RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01864
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061120

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Administrative Specialist, medically separated for “left foot pain,” “right knee pain” and “pain [in] both shoulders and left elbow,” rated 10%, 0% and 0%, respectively, with a combined disability rating of 10%. 

CI CONTENTION:  Review the left biceps rupture with reattachment, right knee ACL replacement and left plantar fasciitis.  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 - 20061020	VARD - 20070308	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Foot Pain	5399-5310	10%	Plantar Fasciitis, Left Foot	5276	0%	20070202	
Right Knee Pain	5003	0%	Degenerative Joint Disease, Right Knee	5261	10%	20070202	
Bilateral Shoulder and Left Elbow Pain	5099-5003	0%	Left Bicep Repair	5299-5211	10%	20070202	
			Bilateral Shoulder Condition	5299-5201	NSC	20070202	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY: 

Left Foot Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s left foot condition began in 1995 when he was diagnosed with plantar fasciitis.  X-rays and bone scan revealed an old fracture deformity of the left fifth metatarsal and a calcaneal (heel) spur.  In February 2006, an orthopedic examination continued the diagnosis of plantar fasciitis of the left foot.    At the 22 June 2006 MEB NARSUM examination, 5 months prior to separation, the CI endorsed daily pain about the left foot.  The physical examination (PE) referred to a prior orthopedic examination noting marked tenderness along the left plantar fascia.  

At the 2 February 2007 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported persistent left plantar fascial pain.  His PE revealed a flattened and tender left foot arch treated with inserts.     

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left foot condition 10%, analogously coded 5399-5310 (group X, muscle function), citing “moderate pain.”  The VA rated the left foot condition 0%, coded 5276 (flat foot, acquired), based on the C&P examination, citing the presence of mild symptoms relieved with built-up shoe or arch supports.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel agreed there was no evidence to support a rating higher than the 10% rating adjudicated by the PEB.  Therefore, the panel concluded there was insufficient cause to recommend a change in the PEB’s adjudication for the left foot condition.

Right Knee Pain.  According to the STR and MEB NARSUM, the CI underwent surgery to debride a loose body in the right knee in June 1998.  He also underwent a right anterior cruciate ligament (ACL) reconstruction in 2004.   Post-surgical X-rays of the right knee revealed osteoarthritis.   The MEB NARSUM examination referred to the orthopedic examination conducted on 2 February 2006, 10 months prior to separation.  The CI endorsed give-way and instability of the right knee.  Tenderness was present about the inside aspect of the kneecap.  There was no evidence of painful motion, joint effusion or global instability.  A right knee range of motion (ROM) study conducted on 6 June 2006, 5 months prior to separation, showed flexion of 127 degrees (normal 140) and extension of 4 degrees (normal 0).  

At the C&P examination, the CI reported persistent, not incapacitating, right knee pain.  The CI could function and perform daily activities and the condition did not keep him from being employed.  He denied local weakness, fatigability, decreased endurance, incoordination or painful flare-ups.  His PE revealed tenderness over the bottom aspect of the kneecap with slight swelling.  The ROM study showed flexion of 100 degrees and extension of 10 degrees.  No instability was demonstrated.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 0%, coded 5003 (degenerative arthritis), citing arthritis of one major joint.  The VA rated the right knee condition 10%, coded 5261 (leg, limitation of extension), based on the C&P examination, citing reduced extension.  The panel agreed that there was no objective evidence of painful motion with functional loss supporting a maximum 10% rating (based on §4.59, §4.40 and §4.45).  There likewise was no limitation of motion which attained a 10% rating under the diagnostic code for limitation of flexion (5260); however, a 10% rating was supported by limitation of knee extension to 10 degrees as noted at the most probative VA examination, 2 months after separation.  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.  There was no fracture, nonunion or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  No additional functional limitation was evidenced by the examinations.  After due deliberation, considering all the evidence and mindful of VASRD §4.3, the panel recommends a disability rating of 10% for the right knee condition, coded 5261. 

Bilateral Shoulder and Left Elbow Pain.  The PEB combined the left and right shoulder and left elbow conditions under a single disability rating, analogously coded 5003 and rated 0% with application 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 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 adjudicated by the PEB.  The evidence for the right shoulder, left shoulder and left elbow conditions is presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

Left Elbow Pain.  According to the STR and MEB NARSUM, the left-handed CI underwent surgery to repair a rupture of the left distal biceps tendon in September 2000.  Post-surgical X-rays in February 2006 showed no radiographic abnormalities.  At the MEB NARSUM examination, the CI expressed tingling and numbness of the left third and fourth fingers due to the elbow condition.  The PE noted “the left elbow was unremarkable.”  At the VA C&P examination, the CI reported no current musculoskeletal complaints referable to the left elbow.  The PE revealed tenderness over the distal aspect of the left bicep muscle (near the elbow).  There was decreased ROM of the left elbow noting flexion to 120 degrees (normal 130) and extension to 10 degrees (normal 0).  Painful motion was present only upon pronation movement of the left forearm. 

The panel directed attention to its rating recommendation based on the above evidence.  Utilizing the analogous 5003 code, the PEB bundled the dominant left elbow condition with both shoulders into a single condition and rated 0% whereas the VA separately rated the elbow condition 10%, coded analogous to 5211 (ulna; impairment) at 10% citing, residual limitation of motion of the elbow.  The panel first considered whether the painful left elbow condition remained separately unfitting, having decoupled it from the combined PEB adjudication.  In determining a separate unfitting condition, panel members considered the unremarkable pre-separation PE findings; unremarkable X-rays; absent subjective elbow complaints post separation; minimal limitation of motion and painful motion present in only a single movement (1 of 4) of the elbow.  After due deliberation, considering all the evidence and mindful of VASRD §4.3, panel members agreed that the minimal adverse physical findings in relation to the left elbow condition did not support a conclusion that its functional impairment was integral to the CI’s inability to perform the duties of his MOS; and therefore, was not considered separately unfitting.  

Bilateral Shoulder Pain.  According to the STR and MEB NARSUM, the CI’s bilateral shoulder pain began in 2004 without history of direct trauma or other injury.  Although absent a hard copy of a radiologic report, the STR documented prior X-rays noting degenerative arthritis of both acromial-clavicular (AC) joints.  However, the 28 September 2006 MEB radiographic report on both shoulders demonstrated “minimal AC joint degenerative changes on the left” and the examiner’s impression was “unremarkable shoulders.”    

At the MEB NARSUM examination, the examiner documented a history of bilateral shoulder pain while deployed which was further documented as “chronic daily pain.”  The PE revealed “weakness in abduction of the shoulders.”  The NARSUM referred to the physical therapy examination performed on 9 June 2006 for ROM measurements citing, right shoulder flexion of 115 degrees (normal 180) and abduction to 125 (normal 180) and left shoulder flexion to 155 degrees and abduction to 145 degrees.  There was no comment regarding the presence of painful motion.  

At the C&P examination, the CI reported no current musculoskeletal complaints referable to either shoulder nor did the PE document any objective physical findings regarding either shoulder.  There was no diagnosis rendered with regard to either shoulder.   

The panel directed attention to its rating recommendation based on the above evidence.  Utilizing the analogous 5003 code, the PEB bundled both shoulders into a single condition and rated 0% whereas the VA determined the bilateral shoulder condition was not service-connected.  The panel first considered whether each shoulder remained separately unfitting, having decoupled them from the combined PEB adjudication.  Additionally, panel members discussed the X-ray evidence of degenerative arthritis of the A-C joints and concluded that the anatomy of the entire shoulder girdle encompasses numerous bones to include the clavicle; therefore, residual findings of the shoulders were considered in the panel’s final recommendation.  After deliberation, all members agreed that it would be highly speculative to conclude that the minimal objective physical evidence found in either shoulder (separately) would cause the CI’s inability to perform within his MOS; however, members also found it reasonable to surmise that it was the combination of pathology/painful symptoms from both shoulders that rendered him unfit for duty.  The panel agreed there was no objective evidence of painful motion with functional loss supporting a rating based on §4.59, §4.40 and §4.45.  Additionally, having no absolute adverse physical findings at the most probative VA examination lent great support for not recommending a positive rating impairment. Therefore, after due deliberation, considering all of the evidence and mindful of VASRD §4.3, the panel recommends no change in the PEB’s 0% rating for the chronic bilateral shoulder condition.

BOARD FINDINGS:  In the matter of the left foot condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the right knee condition, the panel recommends a disability rating of 10%, coded 5261 IAW VASRD §4.71a.  In the matter of the bundled left elbow and bilateral shoulder pain conditions and IAW VASRD §4.71a, the panel recommends no change in the PEB’s bundling and overall rating adjudication.  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, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Foot Pain	5399-5310	10%	
Right Knee Pain	5261	10%	
Left Elbow and Bilateral Shoulder Pain 	5099-5003	0%	
COMBINED	20%	

AR20180016696 , 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), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557.
A copy of this decision has also been provided to the Department of Veterans Affairs.