RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01032
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070910

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Health Care Specialist, medically separated for low back pain rated at 10%; and cervical pain, bilateral knee pain, bilateral ankle pain, and left shoulder pain rated at 0% each, 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 – 20070625	VARD - 20071022	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5299-5243	10%	Lumbar Spine Degenerative Disc Disease	5242	10%	20070816	
Cervical Pain	5299-5243	0%	Cervical Spine Strain	5237	10%		
Bilateral Knee Pain	5099-5003	0%	Patellofemoral Syndrome Bilateral Knees	5299-5024	10%		
Bilateral Ankle Pain	5099-5003	0%	Left Ankle Stress Fracture	5271	10%		
			Right Ankle Stress Fracture	5024	NSC		
Left Shoulder 	5099-5003	0%	Status Post Tear of the Labrum with Tendonitis of the Left Supraspinatus and Infraspinatus Tendons of the Left Shoulder and Right Shoulder Strain	5024	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Low Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back pain started around May 2006 without specific injury or trauma.  Lumbar spine X-rays on 30 March 2007 revealed mild degenerative disk disease at L5-S1.  MRI of the lumbar spine showed disc protrusion at L5-S1.  The 10 May 2007 MEB NARSUM examination, 4 months prior to separation, noted complaints of constant sharp lower back pain rated 4/10.  The pain reportedly radiated into the tailbone area.  Physical examination showed normal gait, motor strength, sensation, and reflexes.  The range of motion (ROM) measurements for the back performed by physical therapy (PT) on 11 May 2007, 4 months prior to separation, showed flexion of 98 degrees (normal 90) and combined ROM of 230 degrees (normal 240) after repetition.  Limitation of ROM was noted to be due to pain.  

At the 16 August 2007 VA Compensation and Pension (C&P) examination, 1 month before separation, the CI reported chronic low back pain.  Physical examination showed mild spasm.  The CI was able to walk briskly without any difficulties with a normal gait.  There was no evidence of abnormal curvature of the lumbar spine.  During the examination, the CI exhibited a mild manifestation of pain and stiffness of his lumbar spine.  Back ROM after three repetitions showed flexion of 80 degrees and combined ROM of 210 degrees with painful motion noted.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5299-5243 (analogous to intervertebral disc syndrome (IVDS)), citing tenderness to palpation but no muscle spasm, deformity, or gait alteration.  The VA also rated the back condition 10%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination, citing ROM.  

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 and/or combined ROM greater than 120 degrees but not greater than 235 degrees, as reported on the PT and VA examinations.  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.  There was no documentation of IVDS with incapacitating episodes which would provide for a higher rating under that formula.  After 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 low back condition.

Cervical Pain.  According to the STR and MEB NARSUM, the CI’s neck pain started during basic training with no specific injury or trauma.  Cervical spine X-rays on 30 March 2007 were normal, but MRI showed disc protrusion at C5-C6 and C6-C7.  The MEB NARSUM examination noted complaints of chronic pain on both sides of his neck, rated 2/10.  The pain was aggravated by wearing body armor and carrying weight on his shoulders.  The CI reported occasional intermittent numbness and tingling into both hands and fingers.  Physical examination showed no edema or erythema.  Cervical spine ROM measurements performed by PT on 11 May 2007 showed flexion of 50 degrees (normal 45) and combined ROM of 310 degrees (normal 340) after repetition.  Limitation was noted to be mechanical and not secondary to pain.  

At the C&P examination the CI reported continued neck pain despite conservative treatment.  Physical examination showed mild manifestation of pain and stiffness of his cervical spine.  There was a normal gait.  Cervical ROM after three repetitions was flexion of 35 degrees, with pain and stiffness starting at 30 degrees and ending at 45 degrees, and combined ROM of 280 degrees, also with pain and stiffness.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the cervical spine condition 0%, coded 5299-5243 (analogous to IVDS), citing “range of motion [was] essentially normal without muscle spasms or tenderness to palpation.”  The VA rated the cervical spine condition 10%, coded 5237 (cervical spine strain), based on the C&P examination, citing forward flexion greater than 30 degrees and a combined range of motion greater than 170 degrees.   

The panel agreed that a 10% rating, but no higher, was justified for combined ROM greater than 170 degrees but not greater than 335 degrees as reported on the PT ROM examination and the C&P examination.  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.  There was no documentation of IVDS with incapacitating episodes which would provide for a higher rating under that formula.  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 cervical spine condition, coded 5299-5243.  

Bilateral Knee Pain.  The PEB combined the right knee and left knee conditions under a single disability rating, coded analogously to 5003 and rated 0%.  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 the PEB.  

The commander’s statement implicated the knees and ankles as impairing the CI’s duty performance.  The 14 June 2007 permanent profile listed bilateral knee pain and bilateral ankle pain.  Profile limitations of no running, no unlimited walking, no 2 mile run, and no wearing of body armor or load bearing equipment (LBE) were at least partly attributable to the bilateral knees and ankles.  According to the STR and the MEB NARSUM, the CI’s bilateral knee pain started in basic training with increased running and activity, but no reported injury or trauma.  At the 8 August 2005 orthopedic evaluation, the examiner noted minimal degenerative changes of the left knee, but a normal right knee X-ray.  Multiple X-rays of the knees from June 2005 to July 2007 were all reported as normal.  During the 13 April 2007 and 2 May 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 and 5 months prior to separation, the CI reported swelling and pain in his knees.  Physical examination noted pain with knee extension bilaterally.   

The MEB NARSUM examination noted complaints of constant dull pain underneath the patella.  Pain reportedly increased with squatting, kneeling, running, sitting, and walking for prolonged periods of time.  The CI denied locking or mechanical symptoms.  He was diagnosed with bilateral patellofemoral syndrome.  Despite treatment with steroid injections, physical therapy, multiple temporary profiles, and medication, there was no improvement in pain.  No surgery was recommended.  Physical examination showed tenderness of both patellae.  There was also tenderness medial and inferior to the joint line.  There was no swelling, erythema, warmth, or muscle spasm.  There was full knee ROM without pain during the ROM testing.  The MEB NARSUM examiner determined the CI fell below retention standards due to bilateral patellofemoral syndrome.  At the PT ROM evaluation on 11 May 2007, the left knee ROM following repetitive movement was flexion of 138 degrees (normal 140) and extension of 0 degrees (normal 0).  Right knee ROM following repetitive movement was flexion of 134 degrees and extension of 0 degrees.  Bilateral knee ROM was limited by mechanical end feel; no limitations were secondary to pain.
At the C&P examination the CI reported bilateral knee pain.  Physical examination showed a normal gait.  There was no evidence of effusion or swelling of either knee.  There was mild pain with palpation on both of the patellofemoral areas.  On physical examination, knee ROM bilaterally after three repetitions was flexion of 140 degrees, with pain and stiffness beginning at 130 degrees and ending at 140 degrees, and extension of 0 degrees, with pain and stiffness.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 0%, coded 5099-5003 (analogous to degenerative arthritis), citing no joint instability and full ROM.  The VA rated the bilateral knee condition 10%, coded 5299-5024 (analogous to tenosynovitis), based on the C&P examination, citing painful or limited motion of a major joint or group of minor joints.    

The panel first considered if each of the knees, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, both knees were considered to fail retention standards, both were profiled and were implicated by the NARSUM.  The commander’s statement and other STR evidence did not provide any information which would permit the panel to discriminate the performance limitations attributable to either knee over the other. Since undue speculation would be required to conclude that impairment from either knee would not have unacceptably interfered with MOS performance, panel members concluded that each knee was reasonably justified as separately unfitting at separation.  

There was no limitation of flexion or extension of either knee that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  However, there was evidence of painful motion at both the MEB and VA examinations to support a 10% rating (based on §4.59, §4.40 and §4.45) for each knee, coded analogously as 5099-5003 or 5299-5260 (limitation of leg flexion).  There was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259), to support a rating under those codes for either knee.  There was no fracture, nonunion, or malunion of the femur or tibia of either leg to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  There was therefore no higher rating than 10% for either knee under any applicable VASRD code.  After due deliberation, and considering all of the evidence, the panel recommends a disability rating of 10% for the left knee condition and 10% for the right knee condition, both coded 5099-5003.

Bilateral Ankle Pain.  The PEB combined the right and left ankle conditions under a single disability rating, coded analogously to 5003 and rated 0%.  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 commander’s statement and permanent profile are noted above.  Profile limitations of no running, no unlimited walking, no 2-mile run, and no body armor or LBE were at least partly attributable to the ankles.  According to the STR and MEB NARSUM, the CI’s bilateral ankle pain started in basic training with increased running and activity, without injury or trauma.  The MEB NARSUM examination noted complaints of constant, diffuse pain located laterally, graded 2/10, and increased with activity at times.  Physical examination showed no swelling, erythema, or warmth.  The right ankle peroneal longus tendon (posterior to lateral malleolus) was tender.  The left ankle had diffuse tenderness.  Ankle ROM was noted as normal and no pain was elicited on ROM.  At the PT ROM evaluation on 11 May 2007, right ankle dorsiflexion after repetition was 9 degrees (20 normal) and plantar flexion after repetition was 46 degrees (45 normal).  Left ankle dorsiflexion after repetition was 4 degrees and plantar flexion after repetition was 51 degrees.  The therapist stated limitation was due to mechanical limitations and not secondary to pain.  A bone scan on 22 May 2007 revealed findings consistent with a probable stress fracture in the left lateral malleolus.  Bilateral X-rays of the ankles performed on 18 July 2007 were normal.  

At the C&P examination the CI reported he was given an ankle brace for his left ankle (after the bone scan) which he wore for a few months and used crutches for a couple weeks.  He was given insoles and padding and reported he was using these with some relief whenever he ran.  Physical examination showed a normal gait and the CI was able to walk briskly without any difficulties.  The left ankle showed no evidence of swelling or laxity.  Left ankle ROM after three repetitions was dorsiflexion of 15 degrees and plantar flexion of 35 degrees with pain and stiffness.  The right ankle ROM after three repetitions was dorsiflexion of 20 degrees and plantar flexion of 45 degrees.  The examiner stated “there [was] no obvious problem with his right ankle at [the] time.  

The panel directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB bundled the right ankle with the left ankle and applied a single 0% rating, coded 5099-5003.  The VA rated the left ankle condition 10% (coded 5271), citing moderate limitation of motion.  The VA did not service-connect the right ankle, stating a condition must be chronic before service connection can be granted.  The examination did not find any disability in the right ankle.  

The panel first considered if each of the ankles, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, both ankles were considered to fail retention standards, both were profiled and implicated by the NARSUM.  The commander’s statement and other STR evidence did not provide any information which would permit the panel to discriminate the performance limitations attributable to either ankle over the other.  Since undue speculation would be required to conclude that impairment from either ankle would not have unacceptably interfered with MOS performance, members concluded that each ankle was reasonably justified as separately unfitting at separation.  

There was limitation of left ankle dorsiflexion noted at the MEB NARSUM and VA examinations to support a 10% rating for moderate limitation of ankle motion (5271).  The MEB NARSUM examination noted limitation of right ankle dorsiflexion.  However, at the VA examination 1 month prior to separation, right ankle ROM was completely normal with no findings of disability in evidence.  The panel considered alternative VASRD ankle and analogous codes, but all were less applicable and/or not advantageous to rating.  There was therefore no higher than a 10% rating available for the left ankle and no higher than a 0% rating available for the right ankle under any applicable VASRD code.  After due deliberation, and considering all of the evidence, the panel recommends a 10% disability rating for the left ankle condition, coded 5271, and a 0% rating for the right ankle condition, coded 5099-5003.  

Left (Non-Dominant) Shoulder Pain.  According to the STR and MEB NARSUM, the CI’s left shoulder pain started in 2006 with no history of trauma or injury.  A scapula X-ray on 30 March 2007 was normal.  Left shoulder MRI on 10 May 2007 revealed blunting of the superior labrum and an abnormal appearance of the anterior/inferior labrum consistent with a tear.  There was mild tendinopathy of the supraspinatus and infraspinatus tendons.  The MEB NARSUM examination noted complaints of constant sharp pain in the lower part of his scapula.  Physical examination showed no swelling, edema, or erythema.  There was no muscle atrophy.  There was tenderness of the left lower trapezius muscle.  At the PT ROM evaluation on 11 May 2007, left shoulder flexion was 173 degrees (180 normal) after repetition.  Shoulder ROM was not limited secondary to pain.  Bilateral shoulder X-rays performed on 18 July 2007 were normal.  At the C&P evaluation the CI reported the shoulder pain was responding well to PT and he obtained moderate relief from a steroid injection.  Physical examination noted the CI was right hand dominant.  Left shoulder ROM was flexion of 175 degrees (180 normal) with pain and stiffness.  Left shoulder X-rays showed “mild tendinitis.”  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 0%, coded 5099-5003 (arthritis, degenerative), citing no significant loss of joint motion and no evidence of joint disease.  The VA rated the left shoulder condition 10%, coded 5024 (tenosynovitis), based on the C&P examination, citing painful or limited motion of a major joint or group of minor joints.  The VASRD §4.71a threshold for ROM impairment (code 5201, arm limitation of motion) is “at shoulder level” (approximately 90 degrees from the side), and the examinations in evidence demonstrated motion above this level.  However, panel members agreed that a 10% rating was justified under 5024 (tenosynovitis) for painful, limited motion with imaging evidence of tenosynovitis (MRI and X-ray).  There was no malunion or recurrent dislocation of the humerus (5202), and no dislocation or nonunion of the clavicle or scapula (5203), to justify a higher rating under these codes.  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 shoulder condition, coded 5024.  

BOARD FINDINGS:  In the matter of the low back condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the cervical spine condition, the panel recommends a disability rating of 10%, coded 5299-5243 IAW VASRD §4.71a.  In the matter of the bilateral knee conditions, the panel recommends that each joint be separately adjudicated as follows: an unfitting right knee condition and an unfitting left knee condition, both rated 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the bilateral ankle conditions, the panel recommends that each joint be separately adjudicated as follows: an unfitting left ankle condition, rated 10%, coded 5271, and an unfitting right ankle condition rated 0%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the left shoulder condition, the panel recommends a disability rating of 10%, coded 5024 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; and, the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Low Back Pain	5299-5243	10%	
Cervical Spine Pain	5299-5243	10%	
Left Knee Pain	5099-5003	10%	
Right Knee Pain 	5099-5003 	10%	
Left Ankle Pain	5271	10%	
Right Ankle Pain	5099-5003	0%	
Left Shoulder Pain	5024	10%	
COMBINED	50%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170219, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record  

AR20180007397, 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 50% 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 and to the counsel you listed on your application, XXXXXXXXXXXXXXXXXX.

Sincerely,					      
Enclosure