RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX 	CASE:  PD-2017-02835
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080117

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Combat Engineer, medically separated for “left distal radial ulnar joint (minor) instability” and “bilateral hip pain.” rated 10%, 0%, respectively with a combined disability rating of 10%.  “Bilateral shoulder pain” was determined to have existed prior to service (EPTS) with no permanent service aggravation (PSA) and was not rated. 

CI CONTENTION:  Review of all conditions requested.  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 - 20080102	VARD - 20080430	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Distal Radial Ulnar Joint (minor) Instability	5299-5212	10%	Left Wrist Tendonitis Status Post (S/P) Left Wrist Surgery	5215-5024	10%	20080310	
Bilateral Hip Pain due to Iliotibial Band Subluxation	5099-5024	0%	Right Hip Tendonitis	5024	10%	20080310	
			Left Hip Tendonitis	5024	10%	20080310	
Bilateral Shoulder Pain	5202	EPTS	Left Shoulder Tendonitis S/P Surgery	5024	0%	20080310	
			Right Shoulder Pain	5021	NSC	20080310	
Bilateral Knee Pain, due to Iliotibial Band Syndrome	Not Unfitting 
	Left Knee Pain 	5257	NSC	20080310	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Left Distal Radial Ulnar Joint (minor) Instability.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s non-dominant left wrist condition initially began in December 2001 while still in high school, however, there was no notation on his entry physical.  The CI entered active duty and did well to include routinely obtaining a maximum score on his Army Physical Fitness Test (APFT).  In November 2004 he re-injured his left wrist with hyperextension of the wrist and dislocation of the thumb during a unit physical fitness football game.  Wrist X-rays were negative.  Subsequently, while deployed, he injured the wrist again when his backpack got caught on something and he was hanging off a vehicle by his wrist; he developed worse pain and hypermobility.  The CI underwent an open repair of the triangular fibrocartilage of the wrist on 2 November 2006.  The repair was not successful and the CI underwent a second surgery in July 2007 for reconstruction.  Post-operatively there was no improvement in his hypermobility or pain.  

During the 1 October 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, physical examination showed scarring of the left wrist that was not tender.  At the MEB orthopedic examination on 14 November 2007 the CI reported wrist pain and instability.  Wrist range of motion (ROM) was 90 degrees of dorsiflexion (normal 70) and 80 degrees of palmar flexion (normal 80).  There was visible subluxation of the DRUJ (distal radioulnar joint).  The MEB NARSUM examination one week later, noted complaints of wrist pain, aggravated by use and subluxation at the DRUJ.  Physical examination cited the DD Form 2808 examination and the MEB orthopedic examinations; no additional physical examination was performed.  

At the 10 March 2008 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported left wrist weakness, stiffness, giving way, and locking but no significant pain.  Physical examination showed tenderness and the CI could subluxate the ulna at will.  Wrist ROM was dorsiflexion of 70 degrees and palmar flexion of 80 degrees with painful motion.  There was no additional loss of motion with repetitive use, but there was additional limitation due to pain.  Wrist X-rays showed post-surgical changes of the distal radius and ulna, without degenerative changes.  There was localized soft tissue swelling adjacent to the ulna styloid.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left wrist condition 10%, analogously coded 5299-5212 (impairment of the radius), citing radio-ulnar instability that prohibits strenuous use of the left arm.  The VA also rated the left wrist condition 10%, dual coded 5215-5024 (limitation of wrist motion-tenosynovitis), based on the C&P examination, citing objective evidence of tendonitis with painful or limited motion of the wrist joint.  There was no limitation of wrist dorsiflexion or palmar flexion that supported a rating under the VASRD diagnostic code for limitation of motion (5215).  The panel concurred that a 10% rating for functional loss (§§4.40, 4.45, 4.59) due to instability and pain was supported for painful motion under 5024 or 5215.  There was no wrist ankylosis (5214) to consider a rating under that code.  There was therefore no higher rating than 10% supported under any applicable VASRD code.  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 left wrist condition.  

Bilateral Hip Pain due to Iliotibial Band Subluxation (snapping hip syndrome).  The PEB combined the bilateral hip conditions under a single disability rating, analogously coded 5099-5024 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 evidence for the bilateral hip conditions is presented below, with attendant recommendations regarding separate unfitness, and separate rating if indicated. 

The permanent profile dated 14 September 2007 listed joint laxity of the hips, shoulders and wrists.  The commander’ statement dated 10 March 2008 implicated the CI’s hypermobility syndrome, specifically noting the CI’s profile limited his successful duty performance.  According to the STR and MEB NARSUM, the CI’s bilateral hip condition began while deployed to Iraq.  The CI reported bilateral hip pain primarily while carrying heavy loads.  In February 2007 imaging was normal, including X-rays and MRI.  He was first diagnosed with iliotibial subluxation in November 2007.  At the MEB orthopedic examination 2 months prior to separation, the CI reported left hip pain.  Bilateral hip ROM was abduction of 45 degrees (normal), external rotation was 90 degrees (normal 60).  There was tenderness over the greater trochanter and palpable subluxation of the iliotibial band over the trochanter, but no pain with ROM.  

The MEB NARSUM examination one week later noted complaints of hip pain with strenuous physical exertion.  The CI reported no hip pain at rest or with normal activity, but with strenuous exertion he had lateral hip pain that would last for days.  Physical examination cited the MEB orthopedic examination summarized above and no additional examination was documented.  The MEB NARSUM examiner determined the CI fell below retention standards due to bilateral hip iliotibial subluxation.  

At the C&P examination the CI reported intermittent hip pain, with weakness after prolonged sitting or standing, and fatigability with instability when he was tired.  The CI reported that he could function with the pain without medication.  Physical examination showed the right hip was normal.  There was moderate subluxation of the left hip at will.  Right and left hip ROM measured in degrees were each flexion of 125 degrees (normal), extension of 30 degrees (normal 20), with normal abduction and external rotation, with painful motion of both hips.  There was no additional loss of ROM with repetitive use but there was additional limitation due to pain of both joints.  Bilateral hip X-rays were normal.  

The panel first considered if each of the hip conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Both hips were profiled, implicated by 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 each of the bundled hip conditions was reasonably considered separately unfitting.  The panel then considered its rating recommendation for the unfitting hip conditions at the time of separation.  

The PEB rated the bilateral hip condition 0%, analogously coded 5099-5024, citing the condition was “without loss of motion.”  The VA rated the right and left hip conditions separately 10% each, coded 5024 (tenosynovitis), based on the C&P examination, citing painful motion.  At the orthopedic examination prior to separation, there was no pain with motion noted, but tenderness and subluxation were documented.  At the post-separation VA examination painful motion of both hips was documented.  The examinations were of equal distance from the date of separation and the VA examination was more VASRD-compliant including repetitive use, therefore the panel resolved reasonable doubt in favor of the CI and concurred that a 10% rating for functional loss (§§4.40, 4.45, 4.59) due to instability and pain was appropriate for each hip.  There was no limitation of motion which supported a higher rating under the diagnostic codes for limitation of thigh flexion or extension, or thigh impairment (5251, 5252).  There was no evidence of hip ankyloses, flail hip joint, or femur impairment (5250, 5254, 5255) for a rating under those respective codes.  There was therefore no rating higher than 10% for either hip 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 unfitting right hip condition and 10% for the unfitting left hip condition, both coded 5299-5252 (analogous to limitation of thigh flexion).  

Contended PEB Conditions:  Bilateral Shoulder Pain and Bilateral Knee Pain Secondary to Iliotibial Band Syndrome.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  

Bilateral Shoulder Pain.  The PEB combined the bilateral shoulder conditions under a single disability rating, and adjudicated them as unfitting but EPTS with no PSA. The conditions were coded 5202 (other impairment of the humerus) and but no disability rating was provided. As elaborated with the bilateral hip condition, the combining of conditions 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’s initial charge in this case was therefore directed at determining if combining conditions was justified.    The evidence for the bilateral shoulder conditions is presented below, with attendant recommendations regarding separate unfitness, PSA and separate rating if indicated. 

The bilateral shoulder condition was profiled and implicated in the commander’s statement and did not meet retention standards.  The panel concluded there was not a preponderance of evidence in the service records which overcame the panel’s presumption that each of the bundled shoulder conditions was reasonably considered separately unfitting. The panel next considered whether or not there was evidence that each shoulder was PSA.  A presumption of service aggravation may only be overcome by a preponderance of competent medical evidence and accepted medical principles that the natural progression of a pre-existing condition was clearly unaltered by any consequence of military service.  

According to the STR and MEB NARSUM, the CI’s bilateral shoulder condition began in high school while wrestling.  He experienced multiple dislocations of the left shoulder and one dislocation of the right shoulder.  His military enlistment physical noted the CI had generalized ligamentous laxity.  However, he was very physically active and fit and a waiver was granted.  The CI initially had no problems with his shoulders.  He reported he reinjured his left shoulder in the unit physical training football game incident mentioned above and since then it had not felt as strong.  He was still able to exceed scores of 300 on his APFTs, pursue kickboxing, and was a successful competitor on the Army 10-Miler team.  However, in the year before separation he reported increased dislocations of both shoulders, with the left dislocating twice per week and the right once per month.  Left shoulder MRI in September 2006 showed humeral head changes consistent with dislocation injuries and a labral tear.  At the MEB orthopedic examination, 2 months prior to separation, the CI reported bilateral shoulder pain and instability.  Shoulder flexion was 180 degrees (normal) bilaterally and he was able to subluxate both shoulders voluntarily.  At the MEB NARSUM examination complaints of frequent bilateral shoulder dislocations were noted.  Physical examination cited the MEB orthopedic examination above and no additional examination was documented.  

At the C&P examination the CI reported intermittent left shoulder dislocations with pain and he had to “relocate” it, as often as once per week.  Physical examination showed a normal right shoulder.  There was tenderness of the left shoulder and the CI could subluxate the shoulder.  Bilateral shoulder ROM was flexion and abduction of 180 degrees each, without painful motion.  After repetitive motion there was additional limitation of the right shoulder due to pain, but there was no pain on the left.  Left shoulder X-rays were normal.  

The panel agreed the PEB did not overcome the presumption of service aggravation for the left shoulder condition based on the following: the CI reported injury of the shoulder in November 2004.  He sought treatment for left shoulder instability, the left shoulder was imaged, and surgery was offered.  However, there was a preponderance of evidence that there was no permanent worsening of the right shoulder condition.  The CI had generalized ligamentous laxity noted at his entry physical and a waiver was granted.  At separation, the right shoulder had full and painless ROM, but with continued ligamentous laxity, which was congenital.  

The panel directed attention to its rating recommendation for the unfitting left shoulder based on the above evidence.  The PEB rated the bilateral shoulder condition as unfitting but EPTS without PSA, coded 5202.  The VA rated the left shoulder condition 0%, coded 5024 (tenosynovitis), based on the C&P examination, citing full left shoulder painless ROM.  

A 0% rating and no higher was supported for left shoulder dislocations, coded 5202.  Despite recurrent subluxations, no guarding of the left shoulder was noted.  In fact the CI voluntarily subluxated his left shoulder.  There was no limitation of motion of the shoulder to support a rating under diagnostic code 5201 (arm, limitation of motion).  The MEB orthopedic and VA C&P examinations did not note findings such as swelling, muscle spasm, satisfactory evidence of painful motion, or other evidence of functional loss to support a 10% rating IAW VASRD §§4.59, 4.40 or 4.45.  There was no nonunion or malunion of the clavicle or scapula to warrant any rating under the 5203 code (clavicle or scapula, impairment).  There was therefore no higher than a 0% rating supported under any applicable VASRD code.  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 shoulder condition, coded 5202.  

Bilateral Knee Pain. The bilateral knee condition was not profiled or implicated in the commander’s statement, and did not fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the left wrist condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the bilateral hip condition, the panel recommends that each joint be separately adjudicated as follows: an unfitting right hip condition coded 5299-5252 and rated 10%, and an unfitting left hip condition, coded 5299-5252, both IAW VASRD §4.71a.  In the matter of the bilateral shoulder condition the panel recommends that each joint be separately adjudicated as follows: an unfitting left shoulder EPTS condition permanently service aggravated, rated 0%, coded 5202 IAW VASRD §4.71a, and an unfitting right shoulder condition, EPTS without permanent service aggravation.  In the matter of the contended bilateral knee condition, the panel recommends no change from the PEB determination as not unfitting.  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 Distal Radial Ulnar Joint (minor) Instability 	5299-5212	10%	
Left Hip Pain	5299-5252	10%	
Right Hip Pain	5299-5252	10%	
Left Shoulder Pain	5202	0%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170307, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20190008798, XXXXXXXXXXXXXXXXXX 

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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 permanent 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.