RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXX	case:  pd1201085
branch of service:  army	BOARD DATE:  20130905
SEPARATION DATE:  20011006

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve component CPT/O-3 (67A5P/Health Care Administrator) on active duty, medically separated for low back pain (LBP), bilateral shoulder pain, bilateral knee pain, cubital tunnel pain of the right extremity, and plantar fasciitis of the right foot.  The CI injured his back in 1987 and again 1999.  His first documented shoulder complaints were in 2000, the right being worse than the left.  His knee pain started without a specific incident or trauma.  He was also diagnosed with plantar fasciitis of the right foot, cubital tunnel syndrome of the right hand and a longstanding history of asthma.  His multiple conditions did not improve with physical therapy, activity modification and anti-inflammatory medications in order to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent U3/L3 profile (with LBP, right shoulder and bilateral knee pain, and asthma listed) and referred for a Medical Evaluation Board (MEB).  Asthma was also identified and forwarded by the MEB.  The Physical Evaluation Board (PEB) adjudicated MEB conditions 1-7 as a single unfitting condition, rated 20%.  Asthma was determined to be not unfitting and therefore not rated.   The CI made no appeals and was medically separated.  The United States Army Physical Disability Agency administrative correction only updated the Soldier’s rank.

CI CONTENTION:  “Please review my PEB to determine why all of my medical conditions that were part of my MEB were not ruled upon.  The PEB only ruled upon my back, shoulder and knee pains and disregarded the other issues clearly noted on my MEB.”  The CI made extensive additional contentions in blocks 12, 13, and 15 of his application, all of which were thoroughly considered by the Board in its deliberations.

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 conditions determined by the PEB to be specifically unfitting for continued military service and when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.”  The ratings for unfitting conditions will be reviewed in all cases.  All conditions identified by the MEB and requested for consideration meet the criteria prescribed in DoDI 6040.44 for Board purview.  These conditions, listed by the PEB as “MEB DX 1-7,” are the low back, bilateral shoulder, bilateral knee, right cubital tunnel and right plantar fasciitis conditions.  The asthma condition determined to be not unfitting by the PEB is also addressed below.  The requested cervical spine and thoracic spine conditions were not identified by the MEB or PEB, and are not within the DoDI 6040.44 defined purview of the Board.  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 Board for Correction of Military Records.

RATING COMPARISON:

UAPDA Admin Correction – Dated 20010725	VA (2.5 Mos. Pre-Separation) – All Effective Date 20011007	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Back, bilateral shoulders, bilateral knees, 
(MEB DX 1-7: 
1) Spondylolysis/Grade I spondylolisthesis
2) DDD w/disc protrusion
3) Degenerative joint disease
4) Bilateral shoulder pain, mild to moderate
5) Bilateral knee pain, moderate, secondary to chondromalacia
6) Cubital Tunnel syndrome, mild
7) Plantar fasciitis, right foot, mild to moderate	5099-5003	20%	DDD L-Spine w/History of Compression Fracture	5293-5292	20%	20010724	
			Left Shoulder Tendonitis	5099-5024	0%	20010724	
			Right Shoulder Tendonitis	5099-5024	0%	20010724	
			Left Chondromalacia Patella	5099-5019	0%	20010724	
			Right Chondromalacia Patella	5099-5019	0%	20010724	
			Right Cubital Tunnel Syndrome	8517	0%	20010724	
			Right Foot Plantar Heel Spur	5099-5024	0%	20010724	
Asthma  (MEB DX 8)	Not Unfitting	Asthma	6602	30%	20010724	
↓No Additional MEB/PEB Entries↓	Cervical Spine Sprain	5290	10%	20010724	
	Thoracic Spine DDD	5293	0%	20010724	
	0% X 2 / Not Service-Connected x 1	20010724	
Combined:  20%	Combined: 50%	

ANALYSIS SUMMARY:  The PEB combined the back, bilateral shoulders, bilateral knees, right cubital tunnel and right plantar fasciitis conditions under a single disability rating, coded analogously to 5003.  Although Veterans Affairs Schedule for Rating Disabilities (VASRD) §4.71a permits combined ratings of two or more joints under 5003, the Board must determine if each “unbundled” condition can be reasonably justified as separately unfitting 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.  To that end, the evidence for the back, bilateral shoulders, bilateral knees, right cubital tunnel and right plantar fasciitis conditions are presented separately with recommendations regarding fitness and separate rating if indicated.  The Board acknowledges the impairment with which the CI’s service-connected conditions continue to burden him but notes the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  With respect to the CI’s contention for rating of his asthma condition, which was determined to be not unfitting by the PEB, disability compensation may only be offered for those conditions that cut short the member’s career.  Should the Board judge that this condition was most likely incompatible with military service, a disability rating IAW the VASRD, based on the degree of disability evidenced at separation, will be recommended.

Low Back Condition.  The CI reported that he first developed LBP after a parachuting accident in 1987, although the service treatment record (STR) did not corroborate that.  Imaging revealed L5 spondylolysis (stress fracture) and mild spondylolisthesis (vertebral slippage).  Although the CI experienced intermittent LBP after that, he returned to full duty and activities.  The CI reported he reinjured his back in another parachuting accident in 1999, again uncorroborated by STR entries, and experienced more persistent and severe low back pain in 2000.  Magnetic resonance imaging studies (MRI) revealed a broad based disc bulge with mild to moderate bilateral symmetrical neural foraminal narrowing at L4-L5 and L5-S1.  There was no residual evidence of the previously reported vertebral compression fractures.  Non-surgical treatment included anti-inflammatory medications, activity modifications and physical therapy (PT).  At the narrative summary (NARSUM) exam performed 8 months prior to separation, the CI complained of sciatic pain in his right buttock and right leg.  His pain had increased with activity and he experienced intermittent numbness on the right back and buttock.  His pain prevented him from running with his unit, bicycling, jumping or sitting for longer than an hour.  Pain severity ranged from 7-8 out of 10 to 10 out of 10.  Physical examination revealed mild tenderness at the L4-L5 level.  There was no spasm with lateral bending.  Range-of-motion (ROM) assessment showed flexion to 60 degrees (normal to 90 degrees by current standards), extension to 20 degrees limited by pain (normal to 30 degrees by current standards), and left and right bending 20 degrees-30 degrees (normal 30 degrees by current standards).  Lower extremity sensation, strength, and reflexes were normal.  The commander’s statement recounted the details of the CI’s reported parachute jump injuries, and cited the back conditions as a basis for the CI’s inability to perform his MOS duties and noted the CI experienced flare-ups of sciatica associated with prolonged sitting.  The permanent profile identified LBP and the commander’s endorsement stated: “Chronic injuries prevent soldier from performing his duties on active duty.”  At the VA Compensation and Pension (C&P) exam performed 2 months prior to separation, the CI indicated that as a result of taking an anti-inflammatory pain medication just prior to the appointment, it was a “good” day and there was no pain at rest.  He reported that some LBP was present each day, but that excruciating pain occurred approximately every month.  Intermittent numbness of the right lower back and buttock occurred, but without any leg weakness.  Hobbies included hiking and running.  He could stand for 15-20 minutes, walk for four miles and run for three miles.  Physical exam revealed flexion of 95 degrees (VA normal 95 degrees), extension 35 degrees (VA normal 35 degrees), right and left lateral bending 40 degrees each (VA normal 40 degrees), and right and left rotation 35 degrees each (VA normal 35 degrees).  Lumbar spinal tenderness was absent.  Although the examiner initially noted “no painful motion…of the lower spine” it was also stated that the lumbar spine was affected by pain and that pain with flexion was present.  Posture and gait were normal, and no assistive devices were required.  Straight leg raise testing was noted to be “positive for both right and left legs at 80 degrees,” but lower extremity sensation, strength and reflexes were normal.  X-ray examination confirmed first degree spondylolisthesis of L5, degenerative disc disease of L5-S1 and mild upper lumbar spondylosis.

The Board first considered if the LBP condition, having been de-coupled from the combined PEB adjudication, remained itself unfitting as established above.  Members agreed that the functional limitations in evidence justified the conclusion that the condition was integral to the CI’s inability to perform his duties and accordingly a separate rating is recommended.  The 2001 VASRD coding and rating standards for the spine, which were in effect at the time of separation and must be applied to the Board’s recommendation IAW DoDI 6040.44, differ from the current §4.71a general rating formula for the spine.  The applicable coding options for this case are excerpted below.

5285 Vertebra, fracture of, residuals:
 With cord involvement, bedridden, or requiring long leg braces.................................... 100
      Consider special monthly compensation; with lesser involvements rate 
          for limited motion, nerve paralysis.
 Without cord involvement; abnormal mobility requiring neck
 	brace (jury mast) .........................................................................................................60
 In other cases rate in accordance with definite limited motion or muscle spasm, 
            adding 10 percent for demonstrable deformity of vertebral body.

           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 VA assigned a 20% rating under a combination 5293-5292 code, citing painful motion with a history of compression fracture.  Board members agreed that the 5285 criteria do not support an additional 10% rating beyond limitation of motion or muscle spasm, since demonstrable vertebral body deformity was not present.  The Board agreed that “characteristic pain on motion” is reasonably conceded given the history of lifestyle-limiting pain and examination findings, and therefore a 10% rating was justified under the 5295 code.  It was likewise concluded that “slight” limitation of motion most accurately described the ROM in evidence, and therefore a 10% rating under the 5292 code was warranted.  Finally, the 5293 code was deliberated; it was agreed that “mild” was the most appropriate descriptor, thus supporting a 10% rating under this code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded a disability rating of 10% for the LBP condition, coded 5295, was most clinically accurate.

Bilateral Shoulders.  The first STR entry in evidence is an outpatient exam in November 2000 (11 months prior to separation).  The CI complained of a symptomatic right shoulder, with reported history of chronic intermittent bilateral shoulder pain without any known precipitating events.  When pain was present, intensity was 2-8 out of 10 in severity and could cause him to temporarily discontinue weight lifting for days to weeks.  An MRI in December 2000 revealed minimal degenerative joint disease and other non-specific findings.  According to the NARSUM examiner (February 2001), the CI developed gradual onset shoulder pain without injury in 1991-1992.  Anti-inflammatory medications and PT had not helped the pain.  The NARSUM noted that pain was intermittent and did not occur at night.  He had pain (right greater than left) with activities like push-ups, pull-ups, overhead throwing and riding his mountain bike or motorcycle, though he noted no loss of ROM.  Examination revealed mild tenderness about the acromioclavicular shoulder joints and signs suggestive of possible rotator cuff impingement.  Although ROM was noted to be “full,” forward flexion was reported as 150 degrees (normal 180 degrees) and abduction 120 degrees (normal 180 degrees).  The shoulder joints were stable.  X-rays were reportedly normal.  The C&P exam noted no shoulder joint tenderness, but biceps groove tenderness was present.  The shoulder joints were stable, normal measured ROM was present, and there was no painful motion.  The commander's letter mentioned that subsequent to 1992, the CI completed an ROTC program, was assigned as a paratrooper with the 82nd Airborne Division, and was assigned to the Joint Special Operations Command.  The commander noted the shoulder problems as a possible consequence of years of physically demanding military duties, but did not implicate the shoulders as a significant contributor to precluding the CI from performing his military duties other than pull-ups and push-ups.  Left shoulder pain was never profiled; right shoulder pain was not profiled until the permanent profile written at the time of the MEB process.  The VA assigned 0% ratings each for right and left shoulder tendonitis.  Members agreed that based on the evidence, the bilateral shoulder condition, having been de-coupled from the combined PEB adjudication, was not separately unfitting.  The well-established principle for fitness determinations is that they are performance based.  The Board could not find evidence that documented any significant interference of the shoulder condition with duty performance at the time of separation, nor were any physical findings documented by the MEB or VA examiners which would logically be associated with significant disability.  Additionally, there is insufficient evidence in support of a compensable rating for the shoulder condition, even if were conceded as unfitting.  After due deliberation, members agreed that the evidence does not support a conclusion that the functional impairment from the bilateral shoulders condition prevented the CI from performing his duties and accordingly cannot recommend a separate rating for it.

Bilateral Knees.  The CI developed knee pain several years prior to separation without any history of specific trauma.  At the NARSUM, the CI noted no swelling, but complained of increased pain going down stairs.  He stated he was unable to run, climb stairs, speed walk, bike or jump.  Anti-inflammatory medications and PT did not help.  Examination of the knees revealed full painless active and passive ROM, normal patellar tracking and no joint instability.  He did have tenderness to palpation about the lower pole of the patella bilaterally.  Although the permanent profile written during the MEB process listed bilateral knee pain, the commander's statement did not implicate the knees as a significant contributor to the CI’s inability to perform his MOS.  At the C&P exam, the CI reported that his hobbies included hiking and running and that he could walk four miles and run three miles.  Examination of the knees revealed normal measured ROM without pain, and there were no signs of instability.  X-rays of the knees revealed no abnormalities.  The VA assigned 0% ratings each for right and left chondromalacia patella.  The Board could not find evidence that documented any significant interference of the knee condition with the performance of duties at the time of separation, nor were any physical findings documented by the MEB or VA examiners which would logically be associated with significant disability.  Additionally, there is insufficient evidence in support of a compensable rating for the knee condition, even if were conceded as unfitting.  After due deliberation, members agreed that the evidence does not support a conclusion that the functional impairment from the bilateral knee condition prevented the CI’s ability to perform his duties and accordingly cannot recommend a separate rating for it.

Right Cubital Tunnel Syndrome.  The CI was evaluated by a physical medicine specialist in November 2000 (11 months prior to separation) with complaints of a 3-4 month history of right hand paresthesias (abnormal sensation), worse in the ring and little fingers.  Symptoms were improving after he reduced activities of hammering, painting and riding a motorcycle.  Physical examination noted normal muscle strength and intact sensation.  Electrodiagnostic studies indicated mild ulnar neuropathy across the cubital tunnel (inner aspect of the elbow).  According to the NARSUM examiner 3 months later, symptoms persisted despite activity modification.  It was stated that the condition prevented heavy lifting with the right arm, but the mechanism by which such impairment resulted was not explained.  He also complained of difficulty grasping objects.  On exam, he had pain with tapping over the nerve at the elbow but sensation and strength of the upper extremities was normal.  At the C&P exam, the CI stated that his hand numbness was bilateral, that the condition lasted for several hours every couple of days, and that anti-inflammatory medication provided relief.  Examination showed no elbow tenderness and normal hand strength.  This condition was not profiled.  The commander's statement mentions the CI’s numbness in his right arm, but does not implicate it as a significant contributor that precluded duty performance.  Members agreed that there was no performance based evidence that the cubital tunnel syndrome condition, having been de-coupled from the combined PEB adjudication, was separately unfitting and accordingly cannot recommend a separate rating for it.

Right Plantar Fasciitis.  The CI developed right heel pain in 1998 without injury.  After symptoms persisted for several months, he was diagnosed with plantar fasciitis and fat pad syndrome.  Treatment included heel cups, stretching, anti-inflammatory medications and steroid injections.  The last outpatient note in evidence was by a physical medicine specialist in February 1999, at which time the CI stated the condition was “healing up.”  A trial of acupuncture was planned if symptom improvement did not continue.  The record was silent until the NARSUM examiner (in February 2001) noted that the CI remained symptomatic and the condition interfered with impact activities.  Examination was normal except for tenderness to palpation at the right plantar fascia insertion.  The C&P examiner indicated that pain was present in his feet since 1998, and that it was relieved with rest, ice and anti-inflammatory pain medication.  As previously elaborated, the CI indicated he could walk four miles and run three miles.  Examination revealed no tenderness to palpation of either foot.  Gait was normal, including heel and toe walking.  The CI's permanent profile did not list plantar fasciitis.  The commander's statement mentions the plantar fasciitis but does not implicate it as a significant contributor to the CI's inability to perform his military duties.  The Board again first considered if the right plantar fasciitis condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting.  The Board could not find evidence that documented any significant interference of the right plantar fasciitis condition with the performance of duties at the time of separation, nor were any physical findings documented by the MEB or VA examiners which would logically be associated with significant disability.  After due deliberation, members agreed that the evidence does not support a conclusion that the functional impairment from the right plantar fasciitis condition was integral to the CI’s inability to perform his duties and accordingly cannot recommend a separate rating for it.

Contended PEB Condition.  The contended condition adjudicated as not unfitting by the PEB was asthma.  The CI had a history of childhood asthma and of exercise-induced shortness of breath (SOB) after an episode of bronchitis in 1988.  Baseline and exercise pulmonary function tests (PFT) in 1995 were normal.  At a clinic visit in July 2000 (14 months prior to separation) the CI reported SOB only during strenuous activity but symptoms had worsened over the last few years, and were helped by use of an inhaled bronchodilator (Albuterol).  He had required no emergency room visits and no use of oral steroids (i.e. steroid pills).  The NARSUM examiner in February 2001 indicated the CI required intermittent use of inhaled bronchodilators.  No hospitalizations occurred due to the condition.  The NARSUM quoted a specialist’s note saying “The patient is doing well on Albuterol inhaler at this time.”  An assessment by pulmonology in March 2001 (7 months prior to separation) included PFTs consistent with asthma.  A diagnosis of mild, intermittent asthma was made and the CI was prescribed inhaled bronchodilators and an inhaled corticosteroid.  At the C&P exam, the CI stated he had never been hospitalized for this condition, and had experienced no asthma attack “since the original incident” (presumably referring to the incident in 1988).  He used an inhaled bronchodilator prior to activity, which resulted in him being “symptom free.”  His current medication list did not include maintenance medication for asthma.  This condition was not profiled until the time of the MEB.  Although the commander noted that the condition had worsened over the prior year, neither the profile nor the commander’s statement specified activity restrictions that were exclusive to asthma.  The Board’s main charge with respect to this condition is an assessment of the fairness of the PEB’s determination that it was not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  An established principle for fitness determinations is that they are performance based.  The Board is confronted in this case with the lack of evidence that the limitations imposed by the asthma condition prohibited the CI’s performance of his duties.  Members agreed that there was no citable evidence which would challenge the PEB’s fitness conclusion, and there were no clinical features or specific functional limitations which would render the condition inherently unfitting.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended asthma condition and therefore no disability rating can be recommended.

The Board notes in conclusion that its overall fitness and rating recommendations offer no benefit to the CI and IAW DoDI 6040.44 the Board may not recommend a rating lower than the PEB’s overall combined rating.  As elaborated above, members agreed that none of the conditions except low back pain were unfitting, and that the low back condition warranted a 10% rating IAW VASRD §4.71a.  However, in order to maintain compliance with DoDI 6040.44, it was concluded that the lumbar spine rating of 20% should not be re-characterized.

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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the low back condition, the Board unanimously recommends no change to the disability rating of 20%, coded 5295.  In the matter of the bilateral shoulder pain, bilateral knee pain, right cubital tunnel and right plantar fasciitis conditions, the Board unanimously agrees that it cannot recommend a finding of unfit for additional rating at separation.  In the matter of the contended asthma condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  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	
Low Back Pain	5295	20%	
Bilateral Shoulders	Not Unfitting	
Bilateral Knees	Not Unfitting	
Right Cubital Tunnel Syndrome	Not Unfitting	
Right Plantar Fasciitis	Not Unfitting	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20120621, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXXXXXXXX, DAF
President
Physical Disability Board of Review
SFMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(TAPD-ZB / XXXXXXXXXXXXXX), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXXXXXX, AR20130021929 (PD201201085)

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						     XXXXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary
						         (Army Review Boards)