RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01538
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060810

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Infantryman, medically separated for “bilateral ankle pain” and “chronic abdominal pain,” rated 10% and 0%, respectively, with a combined disability rating of 10%.   

CI CONTENTION:  His conditions have worsened and negatively affect his daily activities.  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 Medical Evaluation Board (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 - 20060525	VARD - 20070307	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Ankle Pain	5003	10%	Right Ankle Arthritis and Instability	5271	20%	20061229	
			Left Ankle Arthritis and Instability	5271	20%		
Chronic Abdominal Pain and Muscle Spasms Attributed to Spine Degenerative Disc Disease from T6-T11	5243	0%	T6-T11 Nerve Damage to Include Abdominal Pain and Spasms to Thoracic Radiculopathy	8299-8211	10%	20061229	
PTSD	Not Unfitting	PTSD	9411	30%	20060810	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Bilateral Ankle Pain.  The PEB combined the right and left ankle conditions under a single disability rating, coded analogously to 5003 (arthritis, degenerative) and rated 10%.  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 MEB narrative summary (NARSUM), the CI had an 18-month history of multiple right ankle inversion injures without relief from braces and physical therapy.  X-rays revealed osteophytosis (arthritic changes) at the anterior tibiotalar joint and a loose body present within the ankle joint, while magnetic resonance imaging (MRI) demonstrated cortical disruption of the anterior tibial metaphysis and along the anterior talar neck.  The CI underwent right ankle arthroscopy on 24 June 2005 with a loose body removal and diagnosis of tibiotalar impingement.  On 1 August 2005, the CI began experiencing left ankle pain and an MRI on 9 September 2005 revealed a small body adjacent and posterolateral to the flexor halluces longus tendon and a torn anterior tibial fibular ligament.  Thereafter, the CI underwent physical therapy, wore bilateral ankle braces, and took medications for pain relief.  

During the 1 February 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported pain and instability in both ankles.  Physical examination showed bilateral ankle instability and the use of ankle braces.  The 2 February 2006 MEB NARSUM examination, noted complaints of constant pain and stabbing rated at 8-9/10 with a sensation of instability during weight bearing activities.  The CI denied improvement with physical therapy, wore ankle braces for support, and required medication management.  Physical examination showed a normal gait, mild tenderness over the anterolateral aspect of the left ankle, mild edema across the anterior, lateral and medial ankles bilaterally, and positive anterior drawer bilaterally.  Left ankle range of motion (ROM) was dorsiflexion to 13 degrees (normal 20) and plantar flexion to 46 degrees (normal 45), both with pain.  Right ankle ROM was dorsiflexion to 8 degrees and plantar flexion to 44 degrees, both with pain.  

At the 29 December 2006 VA Compensation and Pension (C&P) evaluation, 5 months after separation, the CI reported recurrent ankle injuries.  Physical examination showed he was 68 inches tall, weighed 238 pounds, and had a normal gait. There was pain to palpation of the lateral ankle ligaments bilaterally, right more than left, but no swelling or deformity.  Inversion was increased bilaterally with firm endpoints and no anterior posterior instability.  Left ankle ROM was 5 degrees dorsiflexion and 50 degrees plantar flexion with pain.  Right ankle ROM was 5 degrees dorsiflexion and 40 degrees plantar flexion, again with pain.  There was no loss in motion after three repetitions.  

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the bilateral ankle condition 10%, coded 5003 (arthritis, degenerative), citing some limited ankle motion due to pain alone and some ankle instability without dislocation/subluxation and rated as two or more major joints with X-ray evidence.  The VA rated the right and left ankle conditions 20% each, coded 5271, (marked limited motion of the ankle), based on the C&P evaluation, citing marked limitation of motion for each ankle.  

The panel concluded there was a preponderance of evidence in the STR which overcame the PEB's presumption that the bundled bilateral ankle condition was reasonably considered not separately unfitting.  The panel then considered its rating recommendation for each unfitting ankle at the time of separation.  The MEB NARSUM examination recorded loss of dorsiflexion but a normal gait and near normal plantar flexion, which supported a 10% rating, but no higher, for “moderate” limitation of motion for each ankle under code 5271.  Panel members noted dorsiflexion was further decreased at the VA examination; however, there was no documentation of an accident or injury to account for the decrement in the measurement.  Alternatively, there was evidence of painful motion of each ankle at the NARSUM and VA examinations supporting the 10% rating for each ankle (based on §4.59, §4.40 and §4.45) using code 5099-5003.  There was no ankylosis of the ankle or subastragalar (sub-tarsal) joints, no malunion of the os calcis (calcaneus) or astragalus (talus) or astragalectomy for consideration of a higher rating for either ankle under the respective diagnostic codes (5270, 5272, 5273 or 5274).  After due deliberation, and considering all of the evidence, the panel recommends a disability rating of 10% for the right ankle condition, coded 5271 and 10% for the left ankle condition, coded 5271.

Chronic Abdominal Pain.  According to the STR and MEB NARSUM, the CI first noticed mid and lower back pain in October 2003 without any specific trauma or injury.  While deployed in February 2004, he felt a painful abdominal wall pop and bulge with progressive symptoms including spasms and mid back pain.   In March 2005, he was evaluated by general surgery and reported multiple, painful hernias “popping out” when doing sit-ups.  The bulges occurred bilaterally below the ribs as well as at the belt line with progressive symptoms including spasms and pain that lasted for 4-5 hours.  Examination revealed what was thought to be abdominal wall hernias on the right, and while the CI indicated similar bulges on the left, no hernias were palpated.  Abdominal computerized tomography (CT) in April 2005 showed no evidence of hernias nor did laparoscopy in May 2005, although adhesions were noted in the left lower quadrant in the area of the sigmoid colon.  

Because of a history of diarrhea when deployed and suspected diverticulitis in the past, an esophogastroduodenoscopy and colonoscopy were performed in September 2005, with both showing normal results.  At a pain clinic visit on 24 October 2005, the CI told the examiner his abdominal hernia diagnosis was rescinded and he was re-diagnosed with a muscle spasm.  The examiner assessed the condition as “myofascial syndrome of the rectus muscles versus thoracic radiculopathy” and prescribed a muscle relaxer.  Trigger point injections, daily home physical therapy, and a weight loss program were also recommended.  An MRI in October 2005 revealed multiple tiny midline posterior disc protrusions from T6-T11.  As a result, the CI was diagnosed with chronic atypical abdominal pain and spasms secondary to thoracic disk radiculopathy.        

During the 1 February 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported acute abdominal spasms.  Physical examination revealed abdominal wall spasms during flexion in a sit-up position and limited ROM due to pain and spasms.  The MEB NARSUM examination the next day, noted complaints of abdominal wall pain, spasms and recurrent mid back pain worsened by activities such as sit-ups, prolonged weight bearing, running and carrying an increased load.  Physical examination showed visible and palpable abdominal wall defects with spinal flexion, otherwise described as spasms across the left and right upper quadrants, mid epigastric region, and just inferior and to the left of the umbilicus.  Lumbar ROM in degrees was:  flexion to 80 (normal 90) with discomfort, abdominal spasms and mild pain; extension to 25 (normal 30) with mild pain; right and left rotation to 30 (normal); and right and left lateral flexion to 25 (normal 30).

At a follow-up pain management visit on 23 February 2006, the examiner reported that after a series of three thoracic epidural steroid injections, the CI still rated his pain at 7/10.  He was prescribed an anti-depressant after a muscle relaxer and nerve pain medications did not relieve his symptoms, and other medications were recommended for neuropathic pain.   
At the 29 December 2006 VA Compensation and Pension (C&P) evaluation, 5 months after separation, the CI reported intense abdominal pain twice a day but being pain-free between episodes; onset was associated with a lump in the abdominal muscle.  Physical examination revealed a normal gait, no palpable mass, ventral hernia, or guarding of the abdomen, and no abdominal wall lesions.  Thoracolumbar ROM in degrees was:  flexion to 90, extension to 30, bilateral rotation to 45 each, and bilateral lateral bending to 40 each.  There was pain only with right rotation and no loss of motion with repetition. 

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the abdominal pain and muscle spasms attributed to thoracic spine degenerative disc disease 0%, coded 5243 (intervertebral disc syndrome), citing no significant loss of motion and no tenderness or paraspinous muscle spasm.  The VA rated T6-T11 nerve damage (to include abdominal pain and spasms to thoracic radiculopathy) 10%, coded 8299-8211 (incomplete moderate paralysis of the eleventh cranial nerve), based on the C&P evaluation, citing moderate incomplete paralysis of the accessory nerve.    

Members noted the CI’s abdominal pain was not from an internal organ etiology, but was a result of abdominal wall muscle spasms attributed to thoracic spine disc protrusions/bulges   The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) reported on the NARSUM examination.  A 10% rating was also warranted based on painful motion and muscle spasm without an altered gait or spinal contour as reported in the NARSUM and C&P examinations. However, these routes offered no additional benefit to the CI.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula. 

The VA rated nerve damage using a code for the eleventh cranial nerve, which innervates the sternocleidomastoid and trapezius muscles located in the neck.  However, the etiology of the CI’s spasms and pain was from the thoracic spine for which there is no rating option for a purported or actual radiculopathy involving the thoraco-abdominal nerves.  Members considered the use of code 5319 (Group XIX…support and compression of abdominal wall and lower thorax; flexion and lateral motions of spine…) based on the pain specialist’s assessment (October 2005) that rectus [abdominis] muscles, which coincided with the location of the CI’s symptoms, were affected.  VASRD §4.56 (evaluation of muscle disabilities) indicates that for rating purposes, the cardinal signs and symptoms of muscle disability are “loss of power, weakness, lower threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement.”  Members agreed the CI’s history supported one or more of the cardinal signs and symptoms of muscle disability and documented extensive treatment which did not provide relief.  Thus, the panel considered the rectus abdominus muscle spasms to be of moderate severity for a 10% rating, which was supported by functional loss IAW VASRD §4.40.  However, because the spasms would only warrant single coding rather than separate coding for the left and right rectus abdominis muscles IAW VASRD §4.14 (avoidance of pyramiding), the panel adjudged that code 5243 would more appropriately describe the etiology of the abdominal pain, which was presumed to originate from spinal nerve involvement with certain movements.  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 chronic abdominal pain and muscle spasms due to thoracic spine degenerative disc disease condition, coded 5243.  

Contended PEB Condition:  PTSD (Post Traumatic Stress Disorder).  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition; and so, no additional disability rating is recommended.  
BOARD FINDINGS:  In the matter of the bilateral ankle pain condition, the panel recommends that each joint be separately adjudicated as follows: an unfitting right ankle condition coded 5271 and rated 10%, and an unfitting left ankle condition, coded 5271 and rated 10%, both IAW VASRD §4.71a.  In the matter of the chronic abdominal pain and muscle spasms due to thoracic spine degenerative disc disease condition, the panel recommends a disability rating of 10%, coded 5243 IAW VASRD §4.71a.  In the matter of the contended PTSD condition, the panel recommends no change from the PEB determination of not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Bilateral Ankle Pain, Right Ankle	5271	10%	
Bilateral Ankle Pain, Left Ankle	5271	10%	
Chronic Abdominal Pain and Muscle Spasms Due to Thoracic Spine Degenerative Disc Disease	5243	10%	
COMBINED (w/ BLF)	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161016, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record  

AR20180004646, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs. 

Sincerely,					      
Enclosure