RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01460
BRANCH OF SERVICE:  army	SEPARATION DATE:  20071215

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Radiology Specialist, medically separated for “polyarthralgia involving the feet, knees, left hip, right wrist, both elbows, shoulders and low back” with a disability rating of 10%.

CI CONTENTION:  A true rating was not rendered for all the issues suffered, or the severity of problems, which was “more than polyarthralgia.”  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 MEB, but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.

RATING COMPARISON:

SERVICE PEB - 20070926	VARD - 20080314	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Polyarthralgia Involving the Feet, Knees, Left Hip, Right Wrist, Both Elbows, Shoulders, and Low Back	5099-5003	10%	Bilateral Pes Planus ... Plantar Fasciitis ... Degenerative Arthritis	5020-5276	30%	20071217	
			Patellofemoral Pain Syndrome, Left Knee 	5260	10%		
			Patellofemoral Pain Syndrome, Right Knee	5260	10%		
			Polyarthralgia Left Hip 	5099-5010	NSC		
			Polyarthralgia Right Wrist 	5099-5010	NSC		
			Polyarthralgia Bilateral Elbows 	5099-5010	NSC		
			Polyarthralgia Bilateral Shoulders 	5099-5010	NSC		
			Lumbar Strain	5242	0%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Polyarthralgia Involving The Feet, Knees, Left Hip, Right Wrist, Both Elbows, Shoulders, and Low Back.  The PEB combined the multiple conditions under a single disability rating, coded 5099-5003 (analogous to degenerative arthritis) and rated 10% overall for “two or more major joints, without loss of motion or objective findings on physical examination.”  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.  The evidence for the multiple conditions is sub-divided below as clinically practical, followed by a consolidated fitness analysis with attendant separate coding and rating recommendations if indicated. 

The following facts are relevant with regard to assessing separate unfitness for all of the conditions under consideration.  The MEB’s only DA Form 3947 submission was “polyarthralgia” failing retention standards with no specificity regarding separate conditions.  The permanent U3L3 profile likewise specified “multiple joint pains” but not outline separate conditions or limitations uniquely attributable to any single condition.  The commander’s performance statement did not mention separate conditions and the only functional limitations referenced were prolonged standing (15 minute tolerance) and inability to lift patients.

Bilateral Foot Evidence.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI suffered an atraumatic onset of bilateral foot pain early in training, at least 4 years before separation.  There was no evidence for an acute exacerbation over the clinical course, and based on X-ray evidence, osteoarthritis was diagnosed and treated with orthotics (no surgical indications).  Podiatry notes documented pes planus with excessive pronation (normal arches recorded at service entry), and painful motion with no indication of decreased ankle or foot range of motion (ROM).  The feet were intermittently profiled throughout service, but there was ample STR documentation of a normal gait with no contrary evidence, and no entries indicating any significant ROM limitation, callosities or additional VASRD-ratable findings.  

At a 12 June 2007 rheumatology consult for the MEB, 6 months before separation, the examiner recorded a “normal active gait,” corroborated pes planus, and noted only swelling of the dorsal midfoot without tenderness or inflammation.  Bilateral ankle ROM was characterized as “good” without mention of painful motion.  These same findings had also been documented in two earlier rheumatology entries.  

The 6 August 2007 NARSUM, 4 months prior to separation, did not address separate severity or specific functional limitations for the feet versus the CI’s other joint and spine pain.  The overall pain was “self-rated at 5 to 6/10, increasing with activity” and assessed by the examiner as “constant and slight.”  She was prescribed an anti-inflammatory medication as the sole treatment for all conditions in addition to orthotics for the foot condition.  The examiner opined that she was capable of performing her routine duties, but not able to satisfy many general soldiering physical requirements.  The physical examination recorded plantar tenderness, no deformities or callosities, and normal ankle and subtalar joint ROM without note of painful motion.

The 17 December 2007 VA Compensation and Pension (C&P) examination, 2 days after separation, documented “daily” nonspecific foot pain with continued use of orthotics and an anti-inflammatory.  The only noted functional limitations were prolonged standing (15 minutes) and a 2-mile walking tolerance.  This was identical for all lower extremity and lumbar conditions, and it was impossible to differentiate functional limitations attributable to any single condition from the overall limitations.  The physical examination recorded a normal gait and pes planus (only with weight bearing) with callosities.  There was mild tenderness over the posterior arch, mild pronation, and slight inward bowing of the Achilles tendon, but no pain with manipulation, no malalignment, and normal ankle ROM without note of painful motion.  

The VA rated the bilateral foot condition 30%, coded 5020-5276 (synovitis rated as acquired pes planus), based on the C&P examination.  The panel noted that the 30% rating criteria for code 5276 requires “marked deformity” and “pain on manipulation” in addition to swelling and callosities, and the bilateral 10% rating also specifies pain on manipulation.  The latter was refuted by the C&P examiner and not supported by any of the service evidence, and the only deformity was “mild” pronation.

Bilateral Knee Evidence.  The CI suffered an atraumatic onset of bilateral knee pain soon after she developed foot pain.  The knees were temporarily profiled in 2003 and not permanently profiled until the MEB.  There was no documentation of an acute exacerbation over the clinical course, and knee X-rays were normal.  There was ample STR evidence of grossly normal bilateral knee ROM with no mention of painful motion, and no entries recorded any ROM limitation, persistent effusion and locking, instability, or other VASRD-ratable findings.

The rheumatology consult documented “normal” bilateral knee ROM with no stiffness, painful motion, or other ratable findings.  These same findings had also been documented in two earlier rheumatology entries.  The NARSUM evidence for severity and functional limitations was encompassed with all other conditions.  There was no note of subjective instability or locking.  The physical examination recorded bilateral patellofemoral tenderness without note of effusion, instability, or locking, and “full” bilateral ROM without mention of painful motion.

The C&P examination documented the CI’s complaint of “daily...severe” pain and functional limitations included with other conditions.  The physical examination recorded the absence of tenderness, effusion, instability, locking, or any positive findings.  Measured ROM was flexion to 130 degrees (normal 140) on the right, and 140 degrees on the left, with bilateral extension of 0 degrees (normal) and no specified painful motion for either knee.

The VA, conferred separate 10% ratings for each knee under code 5260 (limitation of flexion) citing “limited motion of a major joint” for the right and “pain on use” for the left, based on the C&P examination.  The panel noted that, in the absence of painful motion, the minimum 10% rating under code 5260 requires limitation to 45 degrees.

Left Hip Evidence.  The CI suffered an atraumatic onset of left hip pain concurrently with or soon after the knee pain.  There was no associated profile prior to the MEB, and no evidence for an acute exacerbation over the clinical course; hip X-rays were normal.  There were several STR entries that documented painful motion, and later chiropractic notes reflected non-specific ROM limitation that improved with treatment.  There were no STR entries that indicated significantly limited ROM or documented any other VASRD-ratable findings.

The rheumatology consult documented “discomfort around the left lateral hip.. and normal [ROM]” without specifying painful motion (also corroborated by earlier rheumatology notes).  The NARSUM evidence for severity and functional limitations was encompassed with all conditions, and the examiner noted that “hip motion is symmetric bilaterally; there being pain at extremes of motion on the left” with no further elaboration.  

The C&P examination documented the CI’s complaint of “daily...severe” pain and functional limitations encompassed with other conditions.  The physical examination recorded the absence of tenderness or other positive findings.  Measured ROM was flexion to 120 degrees (normal 125), extension to 30 degrees (normal 20), external rotation to 60 degrees (normal 45), abduction to 50 degrees (normal 45), and adduction to 30 degrees (normal 45), specifying painful motion in most planes, but no ROM degradation with repetition.  The VA subsumed the left hip as an element of a general “polyarthralgia” condition that was not service connected, stating, “Pain alone without a diagnosis or identifiable underlying condition does not in and of itself constitute a disability for which service connection may be granted.”

Right Wrist, Bilateral Elbow, and Bilateral Shoulder Evidence.  The CI suffered an atraumatic onset of these multiple joint pains concurrently with the left hip pain.  There was a temporary profile for the right wrist in 2005, but otherwise no associated profiles in evidence prior to the MEB.  There was no record of acute exacerbations of any of these joints over the clinical course, and all X-rays were normal.  There were no STR entries that documented any ROM limitation, painful motion, or other VASRD-ratable findings.

The rheumatology consult documented normal ROM of the wrists, elbows, and shoulders, specifying the absence of painful motion.  The consultant opined that criteria were not met for any rheumatologic disorder based on applicable laboratory screening.  The NARSUM evidence for severity and functional limitations was encompassed with all conditions, and was of limited applicability to upper extremity conditions.  The physical examination recorded normal ROM for all joints, noting “some pain during the range” for the shoulders, with no painful motion.  

The C&P examination documented the CI’s complaint of “daily…severe” pain and functional limitations encompassed with other conditions, and also of limited applicability to upper extremity conditions.  The physical examination recorded the absence of tenderness or other positive findings, and normal ROM of all the above joints specifying the absence of painful motion.  All were subsumed with the general polyarthralgia condition that was not service connected for VA rating.

Lumbar Evidence.  The CI first complained of low back pain associated with patient lifting (no discrete injury) in 2004 during her first duty assignment.  There was no evidence of radiculopathy, and X-rays were normal with no surgical indications.  There was no associated profile prior to the MEB, and there was no evidence for an acute exacerbation over the clinical course.  The STR documented grossly normal to modestly limited ROM, with mention of painful motion by a few examiners and of abnormal spinal contour by one.  Later chiropractic notes documented improving ROM with no painful motion.  

The rheumatology consult documented “good” ROM with no painful motion or tenderness, normal spinal contour and gait, and normal neurological findings.  The NARSUM evidence for severity and functional limitations was encompassed with all conditions.  The physical examination made no note of tenderness, spasm, or abnormal contour; but, recorded ROM measurements of flexion to 45 degrees (normal 90) with a combined ROM of 185 degrees (normal 240), specifying painful motion.  

The C&P examination documented “daily low back pain without radiation” characterized by the CI as “severe,” and functional limitations included with other conditions.  The physical examination recorded a normal spinal contour and gait, the absence of tenderness or spasm, and detailed normal neurological findings.  Goniometric ROM measurements were normal and without painful motion in every plane, and ROM was not degraded with repetition.  The VA rated the lumbar condition 0%, coded 5242 for degenerative arthritis of the spine (despite normal X-rays), citing the lack of any minimum rating criterion from the C&P evidence.

Fitness and Rating Analysis and Conclusions.  With regard to fitness considerations, the panel noted the lack of any condition-specific functional evidence that would permit an assessment of the impact of individual conditions on performance without a considerable degree of speculation.  Also in regard to fitness considerations, the panel noted that each joint and spine condition under consideration was subject to DoDI 1332.38 (E3.P3.3.3 - Adequate Performance until Referral).  This stipulates, “If the evidence establishes that the Service member adequately performed his or her duties until the time the Service member was referred for physical evaluation, the member may be considered fit for duty even though medical evidence indicates questionable physical ability to continue to perform duty.”  With regard to potential ratable severity or separate rating recommendations if indicated, panel members agreed that determinative probative value should reside with the C&P examination.  It was the most comprehensive examination in evidence, was more directed at VASRD rating criteria, and was precisely aligned with the date of separation.  

The panel assessed specific fitness implications of each potentially separately ratable condition.  The foot condition surfaced first with the rigors of early training, and the latter would not logically have caused the pes planus that was a key clinical factor for the pain and resulting complications (osteoarthritis, probable plantar fasciitis).  Although the foot condition was subject to temporary profiles, members agreed that the overall evidence indicated it was a baseline condition managed with orthotics and anti-inflammatory medication; and, more likely than not, would not have in itself prohibited continued military service.  The bilateral knee, elbow, shoulder, and right wrist pain were equally chronic and stable; and, although the wrist required a temporary profile on one occasion, members agreed that the overall evidence indicated that all these were also baseline conditions (or simply symptoms) that were managed with anti-inflammatory medication; and, more likely than not, none of them would have in themselves prohibited continued military service.  The lumbar condition was also chronic and stable, equivalent to and subject to the same fitness conclusion as the preceding conditions, with the exception of the evidence in the commander’s performance statement.  This stated that the CI was unable to lift patients, a critical requirement for her military specialty.  It could be logically argued that the back condition was more implicated than the other conditions with this impairment, and justified as separately unfitting on that basis.  Members ultimately agreed, however, that this rationale was overly speculative since all of the lower and upper extremity conditions were implicated in patient lifting, and there was no documentation that back pain was the limiting factor.  It was thus concluded that the lumbar condition was another baseline condition that, more likely than not, would not have in itself prohibited continued military service.

There was no evidence that any of the above conditions was associated with an injury or other acute exacerbation that would have rendered it acutely unfitting after years of satisfactory performance while it was present.  Members also agreed that there was insufficient evidence that any of the preceding conditions merited a minimum compensable rating, even if conceded as separately unfitting.  This conclusion was based on the dominantly probative C&P evidence and took into consideration the dubious foundations for the VA’s foot and knee ratings as elaborated above.  Members thus agreed that the functional limitations associated with any one of the preceding conditions would not have rendered the CI incapable of continuing military service; and, that more likely it was the combined effect from all of them which rendered her unfit.  The panel thus agreed that, except as caveated below, a combined 10% rating under criteria of code 5003 was appropriate, given that no condition could be sufficiently justified as distinctly unfitting and no separate rating was mandated by the VASRD for any of them.  

The single exception from the above conclusions was the left hip condition.  Although there was no ROM limitation or other ratable criterion in evidence that would support a minimum rating, there was satisfactory evidence of painful motion (STR, NARSUM, and C&P) to support a minimum 10% rating IAW VASRD §4.59.  It would therefore conflict with the VASRD to incorporate the left hip with an overall rating under 5003 criteria, and incongruent to single it out as exempt from service rating as not unfitting, since the fitness evidence was equivalent for all conditions under consideration.  The panel therefore concluded that the left hip was appropriately recommended for separate rating.  As previously noted there was no evidence in support of a rating higher than 10% under any applicable code, but a 10% rating under code 5099-5003 (analogous since no X-ray evidence for degenerative changes) was justified by painful motion.  After due deliberation, considering all evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends separate ratings of 10% for polyarthralgias (subsuming feet, knees, elbows, shoulders, right wrist and lumbar spine) under code 5099-5003, and 10% for the left hip condition under code 5099-5003.

BOARD FINDINGS:  In the matter of the PEB-combined polyarthralgia condition subsuming multiple joints and the lumbar spine as above, the panel recommends that it be rated for separate conditions as follows:  a multiple polyarthralgia condition (as elaborated below in the recommendation chart) coded 5099-5003 with a disability rating of 10%; and, a left hip condition coded 5099-5003 with a disability rating of 10%, both IAW VASRD §4.71a.  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	
Polyarthralgias of the Feet, Knees, Elbows, Shoulders, Right Wrist, and Lumbar Spine	5099-5003	10% 	
Left Hip Arthralgia	5099-5003	10%	
COMBINED	20%	

AR20180015078, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear  XXXXXXXXXXXXXXXXXX

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.