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-2017-05095
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070529

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Health Care Specialist, medically separated for “chronic right shoulder pain,” “chronic low back pain,” and “chronic bilateral knee and ankle pain,” rated 10%, 10%, and 0%, respectively, with a combined disability rating of 20%.  

CI CONTENTION:  Conditions are preventing the CI from having a normal life, “…all in VA/Army Medical Records.”  The CI also appeared to request review of 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 - 20070501	VARD - 20080317	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Shoulder Pain	5003	10%	Right Shoulder Arthritis	5201-5010	10%	20070226	
Chronic Low Back Pain	5299-5237	10%	DDD, Thoracolumbar Spine	5010-5243	10%	20070226	
Chronic Bilateral Knee and Ankle Pain	5009-5003	0%	Left Knee … Patella	5260	10%	20070226	
			Right Knee … Patella	5260	10%	20070226	
			Right Ankle Sprain	5271	10%	20070226	
			Left Ankle Sprain	5271	10%	20070226	
Mild Conductive Hearing Loss	Not Unfitting	Left Ear Hearing Loss	6100	0%	20070226	
Chronic Headaches	Not Unfitting	Migraines	8100	0%	20070226	
Anxiety Disorder	Not Unfitting	Anxiety Disorder	9413	30%	20070226	
Obesity	Not A Disability	No VA Placement	
Mastoiditis	Not Unfitting		
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Chronic Right Shoulder Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the right hand dominant CI underwent a right shoulder with distal clavicle excision, subacromial decompression and ORIF (open reduction internal fixation) of an unfused acromion.  Although improvement followed, limitations continued.  Radiographic studies in December 2006 showed good healing of the acromion.  At the physical therapy (PT) range of motion (ROM) examination on 8 December 2006, right shoulder flexion was 110 degrees (normal 180) and abduction was 103 degrees after repetition (normal 180).  There was painful motion, some deltoid muscle atrophy and 3-/5 weakness.  [Note: the PEB cited passive abduction of 105 degrees].  

The 21 December 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, showed decreased right arm ROM with pain.  Shoulder abduction was 90 degrees and strength was decreased to 3/5.  During the 17 January 2007 MEB NARSUM examination, 4 months prior to separation (5 months after surgery), the CI reported inability to do pushups, overhead lifting or load bearing over shoulder level.  Physical examination showed mild tenderness over the resected portion of the AC (acromioclavicular) joint.  Motor strength testing showed some deltoid weakness (4/5.  There was no instability and apprehension relocation test was negative.  

At the 26 February 2007 VA Compensation and Pension (C&P) examination, 3 months before separation, the CI reported lifting was worse than before surgery.  Physical examination showed tenderness along the AC joint.  Impingement testing and resisted abduction caused pain.  Strength was decreased to 3/5 due to pain, but muscle tone was normal.  Right shoulder ROM testing showed abduction of 98 degrees with pain starting at 70 degrees and flexion of 135 degrees.  On repetitive motions, he had pain but no weakness or fatigability.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder condition 10%, coded 5003 (arthritis, degenerative), citing pain with motion and 105 degrees of passive abduction.  The VA rated the right shoulder condition 10%, dual coded 5201-5010 (limitation of arm motion due to traumatic arthritis) based on the C&P examination, citing painful motion and weakness.  

The C&P examination was closet and prior to separation, and additionally was furthest from surgery (to allow recovery/rehabilitation) and was adjudged to have the highest probative value for rating at separation.  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.  Although there was insufficient limitation of motion to support a rating under the 5201 code, 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 to justify a rating under the 5202 code (humerus, other impairment of); and no nonunion with loose movement of the clavicle to warrant the next higher 20% rating under the 5203 code (clavicle or scapula, impairment of).  As the CI had surgical excision of his distal clavicle and scapular impairment, the panel adjudged that coding analogous to 5203, without loose movement (10%) was considered predominant.  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 higher rating than the 10% PEB adjudication for the right shoulder condition; however, coding change to 5299-5203 is recommended.  

Chronic Low Back Pain.  According to the STR and MEB NARSUM, the CI had a long history of back pain with multiple deployments and no specific trauma or injury.  Conservative treatment was not successful in resolving his symptoms.  Lumbosacral spine series showed degenerative disc disease at L4-L5 and L5-S1.  During the 5 June 2006 chiropractic clinic examination, thoracolumbar spine tenderness was noted.  Pain was elicited by extension.  Muscle spasm was present over the iliolumbar region, but there was no loss of normal lordosis.   At the PT examination, 5 months prior to separation, ROM examination showed forward flexion of 60 degrees after repetition (normal 90) and combined ROM greater than 145 degrees but less than 170 degrees (normal 240).  There was tenderness, painful motion and decrease of the normal lumbar contour.  

The MEB examination, 5 months prior to separation, revealed pain with flexion at 70 degrees.  The 17 January 2007 MEB NARSUM examination, 4 months prior to separation, noted complaints of pain with prolonged walking, standing, running or ruck marching.  During the 15 February 2007 chiropractic clinic examination, tenderness was noted, pain was elicited by extension and the lumbosacral spine showed normal curvature.  Heel-toe walking was normal.  

At the 26 February 2007 C&P examination, 3 months before separation, the CI reported daily pain with stiffness in the morning.  Strenuous activities were affected.  Physical examination showed a normal gait.  The spine was straight with no spasms or weakness.  The ROM evaluation showed flexion of 75 degrees and combined ROM of 220 degrees, with painful motion and no change on repetition.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, analogously coded 5299-5237 (lumbar strain) citing 65 degrees of flexion limited by pain and severe spasm.  The VA also rated the back condition 10%, dual coded 5010-5243 (arthritis due to trauma - intervertebral disc syndrome), based on the C&P examination, citing limitation of flexion.  

Although the PT ROM testing supports a 20% back rating (flexion not greater than 60 degrees), the panel agreed that the C&P examination was closet and prior to separation and had the highest probative value for rating at separation.  The panel noted that given multiple unfitting conditions, that absent unusual findings, the pre-separation C&P examination had the greater weight for rating all conditions at separation.  

The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees), as reported on the VA examination.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no documentation of intervertebral disc syndrome with incapacitating episodes, which would provide for a higher rating under that formula.  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 Bilateral Knee and Ankle Pain.  The PEB combined the right and left knee and right and left ankle conditions as a single unfitting condition analogously coded 5099-5003 and rated 0% with application of the US Army Physical Disability Agency 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 knee and the bilateral ankle conditions is presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

Bilateral Knees.  According to the STR and MEB NARSUM, there was no history of trauma or injury to either the left or right knee conditions.  An MRI of each knee documented a tilted patella with increased signal in the articular cartilage of the lateral patellar facet consistent with mild chondromalacia (degenerative changes).  Additionally on the right, there was a grade 1 degenerative signal in the posterior horn of the medial meniscus without evidence of a tear.  

At the PT ROM examination, the CI related painful knees with flares and antalgic gait after prolonged activity.  Examination showed a normal gait.  Bilateral knee ROM testing showed flexion of 120 degrees (normal 140) and extension of 0 degrees (normal) with painful limitation of motion and slight weakness (4/5).   At the MEB examination, 5 months prior to separation, the CI complained of bilateral knee pain.  Physical examination revealed positive patellar apprehension and painful motion of both knees.  The MEB NARSUM examination, 4 months prior to separation, noted complaints of knee pain with inability to stand or walk for prolonged periods and inability to run or load bear.  Bilateral knee examination showed no joint line tenderness or patellar maltracking.  There was no laxity or instability.  

At the C&P examination, 3 months before separation, the CI reported the use of knee braces.  Pain was reported with going up and down mountains and running.  Physical examination showed a normal gait.  Both knees had tenderness without laxity or instability.  Each knee showed flexion of 145 degrees and extension of 0 degrees, without weakness, pain or fatigability on repetition.  

The panel directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the panel must first consider whether the knee condition and the ankle condition remained separately unfitting, having been de-coupled from a combined PEB adjudication.  The left and right knee conditions were profiled, implicated in the commander’s statement and judged to fail retention standards.  The commander’s statement and other STR evidence did not provide any information which would permit the panel to discriminate the performance limitations attributable to either knee over the other.  Since undue speculation would be required to conclude that impairment from either knee would not have unacceptably interfered with the performance of military duties, members agreed that each knee was reasonably justified as separately unfitting.  The panel directed attention to its rating recommendation based on the above evidence.  The VA rated each knee condition 10%, analogously coded 5260 (leg, limitation), based on the C&P examination, citing functional loss due to pain for each knee.  

As discussed above, the pre-separation C&P examination had the highest probative value for rating at separation.  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261) for either knee, and no painful motion.  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).  However, there was MRI evidence of degenerative changes in each knee which supports a 10% rating under the analogous code 5299-5003 for X-ray evidence of involvement of two or more major joints without evidence of occasional incapacitating exacerbations.  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 bilateral knee condition.  

Bilateral Ankles.  According to the STR and NARSUM, the CI’s left ankle was injured while deployed in 2001 when he sustained an inversion injury on uneven terrain.  Swelling, bruising and inability to bear weight followed.  His left ankle symptoms became unresponsive to treatment and worsened creating instability with high levels of activity.  His right ankle sustained no specific injury; however, he had persistent pain and symptoms of instability despite conservative treatment.  MRIs of the both ankles in June 2006 were normal.  The PT ROM examination, 5 months prior to separation, showed bilateral ankle dorsiflexion of 15 degrees (normal 20) and plantar flexion of 40 degrees (normal 45) with limitation due to pain.  At the MEB NARSUM examination, 4 months prior to separation, the CI complained of bilateral ankle pain and instability.  Physical examination showed bilateral ankle tenderness without laxity or instability.  

At the C&P examination, 3 months before separation, the CI reported a sensation of instability, right worse than left.  He worked on his feet all day as an orthopedic technician which caused a small amount of swelling.  Physical examination showed tenderness but no swelling.  Looseness was noted with inversion bilaterally, but there was no crepitus and drawer testing (for front to back looseness) was negative.  Right ankle dorsiflexion was 5 degrees and plantar flexion was 75 degrees.  Left ankle dorsiflexion was 5 degrees and plantar flexion was 65 degrees.  There was no pain, weakness or fatigability with repetitive motion for either ankle.  

The panel directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the panel must first consider whether the left and right ankle conditions remained separately unfitting after being de-coupled from the combined PEB adjudication.  The left ankle condition was profiled, but not the right, and both ankles were implicated in the commander’s statement and judged to fail retention standards by the MEB.  The commander’s statement and other STR evidence did not provide sufficient information which would permit the panel to discriminate the performance limitations attributable to either ankle over the other.  Since undue speculation would be required to conclude that impairment from either ankle would not have unacceptably interfered with the performance of military duties, members agreed that each ankle was reasonably justified as separately unfitting.  

The VA rated the left and right ankle conditions 10%, each coded 5271 (ankle, limited motion), based on the C&P examination, citing ankle instability.  The STR examinations provided evidence of painful motion causing functional loss supporting the 10% rating (based on §4.40, §4.45 and §4.59) for each ankle.  While the C&P examination did not document painful motion of either ankle, the ROM limitations (5 degrees of dorsiflexion) and instability alternatively supported a 10% rating for each ankle under the VASRD diagnostic code for limitation of motion (5271).  Because there was no ankylosis, nonunion or malunion, VASRD §4.71a offers no applicable joint code which would yield a higher rating than 10% for each ankle.  After due deliberation, and considering all the evidence, the panel recommends a disability rating of 10% for the left ankle condition and 10% for the right ankle condition, each coded 5299-5271.  

Contended PEB Conditions:  Obesity, Mild Conductive Hearing Loss, Mastoiditis, Chronic Headaches and Anxiety Disorder.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement.  Only obesity was judged to fail retention standards, and the PEB correctly adjudicated it as a condition not constituting a physical disability.  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 determination for any of the contended conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS: In the matter of the right shoulder condition and IAW VASRD §4.71, the panel recommends no change in the PEB’s 10% adjudication, but recommends a coding change to 5299-5203.  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 bilateral knee and ankle condition, the panel recommends that it be adjudicated for three separate conditions:  In the matter of the bilateral knee condition, the panel recommends a separately unfit determination (for both knees combined) with a disability rating of 10% coded 5299-5003.  In the matter of the left ankle condition, the panel recommends a separately unfit determination with a disability rating of 10% coded 5299-5271.  In the matter of the right ankle condition, the panel recommends a separately unfit determination with a disability rating of 10% coded 5299-5271, all IAW VASRD §4.71a.  In the matter of the contended obesity, mild cognitive hearing loss, mastoiditis, chronic headaches and anxiety disorder, 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 Right Shoulder Pain	5299-5203	10%	
Chronic Low Back Pain	5299-5237	10%	
Chronic Bilateral Knee Pain	5299-5003	10%	
Left Ankle Pain 	5299-5271	10%	
Right Ankle Pain 	5299-5271	10%	
COMBINED	40%