RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02778
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050730

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E7, Track Vehicle Repairer, medically separated for “left wrist pain” and “low back pain,” rated 0% each, with a combined disability rating of 0%.  “Right knee degenerative changes” was determined to have existed prior to service (EPTS) and was not rated.  

CI CONTENTION:  “My injuries were sustained in a line of duty accident.  I was doing my job when I got hurt.”  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 - 20041217	VARD - 20051228	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Wrist Pain	5215	0%	Left Wrist Triangular Fibrocartilage Complex Tear	5215	10%	20051008	
Low Back Pain	5237	0%	Degenerative Changes of the Lumbar Spine	5242	NSC	20051008	
Right Knee Degenerative Changes	5003	EPTS	Degenerative Changes of the Right Knee	5010-5260	NSC	20051008	
Left Shoulder Pain Status-Post Rotator Cuff Tear Repair	Not Unfitting	Rotator Cuff Tear of Left Shoulder	5201	20%	20051008	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30% 	

ANALYSIS SUMMARY:  

Left Wrist Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent left wrist arthroscopic synovectomy and arthroscopic assisted triangular fibrocartilage complex (TFCC) repair on 29 September 2004.  During the 30 November 2004 MEB NARSUM examination, 8 months prior to separation, the CI complained of the inability to use his left wrist due to pain.  Physical examination showed well healed incisions over the dorsum and dorsal-volar aspect of the left wrist with no evidence of infection.  His range of motion (ROM) was 40 degrees of dorsiflexion (normal 70) and 40 degrees of palmar flexion (normal 80).  He could ulnar deviate 5 degrees (normal 45) and radial deviate 5 degrees (normal 20).  He was neurovascularly intact distally with normal function of his digits.  Light touch was intact over his left hand.  

A follow-up orthopedic examination on 11 March 2005, 4 months prior to separation, noted complaints of 4/10 wrist pain with activities of daily living, dorsiflexion, loading, griping or twisting.  Physical examination showed ROM of 55 degrees volar (palmar) flexion, 35 degrees dorsiflexion and full forearm rotation with pain at the extremes of ROM.  He had pain with the ulnar deviation grind maneuver.  In addition, the hand showed a 10‑millimeter firm nodule in the long finger palmar fascia band with subtle thickening of the free tenderness cord.  There was full flexion in the digit and very subtle thickening in the ring finger fascia.  

At the 8 October 2005 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI reported constant sharp pains in his left wrist.  The examiner recorded left wrist dorsiflexion of 50 degrees, palmar flexion of 50 degrees and radial and ulnar deviation of 15 degrees each, with pain in all planes of motion).  The ROM was not additionally limited by pain, fatigue, weakness or lack of endurance following repetitive use.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left wrist condition 0%, coded 5215 (wrist, limitation of motion of), citing the condition did not meet minimal rating criteria.  The VA rated the left wrist condition 10%, coded 5215, based on the C&P examination, citing pain.  

There was no ankylosis or limitation of motion which supported a rating under the diagnostic codes for limitation of wrist dorsiflexion or palmar flexion (5214, 5215).  However, there was evidence of painful motion with functional loss supporting a 10% rating for the right wrist based on §4.59, §4.40 and §4.45).  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 wrist condition, coded 5099-5003.  

Low Back Pain.  According to the STR and MEB NARSUM, the CI’s back condition began in November 2003 after he sustained a fall after being struck by a military vehicle.  MRI of the lumbar spine at that time showed degenerative changes with desiccation of the disc, but no acute fracture and no nerve root impingement.    

The MEB NARSUM examination noted complaints of back pain that interfered with bending, stooping, crawling, walking or standing for prolonged periods.  Physical examination showed a non-antalgic gait with tenderness of the lumbosacral spine.  There were no ROM measurements in evidence.  The physical therapy addendum of 6 December 2004, 7 months prior to separation, showed normal lumbar spine active flexion (90 degrees) and combined ROM of 220 degrees (normal 240).  There was no mention of pain.  

At the C&P examination the CI reported constant dull back pain with periodic sharp pains with certain movements.  He also had severe nightly pains that radiated into the left hip.  Physical examination showed a normal gait.  The ROM of the lumbar spine was normal with pain in all planes of motion.  The ROM was not additionally limited by pain, fatigue, weakness or lack of endurance following repetitive use.  Tenderness and spasm were present.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 0%, coded 5237 (lumbosacral strain).  The VA did not rate the back condition, but indicated it was not service-connected coded 5242 (degenerative arthritis of the spine).  The panel agreed that a 10% rating, but no higher, was justified for muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour as reported on the C&P examination.  There was no documentation of intervertebral disc syndrome 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 back condition, coded 5242.  

Right Knee Degenerative Changes.  According to the STR and MEB NARSUM, the CI underwent arthroscopic surgery for debridement of cartilage in 1994.  He again had surgery in 1998 for removal of a foreign object.  The CI was placed on a permanent profile for his right knee after the surgeries where he was only required to walk for the Army physical fitness test.  A 10 December 2004 profile showed no lower extremity diagnosis, limitations or restrictions.  

The MEB NARSUM examination showed normal gait, knee ROM, strength and reflexes.  An addendum on 25 April 2005, 3 months prior to separation, noted ongoing right knee pain.  Physical examination revealed a ROM of 130 degrees flexion (normal 140) and 0 degrees extension (normal) with pain at the extreme ranges of motion.  Lachman's test was negative, as were anterior drawer and laxity with varus/valgus stress.  The 27 April 2005 physical therapy examination, noted complaints of occasional right knee pain.  Right knee ROM evaluation showed flexion of 125 degrees and extension of 0 degrees.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB did not rate the right knee condition, concluding it was EPTS without evidence of permanent service aggravation.  The VA did not rate the right knee condition, indicating that it was NSC, analogously coded 5010-5260 (arthritis, due to trauma and leg, limitation of flexion), citing no evidence of a current disability which began in military service.  The panel noted the STR clearly showed the diagnosis of right knee degenerative joint disease since 1994 when surgery was required.  There was no evidence that the right knee was injured or made worse by the November 2003 vehicle accident.  Although right knee pain continued after the accident, the evidence failed to show any fracture or tear due to the accident.  All available STRs reference treatment and clinic visits for other injuries.  None mentioned the right knee.  Therefore, the panel found the evidence failed to show that the right knee condition was incurred or exacerbated while entitled to base pay.  The degenerative changes of a joint is a chronic disease, which develops over time.  After due deliberation, considering all of 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 that the right knee condition.  

Contended PEB Conditions:  Left Shoulder Pain.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  In November 2003, the CI reported left shoulder pain after being struck by a military vehicle.  He underwent arthroscopic surgical repair his rotator cuff of the left shoulder in July 2004.  The patient rehabbed appropriately and stated the strength in the shoulder had returned but he was having pain with activity.  The pain was exacerbated with overhead activities and reaching across his body.  

The NARSUM ROM examination showed left shoulder flexion of 110 degrees (normal 180), abduction of 180 degrees (normal), with normal strength.  He had pain with overhead motion, as well as positive Neer's and Hawkin's shoulder impingement tests.  

At the C&P examination, the CI reported sharp shoulder pains with certain overhead movements or weight bearing activities.  The examination showed left shoulder flexion of 120 degrees with pain, and abduction of 180 degrees.  The commander’s statement noted that the CI’s injuries resulted in him being unable to perform his assigned duties as track vehicle repairer which required heavy lifting, standing for long periods of time and moving over, under, and around heavy tracked vehicles.  The permanent U3 profile dated 30 November 2004 listed left shoulder pain.  After due deliberation, the panel agreed that the preponderance of evidence with regard to the functional impairment of the left shoulder condition favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 5003 (arthritis, degenerative) and meets the VASRD §4.71a criteria for a 10% rating due to painful motion IAW §4.59.  The shoulder condition directly affecting the CI’s ability to perform his primary duties that involved heavy lifting and regular overhead work.

BOARD FINDINGS:  In the matter of the left wrist condition, the panel recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the back condition, the panel recommends a disability rating of 10%, coded 5242 IAW VASRD §4.71a.  In the matter of the contended left shoulder condition, the panel agrees it was unfitting and recommends a disability rating of 10%, coded 5003 IAW VASRD §4.71a.  In the matter of the right knee condition and IAW VASRD §4.71a, the panel recommends no change in the PEB 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; 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	
Left Wrist Pain	5099-5003	10%	
Low Back Pain	5242	10%	
Left Shoulder Pain	5003	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170419, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180008720, 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. 

Sincerely,					      
Enclosure