RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX		CASE: PD-2017-04287 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20080105

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Wheeled Vehicle Mechanic, medically separated for “left (non-dominant) wrist pain” and “bilateral knees patellofemoral pain syndrome (PFPS),” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION: Review requested of his left wrist, bilateral knees and 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 - 20070921	VARD - 20080411	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left (Non-Dominant) Wrist Pain	5099-5003	10%	S/P Traumatic Fracture and Repair of the Left Wrist	5215	0%	20080125	
Bilateral Knees PFPS	5099-5003	0%	Degenerative Joint Disease (DJD) of the Right Knee	5003	0%	20080125	
			DJD of the Left Knee	5003	0%	20080125	
Right Shoulder Pain	Not Unfitting	DJD of the Right Shoulder	5201-5024	10%	20080125	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 10%	

ANALYSIS SUMMARY:

Left (Non-Dominant) Wrist Pain. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI originally injured his left wrist when he fell on his out- stretched hand while playing basketball in 2001. Despite long-term conservative therapy, he was

diagnosed with nonunion of a scaphoid (wrist bone) whereby X-rays noted extensive degenerative changes involving the left wrist bones, including what appeared to be a nonunion scaphoid bone fracture with suspected avascular necrosis of a portion of the same. The CI underwent left wrist surgery in October 2006 with a pin and fusion using a bone graft from his hip. At the 24 August 2007 MEB NARSUM examination, 4 months prior to separation, the CI endorsed having continued pain and stiffness of the left wrist. The physical examination (PE) revealed tenderness with painful range of motion (ROM). Palmer flexion measured to 60 degrees (normal 80) and dorsiflexion (extension) to 15 degrees (normal 70). The CI’s wrist pain assessment was noted as slight and constant.

At the 25 January 2008 VA Compensation and Pension (C&P) examination, one month after separation, the CI reported having improved function of the left wrist after 4 months of post- surgical physical therapy. Although having improved function, the CI continued to have intermittent pain in the wrist two to three times per week with each episode lasting 20 minutes. Aggravating factors included impact activities or actions requiring twisting or torqueing of the wrist.  The PE revealed near normal ROM which was non-painful.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the left wrist condition 10%, analogously coded 5003 (degenerative arthritis), citing the US Army Physical Disability Agency (USAPDA) pain policy. The VA rated the left wrist condition 0%, coded 5215 (wrist, limitation of motion), based on the C&P examination, citing VASRD ROM criteria. The VASRD criteria in regards to the wrist is based upon two categories which includes either joint ankylosis (essentially, a fused joint) or limitation of motion. In this case, the absence of a fused joint or significant limitation of joint motion in both pre and post separation examinations would not support any degree of a positive impairment rating. Additionally, the painful wrist motion noted at 4 months pre-separation appeared to improve and disappear closer to separation as noted in the C&P examination and thus would not support VASRD §4.59. However, the radiographic findings of degenerative changes about the complex of wrist bones would support the PEB’s current 10% rating. Therefore, 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 for the left wrist condition.

Bilateral Knee Pain. The PEB combined the right and left knee conditions under a single disability rating, coded 5003 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 right and left knee conditions is presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

According to the STR and MEB NARSUM, the CI’s knee conditions began separately whereby he struck his right knee against the seat of a motor vehicle in 1995 and fell onto both knees approximately one year later. Radiographic imaging of both knees performed on 27 April 2007 revealed a degree of meniscal degeneration bilaterally and softening of the underside of the left kneecap.

At the 24 August 2007 MEB NARSUM examination, the provider documented, “During the last two months, the (CI’s bilateral knee) pain has increased to the point where it is interfering with his ability to do his duty.” The PE revealed bilateral knee tenderness. Right and left knee ROM were painful noting flexion to 95 and 105 degrees, respectively (normal 140). Extension of either knee was not documented. The pain assessment of both knees was noted as slight and constant.

At the 25 January 2008 C&P examination, the CI reported increasing pain and discomfort in both knees. Specifically, the CI endorsed bilateral intermittent knee pain (3/10) which occurred seven times per day with each episode lasting 30 minutes. Pain aggravating factors included sitting greater than 2 hours and lifting greater than 60 pounds. Pain relieving factors were noted to be exercise and aspirin. The PE revealed normal ROM of both knees. There was no evidence of local tenderness, joint instability, or motion limitation upon repetition.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the bilateral knee condition 0%, analogously coded 5003 (degenerative arthritis), citing the USAPDA pain policy. The VA separately rated the right and left knee condition 0% each, coded 5003 (degenerative arthritis), based on the C&P examination, citing the absence of VASRD ratable criteria. Despite a 0% rating by both the PEB and VA, panel members first deliberated if the left and right knees, having been de-coupled from the combined PEB adjudication, remained separately unfitting and therefore subject to separate Service ratings. Panel members deliberated and agreed that the reported increase and persistence of knee pain either in one or both knees would likely have rendered the CI incapable of performing his military duties as an infantryman and or as a wheeled vehicle mechanic. Therefore, panel member consensus was that the bilateral knee condition was reasonably justified as separately unfitting and that it met VASRD §4.71a criteria for separate ratings.

In deliberation for final impairment ratings panel members considered the presence of subjective pain, but in the absence of abnormal or limiting physical parameters, members agreed that a rating of 0% was an appropriate representation of the CI’s condition near the time of service separation. After due deliberation, and considering all the evidence, the panel recommends separate unfit determinations with disability ratings of 0% for each knee. The panel concluded that having no additional benefit to the CI with either rating scheme, there was insufficient cause to recommend a change in the PEB adjudication for the bilateral knee condition.

Contended PEB Condition: Right Shoulder Pain. The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting. The contended 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 or near separation. After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB’s fitness determination for the contended condition, so no additional disability rating is recommended.

BOARD FINDINGS: In the matter of the left wrist condition as well as the bilateral knee condition, and IAW VASRD §4.71a, the panel recommends no change in the PEB’s adjudication. In the matter of the contended right shoulder pain, 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. Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

AR20190012180, XXXXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXX

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.