RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00990
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20040903

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Infantryman, medically separated for “chronic pain, due to left Achilles tendonitis and bilateral degenerative joint disease” and “left pectoralis major muscle rupture and pain,” rated 10% and 0% respectively, with a combined disability rating of 10%.  

CI CONTENTION:  “See page 1 Form DA 3947 Sep 83.”  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 conditions at the time of separation.  The panel has neither the role nor the authority to compensate for progression or complications of service-connected conditions after separation.  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 - 20040714	VARD - 20041025	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Due to Left Achilles Tendonitis and Bilateral Degenerative Joint Disease	5099-5003	10%	Left Ankle Degenerative  Joint Disease with Achilles Tendonitis	5010-5271	10%	STR	
			Degenerative Joint Disease of the Right Ankle	5010-5271	10%		
Left Pectoralis Major Muscle Rupture and Pain	5302	0%	Rupture of the Left Pectoralis Major	530-5203	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Pain, Due to Left Achilles Tendonitis and Bilateral Degenerative Joint Disease.  The PEB combined the chronic left Achilles tendonitis and bilateral ankle degenerative joint disease (DJD) conditions under a single disability rating, coded analogously to 5003 and rated 10% with application of the US Army Physical Disability Agency pain policy and AR 635-40 B24.f.]  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 panel 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 panel’s initial charge in this case was therefore directed at determining if combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel 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 panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI presented for care for left Achilles pain with running and jumping in March 2002.  The CI reported a prior to service entry history of left Achilles rupture and repair 1998. He reported persistent tingling at the surgical site since surgery.  The CI reported increased pain and swelling with running and jumping.  Radiographic (X-ray) and magnetic resonance imaging (MRI) evaluations in 2003 demonstrated a left tendon ossicles which were surgically removed on 2 September 2003.  Radiographic evaluation of the left ankle showed degenerative joint disease.  Post-operatively the CI continued to report left ankle pain.

The 25 June 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of bilateral ankle pain since April 2001.  Physical examination showed left Achilles tenderness to palpation over the surgical scar.  There was no ligamentous instability.  The range of motion of both ankles was noted at 15 degrees of dorsiflexion (normal 20) and 40 degrees of plantar flexion (normal 45).  There was no VA Compensation & Pension examination in evidence proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left Achilles tendonitis and bilateral DJD (ankle) conditions 10%, analogously coded 5003 (arthritis, degenerative), citing slight frequent pain IAW the US Army Physical Disability Agency pain policy.  The VA rated the right ankle condition 10%, coded 5010-5271, (traumatic arthritis-ankle limitation of motion), based on the service treatment records, citing pain limited motion.  The VA additionally rated the left Achilles tendonitis and ankle DJD conditions 10%, coded 5010-5271, citing left tendonitis and pain limited motion.  

The panel first considered if the right and left ankle conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Although bilateral DJD was noted the preponderance of the treatment records and profile addressed left ankle pain.  Panel members agreed that the left ankle pain secondary to Achilles tendonitis and DJD was reasonably justified as separately unfitting.  In the matter of the right ankle DJD condition panel members agreed that it would not have caused the CI to be referred into the DES or to be found unfit.  

The panel then considered it rating recommendation for the left ankle pain condition.  Although the Achilles tendonitis and left ankle DJD were separate diagnoses, the functional impairment from both were a result of pain.  IAW VASRD 4.14 (avoidance of pyramiding) a single rating for both diagnoses is applicable in this case.  The limitation of ankle motion described by the MEB examination was slight and did not approach the “moderate” stipulation required for a 10% rating under diagnostic code 5271 for limitation of ankle motion.  However there was evidence of painful motion causing functional loss supporting the 10% rating (based on §4.59, §4.40 and §4.45).  fter 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 due to left Achilles tendonitis and bilateral DJD conditions because the overall rating recommendation would not result in a higher rating than that adjudicated by the PEB.  

Left Pectoralis Major Muscle Rupture and Pain.  According to the STR and the MEB NARSUM, the CI’s left pectoralis major muscle rupture and pain condition began in October 2002 after heavy lifting.  The left pectoralis rupture was repaired on 17 December 2002.  The CI underwent post-operative physical therapy.  An orthopedic noted dated 8 April 2003 noted a chronic left pectoralis major tear.  The CI reported slight pain and bulging.  

The 25 June 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of pain with push-ups and overhead left arm motions.  Physical examination showed left shoulder flexion and abduction of 70 degrees each (normal 180).  Pain was noted with external rotation and abduction.  There was a palpable partial pectoralis muscle retraction consistent with a persistent partial tear.  Motor strength was normal for the left upper extremity.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left pectoralis condition 0%, coded 5302 (muscle injury group II), citing “slight pain” IAW the US Army Physical Disability Agency pain policy.  The VA rated the left pectoralis pain condition 10%, coded 5303-5203, (muscle injury group II-clavicle impairment of), based on the STR, citing painful motion.  The panel noted the MEB NARSUM documented satisfactory evidence of painful motion secondary to the persistent tear in the clavicular insertion of the left pectoralis muscle to support a 10% rating IAW VASRD §4.59, §4.40 or §4.45.  There was no limitation of motion of the shoulder to support a rating under diagnostic code 5201 (arm, limitation of motion of).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left pectoralis pain condition, coded 5303-5203.  

BOARD FINDINGS:  In the matter of the chronic pain due to left Achilles tendonitis and bilateral DJD conditions condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the left pectoralis pain condition, the panel unanimously recommends a disability rating of 10%, coded 5303-5203 IAW VASRD §4.71a and §4.73.  There are 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	
Chronic Pain Due to Left Achilles Tendonitis and Bilateral DJD	5099-5003	10%	
Left Pectoralis Pain	5303-5203	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160921, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Rating Decision 

AR20170018525, 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