensation and Pension (C&P) examination in evidence proximate to separation.  The initial VA C&P examination was performed on 12 September 2015, more than 7 years after separation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right ankle condition 10%, coded 5024-5271 (tenosynovitis-ankle, limited motion), citing continued ankle pain and stiffness, rated 10% for moderate limitation of ankle motion.  The VA also rated the right ankle condition 10%, coded 5271 (ankle, limited motion), citing painful motion.  The VA additionally rated the painful scar at 10% under code 7804 (scars, unstable or painful) and rated the surgical scar at 0% under code 7805 (scars, other).  

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.  The VA C&P examination performed on 12 September 2015 was well beyond the panel’s normal 12 month window for consideration, and provides no probative information for the panel rating recommendation at separation.  

The PEB assigned a 10% rating and therefore the panel reviewed to see if a higher rating was supported for the right ankle condition with any applicable VASRD code.  There was no limitation of dorsiflexion or plantar flexion that supported a higher rating for “marked” limitation of ankle motion (5271).  There was no evidence of tarsal malunion or nonunion (5283) for consideration of rating under this code.  The panel consensus was that the right ankle condition could not be characterized as “moderately severe” based on the evidence of no swelling, near normal ROM, and a normal gait for higher rating for other foot injury (5284).  The panel considered alternative VASRD ankle/foot and analogous codes, but all were less applicable and not advantageous to rating.  The panel does not recommend disability rating for scars unless their presence imposes separate functional limitation that renders the CI unfit.  The right ankle scar did not provide functional limitations other than ankle pain or limitation of motion and any contribution from pain and/or ROM limitation was subsumed in the VASRD §4.71a rating recommendation for the ankle above.  Thus the panel concluded that the scar condition could not be recommended for additional disability rating.  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 ankle condition.  

Chronic Low Back Pain.  According to the STR and the MEB PM&R addendum, the CI’s back condition began in 2005 without any specific injury or trauma and gradually got worse with time.  In April 2007, lumbosacral and thoracic spine X-rays were normal.  

During the 17 October 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 9 months prior to separation, the CI reported constant low and middle back pain.  The physical examination showed TTP of the lumbar musculature bilaterally  

At the time of the MEB NARSUM examination on 10 December 2007, 7 months prior to separation, the physical examination showed no focal neurologic deficits, no muscle atrophy, straight leg raise was negative for radiculopathy, and Faber’s sign (hip pain) was negative.  There was no tenderness, muscle spasm, abnormal spinal contour or curvature noted.  The lower extremities were neurovascularly intact and reflexes were normal.  The examiner noted that the “lumbago” met retention standards.  

Lumbar computed tomography (CT) performed on 12 December 2007 showed mild degenerative changes of the lumbar spine, without disc herniation, spinal stenosis, or nerve root compression.  

The 6 February 2008 Informal PEB adjudicated the lumbago condition as not unfitting and the CI appealed the findings.  At a 12 February 2008 family practice visit, 6 months before separation (for referral to PM&R for MEB evaluation), the CI reported low back pain without radiation to the lower extremities or neurological problems.  The physical examination showed a normal gait and stance.  The thoracolumbar (TL) spine was normal in appearance.  There was tenderness to palpation, without muscle spasms.  There was full TL ROM, with painful motion noted.  Lower extremity strength, sensation, and reflexes were normal and straight leg raise testing to elicit nerve tension signs was negative.  At the 22 February 2008 physical medicine and rehab clinic appointment, 6 months before separation, the CI reported lower thoracic and middle lumbar back pain.  The physical examination showed a normal gait and stance.  There was TTP and the exam note documented both muscle spasm and no muscle spasm of the low back.  The examiner noted a step deformity of the lumbar spine.  Pain was not elicited by motion, and maneuvers to elicit radicular symptoms were negative.  Lower extremity strength, sensation, and reflexes were normal.  The PM&R examiner did not address ROM measurement.  The diagnoses were spinal degenerative joint disease and myofascial pain and a MEB was recommended.  

The 6 March 2008 permanent profile listed right ankle os trigonum excision and low back pain.  

The 6 March 2008 MEB PM&R addendum examination, 5 months prior to separation, noted complaints of low back pain, with occasional radiation to the back of the right knee.  The examiner noted the CI had been treated with physical therapy, anti-inflammatory medications, muscle relaxants, and opioid pain medications without relief.  The physical examination showed a normal gait.  There was TTP and tests to identify facet joint pain were positive (pain with extension) and worse on the right than left.  Thoracolumbar ROM after three repetitions was flexion 45 degrees (normal 90) and a combined ROM of 165 degrees (normal 240) and all ROM was limited by pain.  Lower extremity strength, sensation, and reflexes were normal.  There was no evidence of further treatment of the CI’s back condition after the MEB NARSUM addendum in March 2008.  

There was no VA Compensation and Pension (C&P) examination in evidence proximate to separation.  The initial VA C&P examination was performed on 12 September 2015, more than 7 years after separation.  The examination indicated the CI had not had any surgery of the back.  Thoracolumbar ROM was flexion 80 degrees and a combined ROM 230 degrees, with painful motion.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, analogously coded 5237 (lumbosacral strain), citing examination shows consistent tenderness and variable limitation of motion that is unreliable for rating.  The VA also rated the back condition 10% coded 5243 (intervertebral disc syndrome), based on the VA C&P examination 7 years after separation, citing limitation of forward flexion, no incapacitating episode during the past 12 months, and painful motion.  

As noted above, the VA examination performed on 12 September 2015 was well beyond the panel’s normal 12 month window for consideration, and provides no probative information for the panel’s rating recommendation at separation.  

The panel noted that the limitation of thoracolumbar motion, flexion of 45 degrees, recorded in the 3 March 2008 MEB NARSUM addendum examination met the threshold for a 20% rating.  However, this was the only clinical evidence in record that supported a 20% rating and it occurred during the appeal of the IPEB finding that the LBP was not unfitting.  The combined ROM of 165 at the same examination supports a 10% rating and the imaging evidence did not show evidence of pathology consistent with limitation of lumbar flexion to 45 degrees, nor were there other findings on PM&R addendum examination to support such limited flexion such as muscle spasm or positive SLR.  The 12 February 2008 family practice examination, which showed full TL ROM less than a month earlier, also supported a 10% rating.  The CI may have had pain at the time of the MEB PM&R addendum that caused greater limitation of motion, but there was no evidence in record that the CI’s back ROM was permanently or frequently limited to 60 degrees or less.  Therefore, based on all evidence, Board consensus was that the disability related to the back condition at separation was more closely approximated by the 10% rating criteria than the 20% rating criteria IAW VARSD §4.7 (higher of two ratings).  

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 low back pain condition.  

Contended PEB Conditions:  Headache Syndrome and Adjustment Disorder with Depressed Mood.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel 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 right ankle and chronic low back pain conditions and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudications.  In the matter of the contended headache syndrome and adjustment disorder with depressed mood conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  There are no other conditions within the panel’s scope of review for consideration. 

The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150602, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	

AR20170015143 , XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

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,					      
						      					
Enclosure