RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1200805 SEPARATION DATE: 20020322 BOARD DATE: 20130315 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty Soldier, SGT/E-5 (71L/Administrative Specialist), medically separated for pain; low back, right wrist, and left foot. The CI was initially seen for his back pain in 1997 when he felt a pop with a sharp pain after bending over to pick up his children’s toys. He was diagnosed with plantar fasciitis of his left foot and seen by podiatry in September 2000. There was no indication of how the wrist pain developed other than it recurred intermittently. The CI did not improve adequately with treatment to meet the minimal physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded slight constant low back pain (LBP), minimal; frequent right wrist pain; and minimal constant left foot pain as medically unacceptable IAW AR 40-501. The MEB forwarded no other conditions for Physical Evaluation Board (PEB) adjudication. The PEB bundled the three MEB conditions and adjudicated the single condition of “pain; low back, right wrist, and left foot” as unfitting, rated 10%, with cited application of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals, and was medically separated with a 10% disability rating. CI CONTENTION: The CI writes: “Degenerative disc disease, lumbar spine, with muscle spasms; left varicocele; diabetes mellitus; carpal tunnel syndrome, right hand.” SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 6040.44 Enclosure 3, paragraph 5.e.(2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings for the unfitting conditions of low back, right wrist, and left foot will be reviewed. The two other requested conditions, left varicocele and diabetes mellitus (DM), are not within the Board’s purview. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Army Board for Correction of Military Records. RATING COMPARISON: Service PEB – Dated 20011206 VA (4 Mos. Post-Separation) – All Effective Date 20020323 Condition Code Rating Condition Code Rating Exam Pain; Low Back, Right Wrist, and Left Foot 5099-5003 10% DDD, L-Spine 5293* 10% 20020711 R Carpal Tunnel Syndrome 8599-8515 10% 20020711 Plantar Fasciitis, L Foot 5099-5020 0% 20020711 .No Additional MEB/PEB Entries. Left Varicocele 7599-7529 20% 20020711 Diabetes Mellitus 7913 10% 20020711 0% X 0 / Not Service-Connected x 1 20020711 Combined: 10% Combined: 40%* *Changed code to 5242 by VARD of 4/27/06 with no change in rating level. Combined increased to 60% in 2006 due to neuropathies related to 7913 (DM); 80% in 2008, and 90% in 2010. ANALYSIS SUMMARY: The PEB combined the low back, right wrist, and left foot conditions under a single disability rating, coded analogously to 5003. Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints. IAW DoDI 6040.44 the Board must follow suit if the PEB combined adjudication is not compliant with the latter stipulation, provided that each ‘unbundled’ condition can be reasonably justified as separately unfitting in order to remain eligible for service rating. If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB. The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings. Pain; Low Back, Right Wrist, and Left Foot Conditions. The CI was right-handed. The narrative summary (NARSUM) indicated that the CI had chronic LBP, chronic left foot pain and recurrent right wrist pain. He was given conservative treatment for mechanical LBP. He had no bladder or bowel dysfunction, no radicular symptoms, no weakness, no paresthesias, and no incapacitating episodes. Back pain led to difficulty with push-ups, sit-ups, and flutter kicks. Radiographs of the lumbar spine showed partial lumbarization of the S1 segment and was considered a normal variant. Medications such as muscle relaxants, nonsteroidal anti- inflammatory drugs, and narcotics provided mild relief. The CI was also diagnosed with left foot plantar fasciitis, evaluated by Podiatry and prescribed pads for his feet due to an increased arch of his left foot. The CI was placed on L3 profile for chronic back pain, foot pain and right wrist pain with “restricted to no flutter kicks, no sit-ups, no push-ups, and no running. He was able to march up to one mile and lift up to 40 pounds as well as able to wear a shoe of comfort for both his feet. Podiatry performed steroid injections into his left foot in October of 2000 due to the chronic foot pain. His right wrist, left foot, and back pain remain recurrent intermittently. He is unable to meet minimal Army standards due to his recurrent condition.” The commander’s statement indicated duty interference “due to chronic back injury, is having difficulty maintaining standards for weight control. The CI’s back does not prevent him from doing his job in a capable manner, however, his debilitating pain and recurring numbness requires regular medication … part of the problem preventing him from meeting the Army weight control standards.” The SF 88 noted “bending at the waist to touch toes fairly easily … positive subjective positive Tinel’s region left wrist … and normal feet.” VA Compensation and Pension (C&P) exam, 4 months after separation, indicated chronic back pain since 1996 with spasm, stiffness and pain; right wrist carpal tunnel syndrome since 1995 with tingling and numbness of the two middle fingers and thumb, with weakness of the fingers; and plantar fasciitis since September 2000 with symptoms of pain, stiffness and swelling. Low Back Pain. Physical Therapy (PT) treatments and the VA exam (4 months post-separation) documented painful motion, and tenderness was documented on most exams. Most treatment notes also indicated complaint of radiating pain. Gait was normal. The single exam documenting more than slight limited ROM was 6 months prior to separation with both the MEB exam (4 months prior to separation) and the VA exam closer to the date of separation and indicating full active ROM with either tenderness or pain, and normal lower extremity motor and sensory findings. The Board first considered if the low back condition met the above criteria for separate rating. The lumbar spine condition history is noted above. It was the principle condition noted in the commander’s statement, had multiple temporary profiles, was undergoing treatment and was noted on duty restrictions. Members agreed, therefore, that the LBP condition was reasonably justified as separately unfitting and that it met VASRD §4.71a criteria for separate rating. Accordingly, it should be afforded separate disability rating. The Board directs attention to its rating recommendation based on the above evidence. The 2002 VASRD coding and rating standards for the spine, which must be applied to the Board’s recommendation IAW DoDI 6040.44, differ significantly from the current §4.71a general rating formula for the spine. The applicable coding options for this case are excerpted below. 5292 Spine, limitation of motion of, lumbar Severe ...................................................................................................................................... 40 Moderate ................................................................................................................................. 20 Slight ........................................................................................................................................ 10 5293 Intervertebral disc syndrome: Pronounced; with persistent symptoms compatible with: sciatic neuropathy with characteristic pain and demonstrable muscle spasm, absent ankle jerk, or other neurological findings appropriate to site of diseased disc, little intermittent relief .............. 60 Severe; recurring attacks, with intermittent relief .................................................................. 40 Moderate; recurring attacks .................................................................................................... 20 Mild .......................................................................................................................................... 10 Postoperative, cured ................................................................................................................. 0 5295 Lumbosacral strain: Severe; with listing of whole' spine to opposite side, positive Goldthwaite's sign, marked limitation of forward bending in standing position, loss of lateral motion with osteo-arthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion ...................................................... 40 With muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing' position ............................................................................................................. 20 With characteristic pain on motion ......................................................................................... 10 The record supported rating at 10% under 5295 (lumbosacral strain) for characteristic pain on motion or at 10% under 5293 (Intervertebral disc syndrome) for mild symptoms. Ideal coding would be 5099-5293 at 10%. Right Wrist. The CI was right hand dominant. The right wrist condition history as noted above was chronic since 1995 with the NARSUM indicating right wrist pain was noted to “remain recurrent intermittently.” The NARSUM exam indicated subjective numbness/tingling with minor decrease ROM (dorsiflexion 70 degrees of 75 degrees and palmar flexion 60 degrees of 75 degrees); and “decreased bilateral grip strength (>20% difference in trials suspicions of suboptimal effort).” The profile listed right wrist pain as part of the L3 profile with U1 noted. The CI could carry and fire a rifle and lift up to 40 pounds. The commander’s statement did not specify any hand condition, but did reference unspecified recurrent numbness. The VA exam indicated full active ROM with normal strength exam and “middle two fingers and thumb showed some decreased sensation.” Reflexes were normal and Tinel's and Phalen's signs were absent. The VA diagnosis was carpal tunnel syndrome. The Board first considered if the right wrist condition met the above criteria for separate rating. The Board adjudged that there was no fixed motor weakness of the right hand and that the sensory component of the wrist/hand condition did not significantly impact duty performance. Members agreed, therefore, that the right wrist condition was not reasonably justified as separately unfitting; and, accordingly, it cannot be recommended for separate disability rating. Left Foot. At the MEB exam, the CI reported recurrent intermittent left foot pain not relieved following a steroid injection for chronic pain. The MEB physical exam noted an increased arch with medial calcaneal tenderness. There was no pain with lateral compression. Diagnosis was left foot pain. The foot condition was part of the CI’s L3 profile, but did not include “wear a shoe of comfort” as prior temporary profiles had included. There was no mention of a foot condition in the commander’s statement as limiting duty performance; however there may have been overlap from the back restrictions to the foot. At the post-separation C&P exam, the CI reported symptoms of pain, stiffness and swelling with an exam documenting tenderness of the sole of the foot with no objective painful motion. Gait was normal. The final profile restriction did not include restriction from military footwear. Although there was a possibility that the impairment of the left foot was overshadowed by those of the back condition, there was insufficient evidence to indicate that the left foot condition was unfitting. Members agreed therefore, that the left foot condition was not reasonably justified as separately unfitting; and, accordingly, it cannot be recommended for separate disability rating. Rating Consideration for Pain; Low Back, Right Wrist, and Left Foot Conditions. The Board deliberated if the PEB’s original 10% rating for chronic pain as 5099-5003, absent the separately unfitting low back condition, should remain for the not separately unfitting foot and wrist conditions. The evidentiary standard was considered to be reasonable doubt, verses preponderance of the evidence. The Board considered that absent the low back condition, there was insufficient evidence of duty impairment from the combined foot and wrist conditions for continuation of the PEB 10% 5099-5003 rating in addition to a 10% rating for the back condition. Although ideal coding in this case would be an unfitting low back condition coded 5099-5293 at 10% with not unfitting/not compensable right wrist and left foot conditions, the PEB rating of 10% under 5099-5003 provides the equivalent rating level and there is no benefit to the CI for any coding change. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB’s 10% adjudication for the pain; low back, right wrist, and left foot condition(s). BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. As discussed above, PEB reliance on the USAPDA pain policy for rating all conditions was operant in this case and the conditions were adjudicated independently of that policy by the Board. In the matter of the pain; low back, right wrist, and left foot condition, the Board unanimously recommends no change in the PEB adjudication. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows: UNFITTING CONDITION VASRD CODE RATING Pain; Low Back, Right Wrist, and Left Foot 5099-5003 10% COMBINED 10% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120614, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxx, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxxxxxxxx, AR20130007733 (PD201200805) I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation and hereby deny the individual’s application. This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail. BY ORDER OF THE SECRETARY OF THE ARMY: Encl xxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)