RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXXXX	CASE: PD-2017-04120
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20051215

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an E-4, Food Service Operations Specialist, medically separated for “right shoulder chronic pain, chronic bilateral knee pain, chronic bilateral ankle pain” and “diabetes mellitus, Type II,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION: Review of the unfitting conditions was requested along with additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20050818	VARD - 20060404	
Condition	Code	Rating	Condition	Code	Rating	Exam	

Right Shoulder Chronic Pain, Chronic Bilateral Ankle Pain, Chronic Bilateral Knee Pain	

5099-
5003	

10%	Residuals, S/P Right Shoulder Surgery	5201	20%	20060322	
			S/P Right Ankle Reconstruction  with DJD	5271	20%	20060322	
			Recurrent Left Ankle Sprains with DJD	5271	10%	20060322	
			PFS Left Knee	5099-
5019	10%	20060322	
			PFS Right Knee	5099-
5019	10%	20060322	
Diabetes Mellitus, Type II	7913	0%	Diabetes Mellitus, Type II	7913	20%	20060322	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 90%	

ANALYSIS SUMMARY:

Chronic Pain of the Right Shoulder, Chronic Bilateral Ankle Pain and Chronic Bilateral Knee Pain. The PEB combined pain of the right shoulder, bilateral ankles and bilateral knees under a single disability rating, coded 5099-5003 and rated 10% with application of the USAPDA pain policy AR 635-40 B24.f. 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 right shoulder, bilateral ankle, and bilateral knee conditions is presented separately, with attendant recommendations regarding separate unfitness and separate ratings if indicated.

Right Shoulder. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s right shoulder condition began in January 1998 at basic training during hand- to-hand drills. He reinjured his shoulder during advance training in March 1998 and had steroid injections and physical therapy (PT). He underwent a right shoulder arthroscopy with debridement of a labral tear and an open repair of his rotator cuff with an acromioplasty in March 1999. Full function occurred after 11 months of PT. He fractured his right clavicle in March 2000, which healed. In 2002 pain worsened with significant loss of range of motion (ROM). At an orthopedic clinic visit on 25 June 2004 forward flexion and abduction were each 110 degrees (normal for both is180). At an examination on 2 March 2005, 9 months prior to separation, his right shoulder was somewhat limited in abduction and external rotation.

The 7 April 2005 MEB NARSUM examination, 8 months prior to separation, noted complaints of right shoulder pain and loss of motion. Physical examination showed pain with forward elevation, side elevation and internal rotation. One month later, right shoulder flexion was 100 degrees and abduction was 85 degrees during a PT clinic visit. At an orthopedic clinic visit on 16 August 2005, 4 months prior to separation, Hawkin’s test (for subacromial impingement) and O’Brien’s and Speed’s signs (to determine labral tears) were positive. Flexion was 120 degrees and abduction was 110 degrees.  Surgery was recommended after discharge.

At the 22 March 2006 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported a painful right shoulder and limitation of motion. Physical examination showed no tenderness over the shoulder. The clavicle and acromioclavicular joint felt normal and there was no loss of bone. Forward flexion and abduction were each 90 degrees. The CI stopped due to pain and would not go any further. He was unable to do any internal or external rotation from the abducted position of 90 degrees due to pain. With repetition and his arm close to his side, he was able to move up to 70-80 degrees.

The panel directed attention to its rating recommendation based on the above evidence. As noted above, the PEB rated the right shoulder, bilateral knees and bilateral ankles as a single condition 10%, analogously coded 5099-5003 (degenerative arthritis), citing use of narcotic medications in accordance with the pain policy. The VA rated the right shoulder condition 20%, coded 5201 (arm, limitation of motion), based on the C&P examination, citing limited ROM of the right shoulder to 70 degrees after repetitive use.

The panel first considered if the right shoulder condition met the panel’s threshold for separate rating. Based on the CI’s permanent profile and the commander’s statement, which referred to the profile, the panel determined the right shoulder was separately unfitting.

The VASRD §4.71a threshold for rating for ROM impairment (code 5201) is “at shoulder level” (approximately 90 degrees from the side), and the examinations in evidence demonstrated motion limited to this level. Panel members noted flexion was 120 degrees and abduction was 110 degrees at an orthopedic examination 4 months prior to separation; however, at the VA examination, 3 months after separation, forward flexion was 90 degrees and with repetition, it decreased to between 70-80 degrees. The panel majority noted abduction at the orthopedic examination was 20 degrees from shoulder level, which is not at the shoulder level, but was relatively close to shoulder level. However, the VA examination was more in depth and included repetition in accordance with DeLuca vs. Brown. Therefore, the panel majority determined the VA examination had a higher probative value for rating purposes than any of the pre-separation examinations, and a 20% rating is reasonable using code 5201.

The minority voter felt the preponderance of evidence prior to separation favored a 10% rating and the CI failed to attempt to move to full painful limits during the C&P examination, therefore not meeting an acceptable standard for a ratable measurement. The next higher 30% rating for the dominant arm requires motion limited to “midway between side and shoulder level.” However, the examinations in evidence did not reflect this degree of limitation. There was no malunion with marked deformity or frequent episodes of recurrent dislocation of the humerus to justify a higher rating under the 5202 code (humerus, other impairment), and no higher ratings available under the 5203 code (clavicle or scapula, impairment). After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 20% for the right shoulder condition, coded 5201.

Chronic Bilateral Ankle Pain. According to the STR and MEB NARSUM, the CI’s bilateral ankle condition began in January 1998 with multiple sprains of the right ankle. He was placed in a cast in December 1999 for a right medial malleolus fracture. In November 2002 he had a Brostrom procedure to stabilize the right ankle, but he had persistent pain that was worse with ambulation. In 1999 he sprained his left ankle and had multiple sprains and pain thereafter. In May 2004 he fell off a ladder and injured his left ankle. X-rays showed soft tissue swelling without a definite fracture. On examination in June 2004 there was tenderness of the anterior talofibular ligament (ATFL) and some tenderness of the right ankle.

An MRI of the left ankle in August 2004 showed focal osteochondral lesions in the distal lateral dome, a prior tear of the ATFL with heterotopic bony changes from prior trauma, and mild tissue edema around the os trigonum. At an ER visit in November 2004, the CI reported ankle swelling with pain for 5 days as a result of forcefully inverting his left ankle while walking into a barbershop. X-rays showed soft tissue swelling and no fracture. He was treated with a splint and crutches for 5 days. At an ER visit in December 2004, the CI was given a refill of Percocet (a narcotic) for left ankle pain. An MRI dated 19 January 2005 showed a lesser degree of subcutaneous soft tissue edema with osteochondral injuries of the medial talar dome and lateral aspect of distal tibia and a chronic injury of the ATFL. At a podiatry clinic visit a week later, he complained of dull, throbbing pain deep inside the joint. He used a cane and had an ankle brace and inserts. The examiner’s assessment was left ankle pain with degenerative joint disease (DJD) with internal joint derangement and left ankle instability.

At an orthopedic specialty care evaluation on 2 March 2005, the CI was noted to have a normal gait. His knees and ankles had normal ROMs. At a podiatry visit 5 days later, dorsiflexion of the ankles was 10 degrees (normal 20) with crepitus and no anterior drawer bilaterally. Same-day X- rays of the left ankle showed mild soft tissue edema and X-rays of the right ankle showed soft

tissue edema and an old avulsion fracture. An MRI of the left ankle on 19 March 2005 showed a lesser degree of subcutaneous soft tissue edema with findings consistent with osteochondral injuries of the medial talar dome and lateral aspect of the distal tibia consistent with a chronic injury of the ATF ligament.

The 7 April 2005 MEB NARSUM examination, 8 months prior to separation, noted complaint of bilateral ankle pain. Physical examination showed the right ankle was stable anteriorly and posteriorly. There was pain with palpation and crepitus (grinding sensation) with dorsiflexion and plantar flexion. The left ankle had pain and crepitus with ROM. No gross edema was present for either ankle. At a PT visit on 3 May 2005 ROM measurements were left and right dorsiflexion of 5 degrees with left plantar flexion of 30 degrees (normal 45) and the right with 35 degrees. No painful motion was reported.

At the 22 March 2006 VA C&P examination, 3 months after separation, the CI reported pain in both ankles and some swelling of the left ankle. He walked with a slight limp despite use of a cane, which was for chronic back pain (not in the scope of review), but also for knee pain (see below) and ankle pain. Physical examination showed right ankle dorsiflexion of 5 degrees and plantar flexion of 30 degrees. Left ankle dorsiflexion was 15 degrees and plantar flexion was 30 degrees, both with some discomfort.

The panel directed attention to its rating recommendation based on the above evidence. Again, as noted, the PEB rated the right shoulder, bilateral knees and bilateral ankles as a single condition, rated 10%, analogously coded 5099-5003, citing use of narcotic medications in accordance with the pain policy. The VA rated the right and left ankle conditions 20% and 10%, respectively, with both coded 5271 (ankle, limitation of motion), based on the C&P examination, citing marked limited motion of ankle dorsiflexion from 5 of 20 degrees for the right ankle and moderate limited motion of the left ankle.

Based on the CI’s permanent profile and the commander’s statement, the panel determined each ankle was separately unfitting, and each ankle warrants a separate rating. The panel then addressed the ankle ratings and noted at an orthopedic examination the ankle ROMs were reported to be normal and each ankle had similar findings at the , NARSUM and VA examinations. However, bilateral ankle dorsiflexion ROMs were 5 degrees at the PT examination and 30 degrees plantar flexion on the left and 35 degrees on the right; At the VA examination dorsiflexion was 5 degrees on the right and 15 degrees on the left and plantar flexion was 30 degrees bilaterally. The panel noted that although dorsiflexion ROMs were decreased prior to separation, the CI’s gait was normal as were the ROMs at the orthopedic specialty examination. The panel did note that the CI had a slight limp and he used a cane at the VA examination, but that was due to pain from his back, knees, and ankles. Therefore, the panel favored a moderate disability based on limitation of motion for each ankle rather than a marked disability for either ankle. 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 ankle and a disability rating of 10% for the left ankle, each coded 5271.

Chronic Bilateral Knee Pain. According to the STR and MEB NARSUM, the CI’s bilateral knee pain condition began in 1999 with no direct injury and was worse since 2003 with squatting, bending, jumping, running, climbing stairs and taking long walks. PT did not help, but a nonsteroidal anti- inflammatory drug and Percocet offered mild relief.

At an emergency room visit on 8 May 2004, the CI reported he fell off a ladder and hurt his left knee. On examination he had mild joint line tenderness without any effusion. X-rays showed no fracture or dislocation. At a 25 June 2004 orthopedic specialty examination, he complained of pain into the anterior aspects of his knees over his patella tendons. Examination of the knees revealed no effusion. ROM measurements were 0-110 degrees (normal 0-140) bilaterally. There

was no instability or laxity, but he did have mild pain with a patellar grind bilaterally. X-rays dated 25 June 2004 demonstrated very minimal patellofemoral disease along the medial patellar facet without evidence of significant degenerative changes. Same-day X-rays showed probable minimal varus of the lower legs bilaterally on the lower extremity alignment examination, but the significance was questionable without other abnormalities seen.

At a 2 March 2005 orthopedic specialty examination, he complained of considerable pain in both knees, which was much more severe when he climbed stairs or sat still. On examination he had mild patellofemoral crepitation and reported tenderness just to the lower edge of the patellas and the proximal edge of the patellar tendons. There were no effusions, and no ligamentous instability, or evidence of a meniscal tear.

The 7 April 2005 MEB NARSUM examination, 8 months prior to separation, noted the complaint of bilateral knee pain. Physical examination showed the knees had no edema and were stable anteriorly, posteriorly, laterally, and medially. There was mild pain with patellar grind testing.  PT ROM measurements of the knees with repetition on 3 May 2005, 7 months prior to separation, were 0-115 degrees for the left knee and 0-100 degrees for the right knee. No painful motion was noted for either knee.

At the 22 March 2006 VA C&P examination, 3 months after separation, the CI reported bilateral knee pain which worsened with his gaining an extreme amount of weight. Physical examination showed both knees appeared normal. There was grinding with passive movement. ROM measurements were 0-120 degrees bilaterally, with pain at 120 degrees, but there was no loss of motion with repetition.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the right shoulder, bilateral knees and bilateral ankles as a single condition 10%, analogously coded 5099-5003, citing use of narcotic medications in accordance with the pain policy. The VA rated the right and left knee conditions 10% each, analogously coded 5099-5019 (degenerative arthritis - bursitis), based on the C&P examination, citing painful or limited motion of a major joint or group of minor joints.

Based on the CI’s permanent profile and the commander’s statement, the panel determined each knee was separately unfitting. The panel then addressed rating the knees and noted that each knee had the same findings at all examinations proximate to separation. There was no evidence of painful motion with functional loss supporting a 10% rating (based on VASRD §§4.59, 4.40 and 4.45), albeit at the VA examination, 3 months after separation, pain was noted at 120 degrees of flexion bilaterally. However, the examiner did state obesity but did not comment whether that limitation and end of ROM pain was attributable to the CI’s habitus due to extreme weight gain or to knee pathology. There was no limitation of motion which attained a 10% rating under the diagnostic codes for limitation of flexion or extension (5260, 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. 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. Therefore the panel concluded there was insufficient evidence to support a rating higher than 0% for either knee. 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 knee condition, coded 5099- 5003 and a disability rating of 0% for the right knee condition, coded 5099-5003.

Diabetes Mellitus, Type II. According to the STR and a 21 January 2005 MEB NARSUM specialty examination, the CI’s diabetes condition began in February 2004, after he was found to have an impaired fasting glucose of 118 mg/dL (normal 70-110), a normal 2-hour glucose tolerance of 157

mg/dL, and an A1C of 5.9%. Weight loss and diet were recommended in March 2004. He was treated with Metformin; however, he gained 36 pounds over 9 months and his BMI (body mass index) was 44.1 (obese) and his weight was 316 pounds. A fasting glucose on 13 January 2005 was 206 mg/dL. On examination he was a well-developed, obese man in no apparent distress, who was alert and oriented times three. His blood pressure was 168/95. Findings were unremarkable except for trace ankle edema bilaterally and a soft, obese, and non-tender abdomen without any masses.

The 7 April 2005 MEB NARSUM examination, 8 months prior to separation, noted the complaint of Type II diabetes. Physical examination showed obesity. Laboratory data on 31 March 2005 revealed urine glucose 2+ and glucose 206 mg/dL. By 8 September 2005 his A1C was 11% and he had proteinuria. Additional medications (Avandia and irbesartan) were added to control the diabetes and prevent kidney impairment. Diet was reviewed. In October 2005, he reported his blood sugars were in the 180 mg/dL range. At a clinic visit on 28 November 2005, Lantus (insulin) was to be his next step to control the diabetes, but he was about to go on terminal leave and it was not started.

At the 22 March 2006 VA C&P examination, 3 months after separation, the CI reported Type II diabetes with no ketoacidosis, hypoglycemic reactions, or hospitalizations. He indicated he avoided sugar, but had gained 60 pounds since the diagnosis was made. He had no restriction of activities and treatment was with Actos (an oral hypoglycemic medication). Physical examination showed hypoactive to absent deep tendon reflexes, but good sensation in the legs and feet to light touch and to monofilament testing. The extremities appeared essentially normal with some stasis changes of both legs related to obesity. At a separate ophthalmology examination, there was no evidence of diabetic retinopathy.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the diabetes condition 0%, coded 7913 (diabetes mellitus), citing the CI’s poor control on oral hypoglycemic agents with a fasting blood glucose of 206 in February 2005, weight gain of 36 pounds in 9 months, and prognostication that the condition would not improve unless the CI lost weight. The VA rated the diabetes condition 20%, coded 7913, based on the C&P examination, citing a requirement for insulin and restricted diet, or oral hypoglycemic agent and restricted diet.

The panel agreed that although the CI just restricted his sugar intake and there was no evidence of a prescribed calorie or carbohydrate limiting diet, the requirement for an oral hypoglycemic agent and restricted diet, justified a 20% rating. Because there was no evidence of medically- prescribed regulation of activities, the next higher 40% rating was not justified. Furthermore, following initiation of treatment at the time of diagnosis, the STR showed no episodes of ketoacidosis or hypoglycemia requiring hospitalizations or frequent visits to a diabetic care provider (twice a month or more frequently), or complications that could support higher ratings. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the Type II diabetes mellitus, coded 7913.

BOARD FINDINGS: In the matter of the right shoulder condition, the panel majority recommends a disability rating of 20%, coded 5201 IAW VASRD §4.71a. The single voter for dissent recommends no change from the PEB 10% rating and did not elect to submit a minority opinion. In the matter of the right ankle condition, the panel recommends a disability rating of 10%, coded 5271 IAW VASRD §4.71a. In the matter of the left ankle condition, the panel recommends a disability rating of 10%, coded 5271 IAW VASRD §4.71a. In the matter of the right knee condition, the panel recommends a disability rating of 0%, coded 5099-5003 IAW VASRD §4.71a.       In the

matter of the left knee condition, the panel recommends a disability rating of 0%, coded 5099- 5003 IAW VASRD §4.71a. In the matter of the Typ e II diabetes mellitus, the panel recommends a disability rating of 20%, coded 7913 IAW VASRD §4.119. 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 Right Shoulder Pain	5201	20%	
Bilateral Ankle Pain, Right Ankle	5271	10%	
Bilateral Ankle Pain, Left Ankle	5271	10%	
Bilateral Knee Pain, Right Knee	5099-5003	0%	
Bilateral Knee Pain, Left Knee	5099-5003	0%	
Diabetes Mellitus, Type II	7913	20%	
	COMBINED (w/BLF)	50%	

The following documentary evidence was considered:

	PD-2017-04120

AR20190011649, XXXXXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXXX

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 50% 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 permanent 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), 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

	PD-2017-04120