RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME: XXXXXXXXXXXXXXXXX	CASE: PD-2020-00161
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20051220

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Infantryman, medically separated for “left ankle pain with a multiple ligamentous tear…[and] clinically diagnosed Reflex Sympathetic Dystrophy [RSD],” and “left shoulder with a history of injury,” rated 10% and 0%, respectively. Right knee pain was determined to have existed prior to service (EPTS) and was not rated.

CI CONTENTION: “Review all conditions I was not rated properly. I was pushed out fast with a cheap pay off. I had several issues. I am deaf, I have PTSD, I have had 4 shoulder surgeries. I have back issues. I want everything looked at.” 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 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 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 - 20050922	VARD - 20060511	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Ankle Pain	
5257	
10%	Residuals, Multiple Ligamentous Tears, Left Ankle w/ Reflex Dystrophy Syndrome	
5271	
0%	
20060215	
Reflex Sympathetic
Dystrophy (RSD)							
Left Shoulder Injury	5201	0%	Residuals, Grade I SLAP Lesion,
Left Shoulder, Grade I Chondromalacia, Left Glenoid	5299-5201	0%	20060215	
Right Knee Pain with History of Bilateral Meniscal Tear	5099-5003	EPTS	Right Knee Condition	5299-5260	NSC	20060215	
			Left Knee Condition	5299-5260	NSC	20060215	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 0%	

ANALYSIS SUMMARY:

Left Ankle Pain. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s left ankle condition began in January 2004 after he sustained a twisting injury when he jumped out of a helicopter carrying a full combat load. An MRI in March 2004 showed “a question of ligament tear” involving the anterior talofibular, calcaneal fibular, and tibiofibular ligaments. There was no surgical indication.

The 6 January 2005 MEB examination (recorded on DD Form 2808), noted left ankle pain with flexion and decreased range of motion (ROM). During the 1 February 2005 NARSUM, 10 months prior to separation, the CI reported on-going left ankle pain and that he was unable to run or march with a fighting load. Physical examination showed left ankle tenderness and laxity, but no edema or evidence of compromised blood flow or inflammation. The 16 February 2005 MEB physical therapy (PT) examination recorded left ankle dorsiflexion to 5 degrees (normal 20) and plantar flexion to 30 degrees (normal 45), with severe pain in all directions. At a follow-up PT visit on 21 July 2005, 5 months before separation, measured left ankle dorsiflexion was to 0 degrees and plantar flexion to 30 degrees, with painful motion in all directions.

During the 15 February 2006 VA Compensation and Pension (C&P) examination, the examiner was able to document the CI’s complaints, but could not complete a physical examination because the CI had to depart for a job interview. The examiner noted CI reports of continued left ankle pain and swelling, difficulty navigating stairs, and an inability to jump. However, he could run 2 miles before his ankle hurt. After reviewing the STR, the examiner opined that “from all I can gather there is no RSD.”

The panel directed attention to its rating recommendation based on the above evidence. The PEB bundled the left ankle condition with the RSD and applied a single 10% rating under code 5257 (knee-other impairment of), citing pain-limited ROM. The panel noted the PEB’s use of a knee code and presumed this was in error. The VA rated the left ankle condition with RSD 0%, coded 5271 (limited motion), citing a non-compensable rating.

The panel first considered the left ankle condition, and the majority agreed the 10% rating was justified under code 5271 (ankle, limited motion of) for moderate limitation of motion as reported during the PT examinations. Other VASRD ankle and analogous codes were considered, but all were less applicable and not advantageous for rating.

The panel next considered the RSD, noting that the PEB implied this condition was the cause of the CI’s pain complaint. The NARSUM examiner referenced previous orthopedic evaluations documenting that the CI “likely did develop reflex sympathetic dystrophy,” but RSD symptoms (temperature changes at the ankle, numbness, tingling, etc.) were never recorded in the NARSUM, and there was no STR evidence of a confirmed RSD diagnosis. The condition was not profiled or implicated in the commander’s statement, and the C&P examiner found no STR documentation of RSD. Panel members concluded there was not a preponderance of evidence showing the RSD standing alone would have caused the CI to be referred into the disability evaluation system or be found unfit. 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 left ankle condition.

Left Shoulder. According to the STR and MEB NARSUM, the right-hand dominant CI injured his left shoulder in December 2003 while doing physical training. An MR arthrogram showed a “questionable anterior labral tear,” and in April 2005, he underwent a shoulder arthroscopy with debridement that showed a Grade I superior labrum anterior-to-posterior lesion.

At the 16 February 2005 MEB PT ROM study, both left shoulder flexion and abduction were to 120 degrees (normal 180), with painful motion present in all directions. At the 11 May 2005 MEB NARSUM orthopedic examination, 6 months prior to separation and one month after surgery, the CI complained of persistent left shoulder pain, especially when lifting weights, but did not report any dislocations. Physical examination showed decreased pain and no evidence of instability. At the 21 July 2005 MEB PT ROM re-evaluation, 5 months before separation, left should flexion was to 150 degrees and abduction to 160 degrees, with no mention of tenderness or painful motion.

During the VA C&P examination, the CI reported that he still experienced left shoulder pain when he slept on it and during abduction. He was able to lift weights but experienced flare-ups when bench pressing heavy weights. As noted above, no physical examination was conducted.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the shoulder condition 0%, coded 5201 (limitation of arm motion), citing “abduction to 160 degrees.” The VA also assigned a 0% rating, analogously coded 5299-5201, citing non- compensable limitation of motion. Panel members considered all VASRD shoulder and analogous codes, but there was no higher rating than the 0% adjudicated by the PEB. Also, the MEB NARSUM and PT examinations closest to separation did not provide evidence of painful motion or other evidence of functional loss to support a 10% rating IAW VASRD §4.59, §4.40 or §4.45. After due deliberation, considering all the evidence and mindful of VASRD §4.3, the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the left shoulder condition.

Contended PEB Conditions: Right Knee Pain, Bilateral Meniscal Tear, and Left Knee Surgery. The panel’s main charge is to assess the fairness of the PEB’s determination that the right and left knee conditions were not unfitting. Neither of the knee conditions were profiled or implicated in the commander’s statement; however, the MEB forwarded “bilateral meniscal tear” as a medically unacceptable condition.

Left Knee. Although the left knee meniscal tear was forwarded by the MEB to the PEB, the lack of service treatment notes indicates that the left knee condition was never a subject of clinical concern and the panel agreed it was not unfitting.

Right Knee. The STR noted an initial complaint of right knee pain in 2002. Although a right knee MRI in April 2003 reportedly showed a possible Grade III tear of the posterior horn of the medial meniscus, there was no indication that any treatment was recommended. In December 2003, the CI was placed on a brief profile due to reports of infrapatellar pain, but treatment notes were silent until 2005, when an MRI reportedly showed no evidence of internal derangement and X- rays showed changes that were “most probably secondary to arthritis.” The January 2005 MEB examination documented right knee pain and patellar tendon tenderness, but treatment did not occur until August 2005. At the 5 August 2005 primary care visit, the CI reported a 1-month history of right knee pain of different character than his typical knee pain. On examination, there was tenderness along the medial joint line, clicking during McMurray’s testing, and valgus popping, but no locking or knee instability. The examiner diagnosed a right knee medial collateral ligament sprain. At a PT visit on 26 August 2005, the provider noted “knee ROM is full except lacks knee extension in the 90/90 position.” Lachman’s testing was negative. At a follow- up PT visit on 29 August 2005, the CI reported benefit from the using a knee brace that he tested on an elliptical trainer and a 1-mile run.

Although the right knee condition was not profiled or implicated in the commander’s statement, panel members agreed it was unfitting. The panel directed attention to its rating recommendation based on the above evidence. 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 also 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. 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 right knee condition, coded 5003.

BOARD FINDINGS: In the matter of the left ankle condition and IAW VASRD §4.71a, the panel majority recommends no change in the PEB adjudication. The single voter for dissent recommends modification to 20%, but did not elect to submit a minority opinion. In the matter of the left shoulder condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. In the matter of the contended right knee condition, the panel recommends a disability rating of 0%, coded 5003 IAW VASRD §4.71a. There are no other conditions within the panel’s scope of review for consideration. As the proposed new combined disability ratings result in no change to the combined disability rating previously assigned, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Left Ankle Pain	5257	10%	
Left Shoulder Injury	5201	0%	
Right Knee Pain	5003	0%	
	COMBINED	10%	

The following documentary evidence was considered:

AR20210008028

Dear XXXXXXXXXXXXXXXXXXX:

	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.