[AR Number], XXXXXXXXXX

XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXX

Dear XXXXXXXXXX:

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 40% 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 and to the counsel you listed on your application

Enclosure

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-03271
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070603

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Medical Logistics Specialist, medically separated for “asthma” and “chronic pain, bilateral knees and right heel,” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  “Disabilities have become worse over time.”  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 – 20070417	VARD - 20080820	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Asthma	6602	10%	Asthma	6602	10%	20080703	
Chronic Pain, Bilateral Knees and Right Heel	5099-5003	10%	Left Knee Chronic PFS 	5257	10%		
			Right Knee Chronic PFS 	5257	0%		
			Right Heel Pain	5015	NSC		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:

Asthma.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI was evaluated for atypical chest pain on 25 August 2006.  She reported a history of these since the sixth grade, but none had been severe.  She was noted to have shallow and painful respirations, suspected of reactive airway disease (asthma), and was given albuterol (inhalational bronchodilator).  Pulmonary function testing (PFT) 3 days later showed an FEV1 of 60% after bronchodilator and an FEV1/FVC of 86%.  She was seen in the emergency room (ER) on 12 September 2006 for atypical chest pain, but did not have respiratory distress.  Chest X-rays at both clinical encounters were normal.  Advair (inhaled anti-inflammatory) was added to her medications the next day in primary care.  She was seen in the allergy clinic on 30 January 2007 and the asthma diagnosis was confirmed.  

The 30 January 2007 MEB NARSUM allergy addendum, 4 months prior to separation, noted complaints of mild shortness of breath becoming more frequent with shortness of breath on exertion and wheezing at night.  Current asthma medications were Advair and Xopenex (albuterol).  Physical examination showed a normal respiratory rate, normal oxygen saturation and clear lungs on auscultation.  The PFT showed an FEV1 of 72% after bronchodilator and an FEV1/FVC of 91%; both with a significant bronchodilator response.  

An ophthalmological evaluation on 4 March 2008, 9 months after separation, noted continued use of both albuterol and Advair.  At the 3 July 2008 VA Compensation and Pension (C&P) examination, 13 months after separation, the CI reported continued use of a bronchodilator and inhaled anti-inflammatory steroid.  Physical examination showed clear lungs and a normal respiratory rate.  The PFT done 2 days earlier showed FEV1 of 73% and an FEV1/FVC of 108%, both after bronchodilator and with good effort.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the asthma condition 10%, coded 6602 (asthma, bronchial), citing the CI only had a 1 month supply of Advair on 3 September 2006 (8 months previously).  The VA rated the asthma condition 10%, coded 6602, based on the C&P examination, citing PFT findings.  Although the panel agreed that the PFT findings met the criteria for a 10% rating, the CI’s continued use of inhaled anti-inflammatory medication supported a 30% rating.  No other VASRD §4.97 asthma criterion supported a higher rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the asthma condition, coded 6602.

Chronic Pain Bilateral Knees and Right Heel.  The PEB combined the bilateral knees and right heel conditions under a single disability rating, coded analogously to 5003 and rated 10% 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 of the PEB.  The evidence for the bilateral knees and right heel conditions are intertwined in the record and are therefore presented together.  However, individual recommendations are made regarding separate unfitness, and separate rating if indicated.  

According to the STR and MEB NARSUM, the CI’s left knee pain began in March 2005 during a run.  On 10 November 2005 she reported a 6-month history of left knee pain, but X-rays and MRI were normal.  A primary care examination on 17 January 2006, revealed global left knee pain.  Range of motion (ROM) was “within normal limits.”  A whole body bone scan on 19 January 2006 revealed no left or right knee stress changes but the right hind foot had non-specific stress changes.  A physical medicine examination on 8 February 2006 documented left knee pain throughout ROM testing, but an orthopedics examination a week later showed “full” ROM without address painful motion.  The CI was diagnosed with patellofemoral dysfunction.  A physical therapy examination on 24 February 2006, revealed left knee flexion of 103 degrees (normal 140) and extension of 4 degrees (normal 0); right knee flexion of 133 degrees and extension of 0 degrees.  Painful motion was not addressed for either knee.  Meniscal irritation testing was negative.  The examiner also documented the left knee was globally tender due to a tight hamstring and IT band.  The CI was also noted to have pes cavus (high arches) and issued orthotics.  She had right heel pain but no examination was performed.  Physical therapy on 26 April 2006 noted the right knee ROM remained 0-133 degrees, but the left knee ROM was reduced to 20-92 degrees.  However, a primary care examination on 31 August 2006, showed a normal gait and left knee ROM was limited by “stiffness,” the remainder of the examination was unremarkable.  A physical medicine examination on 5 October 2006, noted “normal” left knee ROM that elicited pain.  

During the 20 November 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, the CI reported the use of a left knee brace and inserts for her right heel.  Physical examination showed “decreased” left knee flexion which elicited pain.  The right heel was tender to palpation.  The 18 December 2006 MEB NARSUM examination, 6 months prior to separation, noted complaints of chronic left knee pain and intermittent right foot pain.  Physical examination showed left knee flexion of 120 degrees and extension of 0 degrees; painful motion was present.  There was mild kneecap and right heel tenderness.  Meniscal irritation testing was negative and the gait was not recorded.  

At the 3 July 2008 C&P examination, 13 months after separation, the CI reported that her right knee pain had “resolved” but occurred after prolonged walking with “certain shoe styles.”  She endorsed constant left knee pain and “grinding.”  Physical examination of the right foot was normal and free from tenderness.  The right heel condition was thought to be resolved.  Physical examination showed a normal gait.  Left knee flexion was 125 degrees and extension was 0 degrees; painful motion was present.  Meniscal irritation testing was negative.  The CI declined a right knee examination.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral feet and right heel condition 10%, analogously coded 5099-5003 (arthritis, degenerative), citing the USAPDA pain policy.  The VA rated the left knee condition 10%, coded 5257 (knee, other impairment), based on the C&P examination, citing painful motion.  The VA rated the right knee condition 0%, also coded 5257, citing declination of examination.  The VA did not service connect the right heel condition, coded 5015 (bones, new growths of, benign), citing resolution without residuals.

The panel first considered if the left and right knee and the right heel were separately unfitting.  The CI was entered into the MEB process for the left knee condition.  The MEB determined that all three conditions were medically unacceptable and the profile listed “chronic knee pain” and “foot pain.”  The CI was treated for over a year for left knee pain which did not resolve.  The evidence supported a finding the left knee was separately unfitting at separation.  The STR did not show right knee treatment and the whole body bone scan was negative for pathology.  At the time of the C&P examination, the CI reported the right knee had resolved and declined examination.  The preponderance of evidence does not support a finding the right knee was separately unfitting at separation.  The first entry for the right heel was an incidental finding (non-specific stress changes) found by the whole body bone scan.  There were two STR clinical entries for the right heel, but both in association with the left knee.  Mild tenderness was noted on the MEB NARSUM examination, but the C&P examination documented resolution of right heel pain.  The preponderance of evidence does not support a finding the right heel was separately unfitting at separation.

The panel then considered a rating recommendation for the left knee.  The panel agreed there was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261). However, there was evidence of painful motion with functional loss supporting a 10% rating based on §4.59, §4.40 and §4.45.  Additionally, there was no meniscal surgery (5259), no sufficient evidence of dislocated meniscus or loss body causing frequent locking with recurrent effusions (5258), nor fracture, nonunion or malunion of the femur or tibia causing a knee impairment (5255, 5262) to support a rating under those codes.  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 left knee condition, coded 5299-5260.  

BOARD FINDINGS:  In the matter of the asthma condition, the panel recommends a disability rating of 30%, coded 6602 IAW VASRD §4.97.  In the matter of the left knee condition, the panel recommends a disability rating of 10%, coded 5299-5260 IAW VASRD §4.71a.  In the matter of the right knee and right heel conditions, the panel agrees they are not unfitting and cannot recommend them for disability rating.  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	
Asthma	6602	30%	
Left Knee Pain	5299-5260	10%	
COMBINED	40%	

The following documentary evidence was considered: