RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00347
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20021017

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Power Generator Equipment Repairer, medically separated for “osteoporosis of left hip, lower back and hips” with a disability rating of 10%.  

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 - 20020722	VARD - 20040310	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Osteoporosis of Left Wrist, Lower Back, Hips	5014	10%	Osteoporosis, left Wrist	5014-5215	10%	20030911	
			Osteoporosis, Lumbar Spine	5014-5242	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Osteoporosis, Left Wrist; Lower Back; Hips.  The PEB combined three conditions under a single disability rating, coded analogously to 5014.  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 if the PEB combined adjudication is not compliant with the 5003 combined rating criteria, each condition subsumed under the single disability rating must be reasonably justified as separately unfitting in order to remain eligible for rating.  The panel’s initial charge in this case was directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  The evidence for each condition is presented along with separately unfitting recommendations.  If panel members determine by performance based fitness criteria that the condition is reasonable justified as separately unfitting and is separately ratable; IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended.  IAW DoDI 6040.44 the combined rating for the conditions determined to be separately unfitting and ratable may not be lower than the single disability rating from the PEB.  

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the osteoporosis was first diagnosed in May 2001, using an average of the bone densities of three areas (right and left hips, and the spine).  

Left Wrist.  At a May 2001 primary care visit, the left hand dominant CI reported left wrist pain.  Physical examination showed tenderness over the lateral wrist without swelling or effusion, full range of motion (ROM), and pain with flexion.  Radiographic evaluations (X-rays and bone scan) in May 2001 documented osteoporosis and no evidence of fracture, arthritic or inflammatory changes.  Five days later, he was diagnosed with wrist tendonitis.  

Low Back Pain.  At an August 2001 primary care visit, the CI reported upper and lower back pain.  The physical examination showed muscle tenderness and “fullness” along the upper and lower thoracic spine.  At an October 2001 primary care visit, the physical examination showed tenderness over the lumbar spine and paraspinous muscles.  ROM was described as both “decreased” and with “flexion to 90 degrees” (normal 90).  

Hips.  At a February 2002 primary care visit, the CI reported left hip pain.  ROM was “normal,” with tenderness noted at the lateral hip.  He was diagnosed with trochanteric bursitis.  

The 6 May 2002 commander’s statement addressed the osteoporosis as being his only limitation.  A profile dated 21 May 2002 addressed the limitations for the osteoporosis, chronic back pain, and left wrist pain conditions, which included allowing an alternate aerobic event, and prohibiting sit-ups, push-ups, jumping, bending and twisting.  At the March 2002 MEB examination (recorded on SF Forms 93 and 88), 6 months prior to separation, the CI reported recurrent lower back and upper thoracic pain and did not address the wrist and hips.  The physical examination of the musculoskeletal system was checked “normal.”  The 14 March 2002 MEB NARSUM examination noted complaints of recurrent low back and upper thoracic pain, and “bone deficiency.”  The CI also reported inability to turn wrenches due to wrist pain.  The physical examination showed full ROM of the upper and lower extremities, with the ability to “forward bend and toe touch,” and “extend… with slight discomfort,” and equal and symmetric strength.   

At the 11 September 2003 VA Compensation and Pension (C&P) evaluation, 12 months after separation, the CI reported that with overuse of the left wrist, he developed wrist pain and lateral swelling causing difficulty tightening the hand.  He reported pain and spasm of the lower back that would radiate to the upper spine, and across the front groin area.  When bending, the pain would radiate down the right lower extremity.  There was no comment regarding the hips.  Physical examination of the left wrist showed no swelling or tenderness.  Dorsiflexion was to 70 degrees (normal), palmar flexion was to 50 degrees (normal 80), with pain.  There was inability to fully flex the thumb and index finger.  Ulnar and radial deviation were normal.  There were no decrements after repetition.  Physical examination of the back showed a normal gait and forward flexion to 70 degrees (normal 90) with pain.  Total combined ROM was 220 degrees (normal 240).  There was no recorded examination of the hips.  

The panel directed attention to the rating recommendation based on the above evidence.  The PEB rated 10% for the osteoporosis condition coded 5014 (osteomalacia), citing confirmation by endocrinology.  The VA rated 10% each for osteoporosis of the left wrist, analogously coded 5014-5215 (wrist limitation of motion) and osteoporosis of the lumbar spine, analogously coded 5014-5242 (degenerative arthritis of the spine) based on the C&P examination 12 months after separation, citing limited palmar flexion and inability to make a fist, along with slightly limited ROM of the spine with pain.  
The panel first considered if the left wrist pain, having been de-coupled from the combined PEB adjudication for “osteoporosis of left wrist, lower back and hips” remained independently unfitting as established above.  In this case, the left wrist condition was forwarded by the MEB examiner and considered to fail retention standards by the PEB.  The commander’s statement noted profile limitations that could be specifically attributed to the wrist (push up restrictions) and that the CI could not perform his MOS.  The NARSUM examiner specifically noted the CI’s inability to turn wrenches due to wrist pain.  The profile included pull-up, chin-up, and push-up limitations that could not be ascribed to the other musculoskeletal complaints.  All members agreed that the left wrist condition, as an isolated condition, would have rendered the CI incapable of continued service for his MOS and accordingly merits a separate disability rating.  

The panel next considered the evidence for rating of the wrist condition.  There was both pre and post-separation evidence of wrist pain on flexion that supported a 10% rating for the left wrist, analogously coded 5013-5024-5215 (osteoporosis with joint manifestations; tenosynovitis; wrist limitation of motion).  There was no evidence of ankylosis (5214) for a higher rating.  

The panel next considered if the back or hip pain, having been de-coupled from the combined PEB adjudication for “osteoporosis, lower back and hips” remained independently unfitting as established above.  In this case, the back condition was forwarded by the MEB examiner and considered to fail retention standards by the PEB under the osteoporosis condition.  The commander’s statement noted profile restrictions that limited weight lifting, jumping, and negotiating an obstacle course.  The NARSUM examiner specifically noted the CI’s inability to stand for greater than 15 minutes and bend to repair equipment and machinery due to back pain.  The profile additionally included sit up, jumping, flutter kick, bending and twisting limitations that could not be ascribed to the other musculoskeletal complaints.  Members agreed that the lower back condition, as an isolated condition, could have rendered the CI incapable of continued service for his MOS and accordingly could warrant a separate Service disability rating.  The October 2001 primary care visit showed normal ROM while the March 2002 MEB NARSUM examination showed normal ROM and pain with extension; and the September 2003 C&P examination showed painful and limited motion to 70 degrees.  All members agreed that this would support a 10% rating for painful and limited motion of the spine.  

The hip condition, however, was not profiled, not implicated in the commander’s statement or the NARSUM, and was not forwarded as a separate condition by the MEB.  The February 2002 primary care visit documented normal ROM for the hips with no other physical examination findings.  The panel concluded that the evidence did not provide sufficient grounds for recommending separate disability ratings for the back or hips in this case, and would not be of benefit to the CI.  Members agreed that a single rating of 10% for the osteoporosis of the spine and hips, analogously coded 5013-5003, was a good analogy to both the pathology and disability.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% rating for the left wrist condition, analogously coded 5013-5024-5215 (osteoporosis with joint manifestations; tenosynovitis; wrist limitation of motion); and a separate disability rating of 10% for the osteoporosis of the back and hips condition, coded 5013-5003.   

BOARD FINDINGS:  In the matter of the left wrist tenosynovitis condition, the panel unanimously recommends a disability rating of 10%, coded 5013-5024-5215 IAW VASRD §4.71a.  In the matter of the osteoporosis, lower back and hips condition and IAW VASRD §4.71a, the panel unanimously recommends a disability rating of 10%, coded 5013-5003 IAW VASRD §4.71a.  There were no other conditions within the panel’s scope of review for consideration.  

The panel recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Wrist Tenosynovitis	5013-5024-5215	10%	
Osteoporosis, Lower Back and Hips…	5013-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160601, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170015415, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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 also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure