RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01494
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060519

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Food Service Specialist, medically separated for “chronic left ankle pain and instability…and chronic right (dominant) wrist pain” with a disability rating of 10%.

CI CONTENTION:  No specific contention was made.  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 - 20060414	VARD - 20070516	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Ankle Pain and Instability and Right (Dominant) Wrist Pain	5099-5003	10%	Left Ankle Fracture Residuals	5299-5271	10%	20070405	
			Right Wrist Surgical Residuals	5215	10%	20070405	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Left Ankle Pain and Instability/Right Wrist Pain.  The PEB combined left ankle and right wrist conditions under a single disability rating, coded 5099-5003 (analogous to degenerative arthritis), citing criteria of the US Army Physical Disability Agency (USAPDA) 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 VASRD 5003 rating criteria, 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 left ankle and right wrist conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

Left Ankle Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI had a long history of strain injuries and intermittent ankle pain that was aggravated by fall in April 2003 while deployed to Iraq.  There was ample STR documentation of a normal gait, and grossly normal range of motion (ROM), with some notations of painful motion.  There was also record of joint laxity (lateral and anterior), characterized variously from “slight” to “mild.”  Serial X-ray studies were normal, and surgery was discussed and reasonably declined.  

The 23 February 2006 MEB physical therapy (PT) examination, 3 months prior to separation, recorded left ankle dorsiflexion to 11 degrees (normal 20) and plantar flexion to 45 degrees (normal); painful motion was not addressed.  The 2 March 2006 MEB NARSUM examination documented left ankle pain aggravated by heavy lifting or excessive walking, that prohibited running, and was associated with infrequent episodes of instability.  Physical examination recorded a normal gait and joint strength, tenderness or swelling, and some unquantified anterior and lateral instability to stress testing.  The MEB NARSUM and MEB Proceedings documented the left ankle condition as a separate diagnosis failing retention standards.  The left ankle was L3 profiled and implicated in the commander’s performance statement as interfering with prolonged standing and field duty.

At the 5 April 2007 VA Compensation and Pension (C&P) joints examination, 11 months after separation, the CI complained of daily left ankle pain and giving way once or twice a month.  Physical examination recorded a normal gait, and no tenderness or instability.  Left ankle dorsiflexion and plantar flexion were “normal,” with pain limited motion.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bundled left ankle and right wrist conditions 10%, analogously coded 5099-5003, citing the USAPDA pain policy.  The VA rated the left ankle condition 10%, analogously coded 5299-5271 (ankle, limited motion) based on the C&P joints examination, citing continuous pain and joint weakness.  The panel first considered if the left ankle condition was reasonably justified as separately unfitting for independent rating.  The panel noted the left ankle was the basis for the L3 profile that specified limitations not compatible with full duty in the CI’s specialty or with general soldiering requirements, which was independent of the right wrist limitations.  This was corroborated by the commander’s statement and by the MEB opinion that the ankle condition failed retention standards.  The panel thus agreed that the left ankle was reasonably justified as separately unfitting.

The panel then deliberated the appropriate coding and rating recommendation.  Code 5271 offers a 10% rating for “moderate” limitation of motion and 20% (highest) for “marked” limitation.  Members agreed that the 50% reduction in dorsiflexion recorded on the MEB PT examination, most proximate to separation, could be reasonably characterized as a “moderate” limitation to support a 10% rating.  Members further agreed that there was satisfactory evidence to concede painful motion to support an alternative 10% rating IAW VASRD §4.59.  There was no ankylosis or active fracture complications (nonunion, malunion), and no other applicable joint code that would yield a rating higher than 10%.  Members agreed that analogous rating for functional loss via 5299-5283 (tarsal, or metatarsal bones, malunion of, or nonunion) or 5299-5262 (tibia and fibula, impairment) could not be justified by objective evidence.  There are no VASRD provisions for additional rating of ankle instability, nor was there evidence of significant disability attributable to it (infrequent episodes).  After due deliberation, considering all evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends the left ankle condition as separately unfitting with a 10% rating, coded 5024-5271 (tenosynovitis-ankle, limited motion).

Right Wrist Pain.  The CI injured her dominant right wrist in 2004 after falling off a recreational dirt bike, and X-rays at that time showed an old chip fracture (ulnar styloid).  She suffered persistent pain and underwent surgical intervention (excision of ulnar styloid and tenosynovectomy) in May 2005, 12 months before separation.  Postoperative STR entries documented an uncomplicated course with improving ROM, but persistent pain.  The final orthopedic note, 3 months post-surgery, recorded grossly normal ROM without addressing painful motion, and normal strength.  There were no postoperative STR provider entries that addressed specific functional limitations or documented any additional VASRD-ratable findings.

The MEB PT examination recorded right wrist dorsiflexion to 70 degrees (normal) and palmar flexion to 60 degrees (normal 80); painful motion not addressed.  Measured grip strength was in the below average range.  The MEB NARSUM examination documented right wrist pain while working, and the examiner detailed specific functional limitations relevant to the CI’s duties as a cook (unable to use a knife, “normal cook activities”) that had not resolved after the surgery; and, stated, “she cannot do repetitive activities at work or she develops significant pain.”  Physical examination recorded “full” ROM and normal strength in fingers and hand without note of tenderness or other positive joint findings.  The MEB NARSUM and MEB Proceedings documented the right wrist condition as a separate diagnosis failing retention standards.  The right wrist was profiled U2 and was not specifically implicated in the commander’s performance statement.

At the C&P joints examination, the CI complained of constant right wrist pain with occasional flares.  The examiner noted that she was employed as a dishwasher and that the right wrist would “bother her” with hard scrubbing, but that it did not affect daily activities.  Physical examination recorded the absence of tenderness and normal strength.  Right wrist dorsiflexion and palmar flexion were “normal,” with pain limited motion.

The panel directed attention to its rating recommendation based on the above evidence.  As noted above the PEB rated the bundled left ankle and right wrist conditions 10%.  The VA rated the right wrist condition 10%, coded 5215 (wrist, limited motion), based on the C&P joints examination, citing “regular pain and flare ups.”  The panel first considered if the right wrist condition was reasonably justified as separately unfitting for independent rating.  Although a level 2 profile does not typically impose unfitting limitations and the commander’s statement did not note any limitations attributable to the right wrist pain, the MEB NARSUM explicitly documented functional interference with duty-specific work requirements and the MEB opinion judged the right wrist did not meet retention standards.  Members agreed that this performance-based evidence satisfied the above standard for bundled conditions, and that the right wrist condition was sufficiently justified as separately unfitting.

The panel then deliberated the appropriate coding and rating recommendation.  The maximum rating for code 5215 is 10%, and the minimum thresholds for that were not satisfied by the ROM evidence.  Panel members agreed there was satisfactory evidence of painful motion to support a 10% rating IAW VASRD §4.59, as recorded on the VA joints examination proximate to separation.  The only alternative joint code for the wrist (5214) specifies ankylosis that was not present.  There is no VASRD §4.71a criterion to support a rating higher than 10%.  After due deliberation, considering all evidence and with deference to reasonable doubt, the panel recommends the right wrist condition as separately unfitting with a 10% rating, coded 5010 (arthritis, due to trauma).
BOARD FINDINGS:  In the matter of the bundled left ankle and right wrist conditions, the panel recommends two separate ratings as follows:  an unfitting left ankle condition rated 10%, coded 5024-5271; and an unfitting right wrist condition, rated 10%, coded 5010, 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	
Chronic Left Ankle Pain and Instability	5024-5271	10%	
Chronic Right (Dominant) Wrist Pain	5010	10%	
COMBINED	20%	

AR20190002409, 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.