RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-01215
BRANCH OF SERVICE:  Army	BOARD DATE:  20141104
Separation Date:  20040712

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (91J/Medical Supply Technician) medically separated for chronic pain bilateral feet following bunionectomy, pubic symphysis, bilateral wrist and left ankle pain.  The conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was issued a permanent U3/L3 profile and referred for a Medical Evaluation Board (MEB).  The bilateral feet, pubic symphysis, bilateral wrist and left ankle condition, characterized as “bilateral foot bunionectomies with chronic pain,” “pubic symphysis pain,” “bilateral wrist pain,” and “left ankle pain” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded four other conditions [gastro esophageal reflux disease (GERD), seasonal allergic rhino conjunctivitis, headache and urinary retention] for PEB adjudication.  The Informal PEB adjudicated “chronic pain bilateral feet following bunionectomy, pubic symphysis, bilateral wrists and left ankle” as a single unfitting condition, rated at 10% citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy.  The remaining conditions were determined to be medically acceptable.  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in her application.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting feet, pubic symphysis, bilateral wrists and left ankle conditions are addressed below; the GERD, allergies, headache and urinary retention conditions were not requested for review and thus are not within the defined scope.  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:

Service IPEB – Dated 20040329 | VA - (1 Mo. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Chronic Pain Bilateral Feet Following Bunionectomy, Pubic Symphysis, Bilateral Wrists, Left Ankle | 5099-5003 | 10% | Residuals of Bunionectomies Both Feet | 5280 | 0% | 20040823
| | | Pes Planus Both Feet | 5276 | 10% | 20040823
| | | Total Vaginal Hysterectomy w/ Bilateral Salpingoophorectomy & Pubic Symphysis | 7617 | 50% | 20040823
| | | Tendonitis of the R Wrist | 5024 | 10% | 20040823
| | | Tendonitis of the L Wrist | 5024 | 10% | 20040823
| | | Bilateral Ankle Sprains | 5299-5271 | 0% | 20040823
Other x4 (Not in Scope) | Other x 6 | 20040823
Rating:  10% | Combined:  80%
Derived from VA Rating Decision (VARD) dated 20041124 (most proximate to date of separation)

ANALYSIS SUMMARY:  The PEB rated chronic pain bilateral bunionectomies, pubic symphysis, bilateral wrists, left ankle condition under the single analogous 5003 (degenerative arthritis), code.  This coding approach is countenanced by AR 635-40 (B.24 f.), but IAW DoDI 6040.44 the Board must apply only VASRD guidance to its recommendation.  The Board must therefore apply separate codes and ratings in its recommendations if compensable ratings for each condition are achieved IAW VASRD criteria.  If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each “unbundled” condition was reasonably justified as separately unfitting.

Chronic Pain Bilateral Feet (Bunionectomies).  The PEB adjudicated the chronic bilateral feet condition as part of a bundled unfitting condition as indicated on DA Form 199.  The Board first considered whether the left and right foot condition (bunionectomies) de-coupled from the combined PEB adjudication, remained independently unfitting as established above.  The CI was issued a profile related to the bunion condition in December 2000 and again upon entry into the Disability Evaluation System (DES) in mid-2003.  The latter profile contained restrictions of no running, no standing more than two hours and no ruck sack or walking on uneven ground.  The commander’s statement documented that the CI had ongoing physical restriction that interfered with her ability to perform her MOS duties.  The service treatment records reflect that the CI had surgical procedures on both feet with resultant restrictions.  All Board members agreed that the left and right foot (bunionectomy) pains are independent condition, which would have rendered the CI incapable of continued service within her MOS and each accordingly merits a separate rating.

The CI was evaluated by orthopedics for right foot pain localized at the first metatarsalphalangeal (MTP) joint, worse with increased activities such as walking and running.  The physical exam findings were bilateral foot pes planus, hallux valgus and tenderness over first metatarsal head.  The examiner diagnosed bilateral sesamoiditis, hallux valgus and pes planus.  A post-operative left foot X-ray was obtained to evaluate surgery in June 2001, showed two screws in near anatomic alignment.  The CI was seen post-operative for left foot surgery 3 months later (date omitted); status post left foot bunionectomy, heel osteotomy and first tarsal metatarsal arthrodesis (fusion of some of the small joints of the middle foot).  The examiner noted that the left foot felt better and there was a decrease in right foot pain.  The left foot X-ray images revealed persistent mild hallux valgus post bunionectomy and mild metatarsal phalangeal joint degenerative joint disease.  A whole body scan showed increased uptake in the bilateral mid feet consistent with stress changes.  The physical exam findings were palpable hardware dorsally, limited ROM at the first metatarsal phalangeal joint and crepitus with ROM.  The right foot exam was normal.  The orthopedist diagnosed persistent left mid-foot pain and scheduled hardware removal the next day.  The orthopedist noted continued pain around the left hind foot that limited activity and rendered her incapable of performing her duties requirements.

The MEB narrative summary (NARSUM) exam (approximately 4 months prior to separation), documented that the persistent bilateral foot pain post bunionectomies on each side was present 100% of the time, caused sleep disturbance and prevented her participation of the Army Physical Fitness Test.  The examiner rated the pain according to the American Medical Association (AMA) pain scale at slight and constant.

The VA Compensation and Pension (C&P) examination performed (approximately 2 months post-separation), documented that as a result of the bilateral pes planus and bunionectomy pain, the CI had weakness at rest, pain while walking/standing and could not climb stairs or move around freely.  X-rays images obtained of the bilateral feet showed postsurgical changes along the medial aspect of each first metatarsal along with fusion procedures of each first metatarsal cuneiform articulation.  There were retained screws within the first metatarsal cuneiform joint of the right foot.

The Board directs attention to its rating recommendation based on the above evidence.  As described above, the PEB bundled the chronic pain bilateral feet, pubic symphysis, bilateral wrists, left ankle conditions coded as 5099 analogous to 5003 arthritis, degenerative (hypertrophic or osteoarthritis) in its rating of 10% with application of the USAPDA pain policy.  The VA coded the residuals of bunionectomies both feet as 5280, unilateral hallux valgus, rated at 0%.  All documents in the service treatment record proximate to separation indicated painful motion of the first MTP joints.  The CI was given a permanent U3/L3 profile for bilateral foot bunionectomies and other orthopedic conditions which supports VASRD §4.40 (functional loss).  Board members considered application of VASRD code 5280; however, members agreed that the CI did not meet the minimal compensable rating criteria under that code.  The evidence adequately supports the presence of painful motion of each first metatarsalphalangeal joint (not a major joint) which allows for application of code 5003 to the bilateral condition (for “two or more minor joint groups”).  Considering the totality of the evidence and with deference to reasonable doubt, the Board recommends a disability rating of 10% for the chronic pain bilateral feet (bunionectomies) condition under code 5280-5003.

Chronic Pain Pubic Symphysis.  The Board first considered if the pubic symphysis pain condition, having been de-coupled from the combined PEB adjudication, remained reasonably justified as separately unfitting as established above.  After review of the evidence, members agreed there was a questionable basis for arguing that it was separately unfitting.  The well-established principle for fitness determinations is that they are performance based.  The Board could not find specific evidence in the commander’s statement or elsewhere in the service treatment records that documented any specific interference of the pubic symphysis condition with the performance of duties at the time of separation.  A plain X-ray image of the pelvis was normal and a whole body scan showed a normal pubic symphysis.  Also documented, was the CI report of having pain relief after a steroid injection.  The Board further noted that the CI had several other subjective pain complaints related to pelvic/gynecological conditions.  After due deliberation, members agreed the evidence does not support a conclusion that the functional impairment from the pubic symphysis was integral to the CI’s inability to perform within her MOS and accordingly cannot recommend a separate disability rating for it.

Chronic Pain Bilateral Wrists Condition.  The Board first considered whether the left and right wrist conditions, having been de-coupled from the combined PEB adjudication, remained independently unfitting as established above.  The evidence makes clear that the right wrist was associated as more disable than the left one in this case.  The disparity was such that the question is raised of whether the left wrist was reasonably justified as separately unfitting as the service treatment records did not contain any entry “solely” related to the left wrist condition.  Additionally, the NARSUM addendum contained the following statement, “As of 4 NOV 03, no mention of left wrist pain has been annotated in her orthopedic consultations”.  After due deliberation, members agreed the evidence does not support a conclusion that the functional impairment from the left wrist was integral to the CI’s inability to perform her MOS and accordingly cannot recommend a separate disability rating for it.

The CI developed atraumatic right wrist pain in April 2003 and was seen by orthopedics.  The physical exam findings were exquisite tenderness to palpation over the flexor carpi ulnaris (FCU) muscle and pain over the triangular fibrocartilage complex (TFCC).  The examiner diagnosed FCU tendonitis.  The CI had no relief from a pain medication injection, nor cast placement and was sent to Rehabilitation Medicine for treatment of her tendonitis.  The occupational therapist applied a splint for daily use for the right wrist.  The right wrist magnetic resonance imaging, electromyelogram and nerve conduction study were normal.  The CI was seen by rheumatology for the ongoing wrist pain and laboratory testing for rheumatoid arthritis was normal.  The MEB NARSUM addendum (completed approximately 6 months prior to separation), documented that the CI failed conservative treatment to include local steroid injections, wrist splinting, casting and profiles that limited her wrist use.  The MEB NARSUM physical examination findings revealed non-compensable ROM measurements and tenderness to palpation.  The examiner rated the pain according to the AMA pain scale at slight and occasional.  The MEB addendum contained essentially the same findings and the examiner rated the pain as slight and constant as so applying the AMA pain scale.  

The VA C&P exam documented constant pain and the CI was unable to do any lifting or cooking.  Bilateral wrist X-rays images were normal.

The Board directs attention to its rating recommendation based on the above evidence.  As described above, the PEB bundled the chronic pain bilateral feet, pubic symphysis, bilateral wrists, left ankle conditions coded as 5099 analogous to 5003 arthritis, degenerative (hypertrophic or osteoarthritis) in its rating of 10% with application of the USAPDA pain policy.  The VA coded the tendonitis of the right wrist and tendonitis of the left wrist as 5024 tenosynovitis rated at 10% each.  There were no ROM measurements or wrist specific conditions that would allow for application of a wrist specific code.  Board members agree that the evidence adequately supports the presence of painful motion and VASRD §4.40 (functional loss) in the right wrist.  Considering the totality of the evidence and with deference to reasonable doubt, the Board recommends a disability rating of 10% for the chronic pain right wrist condition under code 5024.

Chronic Pain Left Ankle.  The Board first considered if the left ankle pain condition, having been de-coupled from the combined PEB adjudication, remained reasonably justified as separately unfitting as established above.  After review of the evidence, members agreed there was a questionable basis for arguing that it was separately unfitting.  The well-established principle for fitness determinations is that they are performance-based.  The Board noted that the CI initially sprained her left ankle in late 1998.  She was evaluated in the emergency room where obtained X-rays images were normal.  She was treated with immobilization and non-steroidal anti-inflammatory medications.  She responded to treatment and was able to pass her next fitness test in February 1999.  After that episode, the evidence did not contain any other documentation of duty limitation related to the left ankle.  The next evidence of any issue related to the left ankle was the profile prepared at entry into the DES.  After due deliberation, members agreed that the evidence does not support a conclusion that the functional impairment from the left ankle condition was integral to the CI’s inability to perform within her MOS and accordingly cannot recommend a separate disability rating for it.

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 the chronic pain bilateral feet, pubic symphysis, bilateral wrists, left ankle condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  The Board adjudicated each condition separately.  In the matter of the chronic pain bilateral feet (bunionectomy) condition, the Board unanimously recommends a disability rating of 10%, coded 5280-5003 IAW VASRD §4.71a.  In the matter of the chronic pain right wrist condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the pubic symphysis condition, the Board unanimously agrees that it was not separately unfitting and cannot recommend it for additional disability rating.  In the matter of the left wrist condition, the Board unanimously agrees that it was not separately unfitting and cannot recommend it for additional disability rating.  In the matter of the left ankle pain condition, the Board unanimously agrees that it was not separately unfitting and cannot recommend it for additional disability rating.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:

UNFITTING CONDITION | VASRD CODE | RATING
Chronic Pain Bilateral Feet Following Bunionectomy | 5280-5003 | 10%
Right Wrist Pain | 5024 | 10%
Symphysis Pubis Pain | Not Unfitting
Left Wrist Pain | Not Unfitting
Left Ankle Pain | Not Unfitting
COMBINED | 20%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130909, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			
XXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXXXX, AR20150002675 (PD201301215)

1.  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 to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     XXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA

PD-2013-01215