[AR Number], XXXXXXXXXX

XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXX

Dear XXXXXXXXXX:

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), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

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

Sincerely,		

			      
Enclosure

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2016-01790
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040806

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Medical Specialist, medically separated for “back pain” and “wrist, hip and foot pain,” rated 10% and 0%, respectively, with a combined 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 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 - 20040217	VARD - 20040423	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Back Pain	5237	10%	Residuals of Low Back Injury	5237	10%	20040308	
Wrist, Hip and Foot Pain	5099-5003	0%	Residuals of a Left Wrist Ganglion Cyst	5299-5215	10%	20040308	
			Bilateral Plantar Fasciitis	5276	10%	20040308	
			Right Hip Enchondroma	5015	10%	20040308	
			Left Heel Spur With Arthritis	5283	0%	20040308	
			Right Heel Spur With Arthritis	5283	0%	20040308	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Back.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began in September 1998 with no specific accident or injury.  Lumbar spine X-rays were unremarkable and surgery was not indicated.  He continued to have intermittent episodes of back pain, occasionally associated with muscle spasms.  

The 15 August 2003 orthopedic addendum noted complaints of mechanical low back pain.  There was no physical examination.  The orthopedic specialist recommended a medical board for the CI’s multiple conditions, including his back, which were the subject of frequent medical visits and a very restrictive profile.  The 27 November 2003 physical therapy range of motion (ROM) study, after repetition, showed flexion of 90 degrees (normal) and combined ROM of 160 degrees (normal 240), limited by pain.  

The 16 December 2003 MEB NARSUM examination, 8 months prior to separation, noted complaints of daily back pain aggravated by prolonged standing or weight-bearing activities.  Physical examination showed a normal gait.  The ROM evaluation showed the CI able to bend forward and bring fingertips to the floor (normal ROM), with pain on returning upright.  Lateral flexion and rotation were full bilaterally and extension was limited to 20 degrees (normal 30).   Lumbar spine X-rays on 18 December 2003 showed straightening of the normal lumbar lordosis suggestive of muscle spasm, but was otherwise normal.  

At the 8 March 2004 VA Compensation and Pension (C&P) examination, 5 months before separation, the CI reported daily back pain worse in the morning and aggravated by lifting or prolonged standing.  Physical examination showed normal gait and spinal curvatures.  There was tenderness but no muscle spasm.  The ROM test, after five repetitions, showed flexion of 90 degrees and combined ROM of 215 degrees.  There was no additional loss of ROM with repetition, but there was pain.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain), citing combined ROM of 162 degrees.  The VA also rated the back condition 10%, coded 5237 (lumbosacral strain), based on the C&P examination, citing slightly decreased ROM with pain on motion.  The panel agreed that a 10% rating, but no higher, was justified for limitation of combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on all examinations proximate to separation.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the back condition.  

Wrist, Hip and Foot Pain.  The PEB combined the wrist, hip and foot pain conditions under a single disability rating, coded analogously to 5003 and rated 0%, with likely application of the US Army Physical Disability Agency pain policy.  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 wrist, hip and foot conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated. 

Wrist Pain.  According to the STR and MEB NARSUM, the CI’s left non-dominant wrist condition began in May 1999 with no specific injury.  The CI presented with complaint of a painful ganglion of the left wrist.  He underwent surgery for the recurrent ganglion cyst in June 2003.  Following surgery the CI continued to report discomfort with ROM, especially push-ups and use of screwdrivers.  The condition was profiled and specifically noted in the commander’s statement, dated 23 September 2003, as impairing duty performance.  The MEB NARSUM determined the CI did not meet retention standards due to the wrist condition.  

The 15 August 2003 orthopedic addendum noted continued limited ROM of the wrist with some swelling still present after the ganglion excision surgery in June 2003.  It was anticipated that the ROM would increase with time.  Recurrence of the ganglion was unpredictable.  The physical therapy ROM study showed, after repetition, left wrist dorsiflexion (DF) of 46 degrees (normal 70) and palmar flexion (PF) of 22 degrees (normal 80).  The 16 December 2003 MEB NARSUM examination noted complaints of wrist pain present up to half the time while awake.  Physical examination showed normal ROM of the upper extremity, but there was discomfort at maximal DF.  Left wrist X-rays on 16 December 2003 were normal.  

At the C&P examination the CI reported pain and weakness of the top of the left wrist, especially with push-ups.  Physical examination showed a well healed surgical scar of the left wrist without deformity.  Left wrist ROM testing, after repetition, showed DF of 70 degrees and PF of 59 degrees, with painful motion.  

The panel first considered if the left wrist, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The left wrist was profiled, implicated in the commander’s statement and was judged to fail retention standards.  The panel concluded there was not a preponderance of evidence in the service records which overcame the panel’s presumption that the bundled left wrist condition was reasonably considered separately unfitting.  The panel then considered its rating recommendation for the unfitting wrist condition at the time of separation.  The VA rated the left wrist condition 10%, analogously coded 5299-5215 (limitation of wrist motion), based on the C&P examination, citing decreased ROM with pain on motion.  There was no limitation of wrist DF or PF that supported a rating under the VASRD diagnostic code for limitation of motion (5215).  However there was evidence of painful motion causing functional loss supporting the 10% rating (based on §4.59, §4.40 and §4.45).  There was no evidence of wrist ankyloses (5214) for consideration of a rating under that code.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left wrist condition, coded 5299-5215.  

Hip Pain.  According to the STR and MEB NARSUM, the CI’s right hip condition began in September 1998 concurrently with the low back pain.  Initially the CI had pain with flexion of the right hip.  An MRI of the hips in March 2003 was normal, but noted a previously identified mass lesion in the middle of the right femur.  A bone scan and CT also showed an abnormality in the mid shaft of the right femur consistent with a benign lesion such as an enchondroma (benign bone tumor that begins in cartilage).  Repeat right femur X-rays in May 2003 showed the right femur lesion with no change since X-rays in 2002 and it was considered most consistent with an enchondroma.  No further evaluation was deemed necessary by orthopedics.  

The orthopedic addendum noted complaints of right hip pain and a right femoral lesion.  The examiner noted that X-rays showed possible subchondral cyst (degenerative changes) of the right femoral head.  There was no femoral tenderness at that time.  There was no physical examination.  The physical therapy ROM study, after repetition, showed flexion of 103 degrees (normal 125), extension of 11 degrees (normal 30), external rotation of 40 degrees (normal 60) and abduction of 37 degrees (normal 45).  

At the MEB NARSUM examination the CI reported hip pain present three quarters of the time, aggravated by running, with occasional flare-ups that caused significant decrease in his activity level.  Physical examination showed hip ROM “essentially within normal limits.”  Standing on the right leg alone was productive of pain.  Straight leg raising (in this case indicative of hip pain) caused discomfort from 90 to 120 degrees.  

During the C&P examination the CI reported daily hip pain aggravated by prolonged standing and walking.  He reported flare-ups about once per month for one week.  He reported decreased abduction, but right hip extension bothered him the most.  Physical examination showed normal posture and gait.  Right hip ROM testing, after five repetitions, showed flexion of 105 degrees, extension or 20 degrees, abduction of 35 degrees and external rotation of 26 degrees, with painful motion.  

The panel first considered if the right hip, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The right hip was profiled, implicated in the commander’s statement and noted to fail retention standards.  The CI had a benign tumor of the right femur which was thought to be causing or contributing the CI’s hip pain.  The panel concluded there was not a preponderance of evidence in the service records which overcame the panel’s presumption that the bundled right hip condition was reasonably considered separately unfitting.  The panel then considered its rating recommendation for the unfitting right hip condition at the time of separation.  The VA rated the right hip condition 10%, coded 5015 (bones, new growths of, benign), based on the C&P examination.

There was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  There was no limitation of motion which supported a higher rating under the diagnostic codes for limitation of thigh extension, flexion or thigh impairment (5251, 5252, 5253).  A 10% rating was also supported under an analogous code for femur impairment (5255) causing slight knee or hip disability.  There was no evidence of hip ankyloses or flail hip joint (5250, 5254) for a rating under the respective codes.  There was therefore no rating higher than 10% supported under any applicable VASRD §4.71a code.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the right hip condition, coded 5299-5252.  

Foot Pain.  According to the STR and MEB narrative summary (NARSUM), the CI’s foot condition began in October 1999 after intensive physical training.  He was treated conservatively with orthotics which were initially helpful but did not provide long term improvement.  Bilateral foot X-rays in May 2003 noted arthritic changes of both heels and a bone scan showed increased uptake in the right mid-foot.  The physical therapy ROM study, after repetition, showed left ankle DF of 42 degrees (normal 20) and plantar flexion of 43 degrees (normal 45); and right ankle DF of 19 degrees and plantar flexion of 37 degrees.  During the MEB NARSUM examination, the CI complained of chronic bilateral foot pain.  Physical examination showed a normal gait and normal foot arches, but there was left greater than right tenderness of the plantar fascia.  

At the C&P examination, the CI reported pain worse at the end of the day aggravated by running or prolonged standing.  Physical examination showed a normal gait, but there was mild loss of the longitudinal arch of both feet.  

The panel first considered if the foot condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The foot condition was profiled, implicated in the commander’s statement and judged to fail retention standards.  The panel concluded there was not a preponderance of evidence in the service records which overcame the panel’s presumption that the bundled foot condition was reasonably considered separately unfitting.  Based on the same evidence the panel likewise concluded that each foot was reasonably considered unfitting.  Since the rating evidence was nearly identical for both feet, the panel considered its rating recommendation for the unfitting left and right foot conditions together at the time of separation.  The VA rated the foot condition 10%, coded 5276 (flatfoot, acquired), based on the C&P examination, citing mild loss of the longitudinal arch of both feet with complaints of daily pain that increased in intensity with use.  
 
The panel considered an analogous rating under code 5310 (Group X muscle injury which includes the plantar fascia).  There were no objective findings of either foot on the VA examination such as swelling, tenderness of the plantar fascia, tenderness of any part of the foot, painful motion or pain on manipulation of the feet.  The panel also noted that the CI had functioned with the bilateral foot condition for approximately 5 years prior to separation, without evidence of significant worsening of the condition of either foot at the time of separation.  The panel concluded that the plantar fasciitis of each foot was appropriately rated as “slight” (0%) and no higher under 5310.  The panel considered other VASRD foot and analogous codes but all were less applicable and/or not advantageous for rating of either foot.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for the left foot and 0% for the right foot condition, both coded 5399-5310.  

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the bundled wrist, hip and foot conditions, the panel recommends that each condition be separately adjudicated as follows: an unfitting left wrist condition rated 10%, coded 5299-5215 IAW VASRD §4.71a, an unfitting right hip condition rated 10%, coded 5299-5252 IAW VASRD §4.71a and an unfitting left foot condition and an unfitting right foot condition, each rated 0%, both coded 5399-5310 IAW VASRD §4.73.  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 the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Back Pain	5237	10%	
Left Wrist Pain	5299-5215	10%	
Right Hip Pain	5299-5252	10%	
Right Foot Pain	5399-5310	0%	
Left Foot Pain	5399-5310	0%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161125, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record