RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-04406
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070620

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Food Service Operations, medically separated for “right ankle pain” and “right shoulder pain,” rated 10% and 0%, respectively, with a combined disability rating of 10%.  

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 - 20070314	VARD - 20070702	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Ankle Pain	5099-5003	10%	Unfused Fracture, Right Distal Medial Malleolus with Chronic Right Ankle Strain	5271	10%	20070502	
Chronic Right Shoulder Pain with Instability	5099-5003	0%	S/P Rotator Cuff Repair, Right Shoulder	5203	10%	20070502	
Supraventricular Tachycardia ; S/P Ablation	Not Unfitting	S/P Electrophysiologic Ablation of Conduction Pathway and Sinus Bradycardia	7010	0%*	20070502	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	
* The VA increased the cardiac rating to a temporary 100% effective 20071023 (due to pacemaker implantation) and then to 30% effective 20080101.  

ANALYSIS SUMMARY:  

Right Ankle Pain. According to the service treatment record (STR) and MEB narrative summary
(NARSUM), the CI’s right ankle condition began in August 2002 after he rolled his ankle and fell during a road march.  There was a reported right fibula fracture and the CI had recurrent intermittent right ankle rolling fpr which hewas prescribed an ankle brace.  The 5 December 2006 MRI of the ankle documented degenerative changes, joint effusion and tenosynovitis.  The 4 January 2007 MEB NARSUM examination, 5 months prior to separation, noted complaints of right ankle pain with use of a cane as needed to lessen pain.  Physical examination showed well healed surgical scars with a tender ankle and pain on all movements.  The physical therapy (PT) MEB evaluation 5 days later documented right ankle range of motion (ROM) with dorsiflexion to 12 degrees (normal 20) and plantar flexion to 40 degrees (normal 45) with painful motion.  

At the 2 May 2007 VA Compensation and Pension (C&P) examination, 2 months before separation, the CI reported right ankle pain, weakness, stiffness, giving way, fatigability, and swelling.  Physical examination showed an abnormal gait with a limp on the right ankle and the CI required a cane for ambulation.  The examiner found no signs of edema, effusion, weakness, tenderness, redness, heat, abnormal movement, subluxation or guarding of movement.  ROM was dorsiflexion of 15 degrees and plantar flexion of 45 degrees with painful motion and weakness after repetition.  X-rays showed an old unfused chip fracture off the distal tip of the medial malleolus.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right ankle condition 10%, analogously coded 5099-5003 (degenerative arthritis), citing application of the US Army Physical Disability Agency pain policy.  The VA rated the right ankle condition 10%, coded 5271 (ankle, limited motion), based on the C&P examination, citing painful limited motion.  The panel noted there was no limitation of dorsiflexion or plantar flexion that supported a rating under the VASRD diagnostic code for limitation of motion (5271).  However there was evidence of painful motion causing functional loss supporting the 10% rating (based on VASRD §§4.59, 4.40 and 4.45).  The panel considered alternative VASRD ankle and analogous codes, but all were less applicable and/or not advantageous to rating.  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 right ankle condition.  

Chronic Right Shoulder Pain.  According to the STR and MEB NARSUM, the right-hand dominant CI’s right shoulder condition began in September 2002 while breaking up a fight.  He dislocated his shoulder in 2003 while deployed and underwent arthroscopic surgery in December 2005 for instability.  He underwent a second surgery in February 2006 for stabilization of his painful shoulder.  Following initial improvement, he developed pain and his shoulder started slipping in and out of the joint.  The 10 July 2006 MRI of right shoulder reported degenerative changes at the acromioclavicular joint with mild tendinopathy of the supraspinatus tendon.  

The MEB NARSUM examination noted complaints of right shoulder pain.  Physical examination showed no erythema, edema, or atrophy.  There was tenderness with signs of instability (+1 sulcus sign and positive apprehension test) but the shoulder was negative for both impingement and labral tears.  ROM was painful.  The 9 January 2007 PT MEB evaluation documented right shoulder ROM with flexion and extension to 180 degrees (normal) with painful motion.  

At the C&P examination, one month before separation, the CI reported stiffness, redness, lack of endurance, fatigability, and dislocation all first thing in the morning.  The examiner found no signs of edema, effusion, weakness, tenderness, redness, heat, guarding or abnormal movement.  ROM was painful with flexion of 100 degrees and abduction of 110 degrees.  X-rays were normal.  VA treatment notes showed on 14 November 2007 the CI underwent right shoulder surgery for instability (Bankart repair with capsulorrhaphy) .  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder condition 0%, analogously coded 5099-5003 (degenerative arthritis), citing painful motion without limitation of motion, and “rated for arthritis one major joint without decrease[d] ROM.”  The VA rated the right shoulder condition 10%, coded 5203 (clavicle or scapula, impairment), based on the C&P examination, citing painful and limited motion.  

The VASRD §4.71a threshold for rating for ROM impairment (code 5201, arm limitation of motion) is “at shoulder level” (approximately 90 degrees from the side), and the examinations in evidence demonstrated motion above this level.  However, panel members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion).  There was no malunion or recurrent dislocation of the humerus with guarding of movement at shoulder level, and no dislocation or nonunion of the clavicle or scapula with loose movement to justify a higher rating under the 5202 (humerus, other impairment of) or 5203 (clavicle or scapula, impairment of) 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 right shoulder condition, coded 5099-5003.  

Contended PEB Condition:  Supraventricular Tachycardia (SVT), Status Post Ablation.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The CI had a history of palpitations and on 11 July 2005 upon noting an irregular heartbeat with intermittent chest pain he was admitted to the hospital through the emergency department.  He was diagnosed with SVT and underwent radiofrequency ablation.  The 14 February 2006 pre-shoulder surgery cardiology evaluation documented that the CI had been doing well since SVT ablation, but had brief episodes of atrioventricular (AV) nodal reentry tachycardia (AVNRT) lasting seconds about once per month since the procedure.  Symptoms included palpitations and fast heart rate.  Cardiac examination was normal and the CI was released without limitations.  EKG on 2 May 2007 showed first degree AV block with sinus bradycardia.  A stress echocardiogram on 31 May 2007 was normal with an ejection fraction of 59% (normal).  

The record showed that 2 months following separation, a cardiology evaluation documented a fixed first degree AV block and an electrophysiology evaluation (3 months after separation) noted post-ablation tachyarrhythmia and bradyarrhythmia symptoms.  On examination, the monitor documented episodes of profound sinus bradycardia and heart block, with the CI seeming not to have a lot of symptoms.  On 23 October 2007, 4 months after separation, the CI underwent attempted cardiac pathway ablation with subsequent permanent pacemaker implantation.  

The contended SVT condition was not profiled and did not fail retention standards.  The commander’s statement mentioned the finding of SVT and surgery (ablation) in October 2005, but did not indicate any duty limitations from the cardiac condition.  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 right ankle condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the right shoulder condition, the panel recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the contended supraventricular tachycardia 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, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Ankle Pain	5099-5003	10%	
Chronic Right Shoulder Pain 	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

AR20190004846, XXXXXXXXXX

Dear XXXXXXXXXX:

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

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