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.

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-04019
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070717

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Patriot Operations/Maintenance Specialist, medically separated for “chronic low back pain,” chronic right knee pain” and “chronic right great toe pain,” rated 20%, 0%, and 0%, respectfully, with a combined disability rating of 20%.

CI CONTENTION:  Review all conditions.  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 - 20070608	VARD - 20070908	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	20%	Low Back Pain	5299-5237	10%	20070712	
Chronic Right Knee Pain	5019	0%	Right Knee Bursitis	5019	10%		
Chronic Right Great Toe Pain	5003	0%	Right Great Toe Arthritis	5010	0%		
Allergic Rhinitis	Not Unfitting	Allergic Rhinitis	6522	0%		
Hypertension		Hypertension	7101	10%		
Folliculitis		Folliculitis	7899-7806	0%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:

Chronic Low Back Pain (LBP).  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s LBP began in June 2006 after falling approximately nine feet from an exercise bar during basic training.  X-rays demonstrated bilateral spondylolysis at L5.  The condition worsened after a motor vehicle accident in September 2006.  An MRI of the thoracic spine showed straightening of the dorsal spine without focal disc pathology, fracture or impingement.  A clinic visit on 18 December 2006 showed tenderness and muscle spasms.  There was decreased flexion and extension, and a straight leg raising test (to determine nerve root irritation) was positive.  Sensation and motor function were intact.  Lumbar spine X-rays on 11 January 2007 were essentially negative.  The CI was seen in the ER on 4 February 2007 with the complaint of right lower back pain as result of a fall 2 or 3 days earlier when he slipped in snow and injured himself in a twisting motion as he fell.  Examination revealed tenderness.  He had slight subjective diminished sensation of the great toe, but was able to dorsiflex without any problem.  X-rays were unremarkable.  

During the 19 April 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported pain in the lower right side of the back.  Physical examination revealed tenderness and there was decreased curvature of the lumbar spine.  An MRI dated 23 April 2007 demonstrated a disc bulge at L4-5 with mild central canal narrowing.  

The 24 May 2007 MEB physical therapy (PT) ROM examination, 2 months before separation, showed 80 degrees of flexion (normal 90) and 190 degrees of combined ROM; painful motion was present.  During the 27 May 2007 MEB NARSUM examination the CI complained of chronic LBP.  Physical examination showed an antalgic gait with abnormal toe and heel walking.  There was also tenderness and muscle spasms noted, but the lumbosacral spine exhibited a normal appearance.  X-rays of the lumbar spine dated 11 June 2007 were essentially negative but for minimal osteophyte formation anteriorly at L4 and L5.  

At the 12 July 2007 VA Compensation and Pension (C&P) examination, less than 1 month before separation, the CI reported spine pain refractory to treatment.  Physical examination showed a slightly antalgic to his right side and use of a cane.  There was mild spasm.  Lumbar ROM was 65 degrees and combined ROM was 190 degrees; painful motion was present. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 20%, coded 5237 (lumbosacral strain), citing muscle spasm, antalgic gait and pain-limited flexion.  The VA rated the back condition 10%, analogously coded 5299-5237, based on the C&P examination, citing limitation of flexion.  The panel agreed that a 20% rating was justified for muscle spasm or guarding severe enough to result in an abnormal gait, as reported on the MEB NARSUM and VA examinations.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula and flexion was much greater than 30 degrees.  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 back condition.

Chronic Right Knee Pain.  According to the STR and MEB NARSUM, the CI’s right knee condition began during the aforementioned fall during basic training.  A bone scan demonstrated diffuse mild increased uptake in the medial tibial plateaus consistent with shin splints and stress reactions in the knees.  An MRI of the right knee revealed pre-patellar bursitis with edema.  At an orthopedic clinic visit on 20 July 2006 the examination showed tenderness of the pes anserinus (conjoined tendons of the sartorius, gracilis and semitendinosus muscles that insert onto the anteromedial surface of the proximal tibia), but ROM was normal.  An MRI showed a signal at the medial meniscus and lateral horn.  A note on 20 October 2006 indicated the CI was referred for Anodyne treatment (near-infrared light therapy) of the pes anserine bursitis.  At the ER visit on 4 February 2007, noted above, examination revealed tenderness to the medial aspect of the knee without swelling or erythema.  X-rays of the right knee, tibia and fibula were negative.  On 13 February 2007 right knee ROM was full with modest soreness at the end range of flexion.  There was no laxity, instability or evidence of a meniscal tear.  A bone scan on 9 March 2007 revealed findings consistent with stress reaction in the knees.  
The MEB examination, 3 months prior to separation, revealed bilateral shin tenderness.  At the MEB PT ROM examination, 2 months before separation, right knee flexion was 104 degrees (normal 140) and extension was 0 degrees (normal); painful motion was present.  During the MEB NARSUM examination, 2 months prior to separation, the CI complained of chronic right knee pain.  Physical examination showed tenderness of the right knee medial and inferior to the joint line.  Right knee ROM was “full,” but painful motion was present.  The C&P examination showed right knee flexion of 135 degrees and extension of 0 degrees; painful motion was present.  The examiner estimated the CI would have a total functional loss equal to flexion limited to 130 degrees.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 0%, coded 5019 (bursitis), citing no significant loss of motion or instability.  The VA rated the right knee condition 10%, also coded 5019, based on the C&P examination, citing painful motion.

There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  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.  Although there was a stress reaction of the right tibia, 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).  However, there was evidence of painful motion with functional loss supporting a 10% rating 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 right knee condition, coded 5019.

Chronic Right Great Toe Pain.  According to the STR and MEB NARSUM, the CI’s right great toe condition began during the aforementioned basic training fall.  At a clinic visit on 16 October 2006 the CI had first toenail discoloration since the fall and pain in the toe persisted.  On 15 March 2007 extension strength was decreased.  The uric acid was elevated at 9.7 mg/dL (normal 3.5-8.5).  At an ER visit on 17 March 2007 the CI developed a significant increase in pain in the right first toe with swelling.  Examination revealed some edema without any real erythema.  There was significant tenderness of the toe and surrounding area up until the distal to mid portion of the foot.  The CI was able to flex and extend the toe, but it was very painful.  Uric acid was 7.8 mg/dL (normal 2.5-7.7).  An X-ray of the right foot was normal.  The examiner’s impression was gout versus complex regional pain syndrome.  On 19 March 2007 the CI was assessed to have gout and was treated with colchicine based on the report of uric acid 9.7 mg/dL on 15 March 2007.  On 22 March 2007 indomethacin was prescribed for the gout.  X-rays on 22 March 2007 of the right foot showed mild degenerative changes about the interphalangeal joint of the first digit with a faint rounded radiolucency in the base of the first phalanx as well as a bony erosion along the medial aspect of the proximal phalanx.  The question of gout was raised.  

During the MEB examination, 3 months prior to separation, the CI reported an 8-month history of right big toe numbness and tingling.  Two weeks earlier the toe swelled to twice its size and was very painful.  He was unable to walk on the foot without a boot and crutches.  Physical examination revealed the right foot first digit was edematous and brawny discolored.  At a clinic visit on 27 April 2007 there was swelling, erythema and warmth of the first toe.  Motion was abnormal and pain was present with motion.  Uric acid was 7.1 mg/dL and colchicine was restarted twice daily.  On 30 April 2007 a urine collection revealed uric acid of 928 mg (normal 250-750).  A note dated 8 May 2007 indicated the CI was not taking the colchicine, but still had problems with ambulation and the colchicine was restarted.  

The MEB PT ROM examination, 2 months before separation, showed right great toe metatarsophalangeal joint dorsiflexion to 50 degrees and plantar flexion to 15 degrees compared to the left great toe with 60 degrees dorsiflexion and 35 degrees plantar flexion; painful motion was present.  Interphalangeal joint ROMs were right and left dorsiflexion to 0 degrees and right plantar flexion to 30 degrees and left to 75 degrees.  Pain limited the right toe passive ROM due to hyperesthesia. During the 27 May 2007 MEB NARSUM examination, 2 months prior to separation, the CI complained of right foot pain.  Physical examination showed tenderness of the right toe with swelling, erythema and warmth. Pain was elicited in the first toe by motion.  At the C&P examination the CI reported pain of the right great toe.  Physical examination showed pain with palpation of the toe and the right great toe flexion elicited painful motion. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right great toe condition 0%, coded 5003 (arthritis, degenerative), citing pain-limited motion.  The VA rated the right great toe condition 0%, coded 5010 (degenerative arthritis due to trauma), based on the C&P examination, citing a noncompensable examination.

The panel noted the CI sustained trauma to the right first toe, which was painful and had some numbness as well.  However, pain became more severe and gout was diagnosed and treated with colchicine based on laboratory and X-ray findings.  Therefore, a 10% rating is appropriate using code 5017-5010 (gout-arthritis due to trauma) and is supported by painful motion of the toe.  Panel members did note that code 5017 is rated using code 5002 (rheumatoid arthritis); however, the CI did not have one or two exacerbations a year in a well-established diagnosis.  On the contrary, the diagnosis of gout was made 4 months prior to separation and the original injury to the toe occurred in June 2006.  Therefore, the finding of gout in the right great toe was a primary diagnosis and not an exacerbation.  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 right great toe condition, coded 5017-5010.

Contended PEB Conditions:  Allergic Rhinitis, Hypertension and Folliculitis.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  The panel determined none of the contended conditions were profiled, implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions 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 determinations for any of the contended conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the back 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 5019 IAW VASRD §4.71a.  In the matter of the right great toe condition, the panel recommends a disability rating of 10%, coded 5017- 5010 IAW VASRD §4.71a.  In the matter of the contended allergic rhinitis, hypertension and folliculitis, the panel recommends no change from the PEB determinations 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	
Chronic Low Back Pain	5237	20%	
Chronic Right Knee Pain	5019 	10%	
Chronic Right Great Toe Pain	5017-5010	10%	
COMBINED	40%