RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-01977
BRANCH OF SERVICE:  Army	BOARD DATE:  20140829
DATE OF PLACEMENT ON TDRL:  20011231
Date of Final PEB:  20050411*
*Date of final separation not in record

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (88H/Cargo Specialist) medically separated for right hand/wrist reflex sympathetic dystrophy, endometriosis and pelvic adhesions, left shoulder impingement and plantar fasciitis.  Her conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was issued a permanent P3U3L3 profile and referred for a Medical Evaluation Board (MEB).  The MEB forwarded the above conditions and gastroesophageal reflux disease (GERD) to the Physical Evaluation Board (PEB) as medically unacceptable IAW AR 40-501.  The MEB submitted no other conditions.  The Informal PEB (IPEB) adjudicated “chronic right wrist and hand pain,” “chronic pelvic pain” “left shoulder impingement with reported pain” and  “chronic plantar fasciitis” as unfitting, rated 20%, 10%, 0% and 0% respectively and placed the CI on the Temporary Disability Retirement List (TDRL).  The GERD condition was determined to be not unfitting and not rated.  The CI remained on the TDRL and a second IPEB met on 24 January 2005 and combined the wrist/hand, left shoulder and feet conditions rated them together at 10% and rated the pelvic condition at 0%.  The CI appealed to a Formal PEB (FPEB) that convened on 11 April 2005 and adjudicated “right hand/wrist reflex sympathetic dystrophy, endometriosis and pelvic adhesions, left shoulder impingement and plantar fasciitis” and rated them at 10%, 10%, 0% and 0% respectively.  The CI made no further appeals and was 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 ratings for the unfitting right hand/wrist, left shoulder, pelvic and feet conditions are addressed below; no additional conditions are within the Board’s defined DoDI 6040.44 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 Board for Correction of Military Records.

RATING COMPARISON:

Final Service PEB - 20050411 | VA (4 Mo. After Final PEB Adjudication Date*) – effective 20020101
On TDRL - 20011231 | Code | Rating | Condition | Code | Rating | Exam
Condition | | TDRL | Sep. | | | |

Reflex Sympathy Dystrophy Right Hand/Wrist

8799-8713
changed to 8799-8515

20%

10%

Reflex Sympathy Dystrophy Right Hand/Wrist Status Post Multiple Surgeries Right Hand (major)

8799-8713

40%

20050831

Endometriosis and Pelvic Adhesions | 7629 | 10% | 10% | Endometriosis with Chronic Pelvic Pain | 7629 | 50%** | 20050831
Left Shoulder Impingement | 5299-5202 | 0% | 0% | Left Shoulder Impingement Syndrome (minor) | 5299-5201 | 20% | 20050831
Chronic Plantar Fasciitis | 5399-5310 | 0% | 0% | Residuals S/P Right Plantar Fasciitis Release | 5299-5276 | 10%*** | 20050831
Other x 1 (Not in Scope) | Other x 3 (Not in Scope) | 20040831
Combined:  30% → 20% | Combined: 80%
*Reflects VA rating exam proximate to TDRL exit/permanent separation
**Initially rated 10% effective 20020101 but increased to 50% effective 20031203
**Initially rated 10% effective 20020101, increased to 100% effective 20040206 following surgery then rated at 10% effective 20040401 

ANALYSIS SUMMARY:

Right Hand/Wrist Condition.  The wrist/hand narrative summary (NARSUM) performed on 10 April 2001 notes the CI experienced fracture/dislocation of her dominant right hand in the area above the index finger (index and middle finger carpometacarpal [CMC] joints) in March 1999 and underwent open reduction and internal fixation of the joints with pinning.  Following the surgery the CI was placed in a cast and developed increased swelling, pain (hyperesthetic) and numbness and was diagnosed with early reflex sympathetic dystrophy (RSD) of the right hand/wrist, currently referred to as chronic regional pain syndrome (CRPS).  The CI’s symptoms were managed with directed self-care with some improvement in swelling and pain, but the CI reported it “still hurts” and was noted to have very limited range-of-motion (ROM).  The CI had undergone right wrist examination under anesthesia on 4 June 1999 and the fracture/dislocations were found to be healed and stable.  The surgeon performed manual ROM manipulation to release tendon scarring to improve ROM of the hand and wrist.  According to treatment notes, following this procedure the right upper extremity had dystrophic skin changes with swelling, discoloration and numbness of the fingers and the forearm.  The CI was treated aggressively for the RSD with occupational and hand therapy and by a pain specialist.  After approximately 9 months the RSD symptoms abated and functional use of the wrist and hand improved, but the CI continued to report hand pain, especially at the base of the thumb and some residual RSD symptoms and was referred to a hand specialist for a second opinion.  Magnetic resonance imaging with dye (arthrogram) and a computed tomography (CT) scan of the wrist were normal and did not indicate any cartilage/ligament tears or arthritis.  Bone scan performed on 12 March 2001 noted chronic post-traumatic and surgical changes of the wrist with significant arthropathy of the second CMC joint.  The CI underwent arthroscopy 20 July 2000, which noted arthritis of the CMC joint and the joint was fused and wrist arthroscopy showed a partial hand ligament tear and synovitis, which was debrided.  Following this surgery, the CI was again in a cast and had recurrent RSD symptoms of pain, swelling, stiffness and dystrophic skin changes.  Imaging studies indicated evidence of recurrent RSD.  She was again treated with aggressive rehabilitation and improved somewhat but continued to report pain and numbness/tingling of the hand.  An OT visit 5 September 2000 noted swelling, decreased ROM of the wrist and of all fingers, and muscle wasting in the hand.  Electromyographic/nerve conduction studies were performed for symptoms of numbness/tingling into the fingers and demonstrated carpal tunnel syndrome and ulnar neuropathy at the wrist.  The surgical note indicated that the CMC fusion was complete and the ulnar paresthesia had subsided, but there was extensive scarring of all of the extensor tendons (“dorsal extensor structures”) which were lysed.  Following this intervention the CI again underwent extensive therapy.

At the MEB examination 10 April 2001, approximately 8 months prior to TDRL entry, the CI reported decreased motion of the right wrist and persistent pain.  The MEB examination cited a physical examination dated 22 February 2001 and noted continued hand swelling, near full flexion and extension of her fingers, but decreased wrist ROM with extension/flexion of 30 degrees/45 degrees (normal 70 degrees/80 degrees) with normal skin color, temperature and appearance and normal sensation.

At physical therapy visits from April 2001 to July 2001, after the NARSUM cited February examination wrist ROM was noted to be flexion/extension 75 degrees/65 degrees, full/65 degrees and 68 degrees/68 degrees, with mildly decreased grip strength on the right and finger ROM was “within functional limits.”  The CI continued with wrist and hand pain but occupational and physical therapy notes in June 2001 indicated symptoms mainly of pain, with significant decreased hand strength without evidence of nerve compression or RSD symptoms and recommended strengthening activities.

There was no VA Compensation and Pension (C&P) examination of the wrist/hand condition proximate to TDRL entry in the record.  The original VA Rating Decision (VARD) is not in the records as well, but the later VARD on 18 September 2003 indicated disability rating as noted below.

At the TDRL wrist/hand evaluation summary 1 December 2004, the CI reported persistent RSD symptoms of the right upper extremity.  The examination noted slight swelling of the back of the hand with increased sensitivity to light touch and guarding of the wrist with limited motion.  The examiner reported that right wrist X-rays performed on 2 July 2004 were normal.  There was an addendum to the TDRL summary dated 26 March 2005 that noted the CI disagreed with the findings of the hand evaluation and her hand function was re-evaluated.  The orthopedic surgeon noted that right hand ROM was 55 degrees, compared to the left, with total ROM of 122 degrees compared with 220 degrees on the left.  Hand strength was 40% and pinch strength was 52% on the right, compared with the left.  In March 2005, occupational therapy noted there was decreased sensation in the thumb, index and ring fingers, decreased strength (graded 3/5) in muscles innervated by both the median and ulnar nerves and decreased ROM.  Physical Therapy ROM performed on 1 March 2005 was wrist flexion of 60 degrees and extension of 25 degrees with painful motion.

At the VA C&P examination of the wrist/hand condition performed on 31 August 2005, performed 4 months after the FPEB, the CI reported constant right wrist and hand pain, with morning stiffness.  She reported that she had to learn how to write with her left hand and that she was doing most things with her left hand despite being right hand dominant.  She reported that her hand impaired her activities of daily living and she experienced muscle fatigue, spasms and numbness in her fingers that occurred every day and additional limitation due to flare-ups.  The CI reported narcotic pain medication was the only thing that would take the edge off.  On examination the hand appeared normal, without swelling, with wrist extension of 50 degrees and flexion of 60 degrees limited by pain and decreased strength on the right.  ROM of all fingers was normal.  The examiner noted that the CI had difficulty with activities such as fastening a button or tearing a piece of paper with the right hand compared to the left.

The Board directs attention to its rating recommendation at TDRL entry based on the above evidence.  The PEB rated the wrist/hand condition 20%, coded 8799-8713 (analogous to neuralgia, all radicular groups), analogous coding for RSD.  The VARD 18 September 2003 indicated the VA rated RSD of the right hand/wrist at 40%, coded 8799-8513 effective the day after separation.  The Board reviewed to see if a higher evaluation than 20% was applicable coding IAW the VA Schedule for Rating Disabilities (VASRD) §4.124a. (neurological conditions).  The 8713 rating criteria are subjective with available ratings of mild or moderate incomplete paralysis of 20% or 40% for the dominant hand IAW VASRD §4.124 (Neuralgia).which says the highest rating under neuralgia coding will be for moderate, incomplete paralysis.  At the MEB examination and subsequent physical therapy visits prior to TDRL entry the CI continued to have swelling of the right dominant hand with decreased wrist ROM and mild decreased grip strength.  The Board noted that the CI’s RSD symptoms were much improved from what they had been during the course of her treatment and concluded that the CI’s disability at TDRL entry most closely met the 20% rating.  The Board reviewed to see if a higher evaluation was achieved coding the wrist and hand separately with applicable codes IAW VARSD §4.71a, but agreed that there was not sufficient evidence that both the wrist and hand would remain separately unfitting when separated from the PEB’s combined adjudication, and therefore, abandoned this rating approach.  However, the Board did investigate if any alternative coding of the combined wrist/hand condition would provide a higher evaluation than rating as CRPS.  The evidence at TDRL entry supports that the wrist ROM did not meet a compensable evaluation coded as 5215 (limited wrist motion) and therefore the Board noted that a 10% rating could be achieved with 5215 IAW §4.59 (Painful motion) or 20% for degenerative arthritis of two joints (hand and wrist) with any coding that defaults to 5003, such as 5014 (Synovitis).  The Board then considered rating the wrist/hand condition analogously under an applicable code for muscle injuries IAW §4.73.  The Board noted that IAW §4.55 (Principles of combined ratings of muscle injuries) a muscle injury cannot be combined with a rating for a peripheral nerve paralysis rating of the same body part, unless the injuries affect entirely different functions, which is not the case here.  The Board agreed that the most applicable muscle code for the noted hand/wrist weakness was 5307 Group VII (wrist and finger flexion) for decreased grip strength, but noted that the associated rating for the noted mild decreased grip strength would be “slight” muscle injury at 0%, but the VASRD notes that the hand is so compact that isolated muscle injuries are rare and the hand should be rated on limitation of motion at a minimum of 10%.  Therefore, the Board agreed that these alternative coding approaches resulted in a 10% or 20% rating, not a higher evaluation than the 20% coding as 8799-8713.  The Board additionally agreed that separate ratings under §4.71a combined with ratings under §4.73 were not appropriate in this case because of avoidance of pyramiding the symptoms of pain, weakness, and limited ROM.  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 adjudication for the right wrist/hand condition at TDRL entry.

The Board next considered its rating recommendation at TDRL exit based on the above evidence.  The FPEB rated the wrist/hand condition 10% at TDRL exit, coded 8799-8715 (median nerve).  The VA rating remained 40%, coded 8799-8713.  The Board reviewed to see if a higher evaluation than 10% was applicable coding IAW VASRD §4.124a.  The Board agreed that coding analogously to 8713 was more appropriate for the CI’s right wrist/hand condition pain and muscle weakness involving more than the median nerve distribution.  The Board noted that at TDRL exit the evidence supported that the CI’s dominant right upper extremity had painful, restricted wrist motion and right hand swelling with 40%-50% strength compared with the left, and objective decreased sensation of multiple fingertips.  The CI had experienced significant loss of the use of her right hand.  The C&P examination noted that the CI had learned to write with the left hand and do most activities with her left hand and the examiner noted that the CI had difficulty performing motor skills with the right hand important to activities of daily living, such as dressing.  The Board agreed that this reflected increased disability since TDRL entry and therefore, most closely met the moderate 8713 rating which is 40% for the dominant upper extremity.  Board discussions centered on insuring that the CI’s multiple impairments of the RUE were fully considered in its rating recommendations.  Therefore, the Board investigated alternative coding as a nerve impairment using 8513 for incomplete paralysis or 8615 for neuritis as opposed to 8617, because at TDRL exit there was greater evidence in record of both decreased strength and sensation of the hand.  However, the Board agreed that the best subjective description of the CI’s disability was moderate, and therefore, using any of these three codes resulted in a 40% rating for the dominant upper extremity and there was no benefit to changing the code used at TDRL entry.  The Board again reviewed to see if a higher evaluation was achieved with alternative coding of the combined wrist/hand condition under §4.124a or §4.73 as noted above, but again found that a higher evaluation was not achieved than if rated as RSD.  Therefore, the Board found no path to a higher evaluation than 40% and agreed that the CI’s disability due to the dominant upper extremity condition at TDRL exit was best rated 40%, coded 8799-8713.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 40% for the right wrist/hand condition at TDRL exit.

Endometriosis Condition.  The endometriosis narrative summary (Endometriosis NARSUM) performed on 3 August 2001 notes the CI had a longstanding history of chronic pelvic pain (CPP) and initial studies, including pelvic ultrasound, were non-diagnostic.  Notes in the treatment record indicated the CI was treated for dysfunctional uterine bleeding (DUB) with oral contraceptive medication and various antibiotics in early 2000.  Radiographs and ultrasound of the pelvis 22 February 2001 and 16 April 2001 were normal.  The CI eventually had a laparoscopy for the CPP performed on 7 May 2001 and was found to have Stage II endometriosis with multiple implants in the pelvis and a left ovarian hemorrhagic cyst, which was excised.  A month after the procedure the CI was seen in the emergency room for acute, right side abdominal pain and was found to have a right ovarian cyst on pelvis ultrasound performed on 9 July 2001.  At the MEB examination 3 August 2001, approximately 5 months prior to TDRL entry, the CI reported CPP with incomplete control despite medications.  The MEB physical exam noted lower abdominal tenderness with uterine tenderness to palpation and a palpable mass on the right side of the pelvis.

There was no VA C&P examination of the endometriosis condition proximate to TDRL entry in the record.  The original VA rating Decision is not in the records as well, but the later VARD dated 18 September 2003 indicated disability rating as noted below.  At the TDRL endometriosis evaluation performed on 11 December 2004 the examiner noted that the CI had undergone a recent laparoscopy in December 2003 which showed severe endometriosis, pelvic adhesions and uterine fibroids.  The CI had been treated with many types of medication and hormonal therapy without relief and continued with daily pain, DUB and painful sexual intercourse.  On examination there was lower abdominal tenderness, an enlarged, tender uterus and the ovaries were tender without any masses noted.  Radiographs indicated small uterine fibroids developed despite treatment.  The examiner recommended continued TDRL.  Another TDRL evaluation on 1 April 2005 was essentially unchanged and noted recent pelvic ultrasound showed larger uterine fibroids.

At the VA C&P exam 30 January 2004, (233) the CI reported CPP and that she had been on specific hormone therapy for endometriosis without improvement.  The CI reported that laparoscopic surgery in 2003 indicated that the endometriosis had worsened to Stage III, with adhesions and large fibroids.  The CI reported frequent pain and DUB despite oral contraceptive use and, at times, the pain was so severe she went to the emergency room for a pain injection.  The CI reported that she had missed approximately 2 months of work in the last year due to the condition.  The examination noted mild discomfort of the lower abdomen and the CI declined a pelvic examination noting results from one a month earlier were available.  At the VA C&P general examination on 31 August 2005, 4 months after the FPEB, the CI reported a history of CPP and DUB and treatment including surgeries, specific hormone therapies and continuous oral contraceptive medication since 1998 and the examiner indicated she had no menstrual period in 5 years.  The CI reported daily pelvic pain and concern that she might not be able to have children.  She denied urinary incontinence.  No examination was performed.

The Board directs attention to its rating recommendation at TDRL entry based on the above evidence.  The PEB rated chronic pelvic pain 10%, coded 7629 (Endometriosis).  The VARD dated 18 September 2003 rated endometriosis 10%, coded 7629 also.  The CI had chronic pelvic pain which failed to improve with surgery and was incompletely controlled with medications at the time of TDRL entry.  The Board agreed that the 7629 code was the most appropriate because the CI was diagnosed by laparoscopy with Stage II endometriosis.  The Board reviewed to see if the endometriosis condition met the next higher evaluation of 50%, but there was no evidence in the record of bowel or bladder lesions noted on laparoscopy with symptoms as specified by the 7629 50% rating.  Therefore, after due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the endometriosis condition at TDRL entry.

The Board directs attention to its rating recommendation at TDRL exit based on the above evidence.  At TDRL exit the PEB rated endometriosis 10%, coded 7629 (Endometriosis).  The VARD dated 23 February 2004 increased the 7629 rating to 50%, which was lowered to 10% based on the 2005 C&P evaluation noted above, but then based on additional information supplied by the CI’s physicians, was increased to 30% by the VARD 20 June 2006.  The evidence at TDRL exit supports that continued treatment failed to control the CI’s endometriosis symptoms and repeat laparoscopy had noted severe disease, but the evidence still did not document bowel or bladder symptoms.  Therefore, the Board agreed that the 30% rating was still applicable.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the endometriosis condition at TDRL exit.

Left Shoulder Condition.  The left shoulder MEB addendum (shoulder NARSUM) notes the CI had a history of shoulder pain for approximately 2 years (since 1999) without specific injury.  Shoulder X-rays performed on 3 February 1999 were normal.  She was diagnosed with left shoulder impingement and treated conservatively but continued with shoulder pain.

At the MEB examination on 15 March 2001, approximately 9 months prior to TDRL entry, the CI reported night pain and paresthesias of the left upper extremity with trouble sleeping on the left.  The MEB physical exam noted full shoulder ROM with painful motion and positive impingement testing without signs of a rotator cuff (RC) tear or noted instability.  There was mild tenderness to palpation (TTP) of the anterior shoulder, below the acromioclavicular joint.  Physical therapy ROM for the MEB measured on 1 March 2005 noted flexion of 140 degrees, 138 degrees, 140 degrees with no pain and abduction of 115 degrees, 117 degrees, 117 degrees with pain.  The MEB examiner indicated that left shoulder X-rays were normal without evidence of degenerative changes and there was borderline RC impingement by radiographic measurements.

There was no VA C&P examination of the left shoulder condition proximate to TDRL entry in the record.  The original VA rating Decision is not in the records either, but the later VARD dated 18 September 2003 indicated disability rating as noted below.

At the TDRL evaluation on 1 December 2004 the CI reported persistent left shoulder pain.  The examination noted TTP diffusely over the shoulder with full strength, but pain with resisted abduction.  There were positive signs for impingement and no evidence of cartilage injury, tendinitis or instability.

At the VA C&P examination dated 31 August 2005, 4 months after the FPEB the CI reported that her left shoulder did not hurt all the time but did hurt if she tried to reach behind her or overhead and this occurred a few times per week.  There was no history of dislocation or subluxation noted.  The CI reported the pain was not incapacitating and her shoulder condition was stable.  On examination left shoulder ROM was both flexion and abduction of 120 degrees, with pain.  The examination noted there were no other shoulder abnormalities. Radiographs of the left shoulder were negative.

The Board directs attention to its rating recommendation at TDRL entry and TDRL exit based on the above evidence.  The PEB rated the left shoulder condition 0%, coded 5299-5202 (analogous to humerus impairment) at TDRL entry and exit.  The VARD dated 18 September 2003 indicated the VA rated the shoulder condition 20%, coded 5299-5201 (limitation of arm motion) effective the day after separation.  The last VARD in record dated 26 February 2013 indicated that the 20% rating was continued.  The CI had shoulder impingement noted at the MEB examination at TDRL entry and TDRL evaluation with painful but full ROM and reduced painful ROM at the C&P examination, without instability noted on any evaluation.  The Board noted that the CI’s documented ROM did not meet a compensable rating for decreased ROM alone utilizing 5201, but did meet a 10% rating IAW §4.59 (painful motion) and there was no other ratable impairment of the left shoulder.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) and IAW §4.59, the Board recommends a disability rating of 10% for the left shoulder condition at TDRL entry and TDRL exit, coded 5299-5201.

Chronic Plantar Fasciitis Condition.  The MEB heel pain NARSUM dated 9 April 2004 noted the CI reported right heel pain for approximately a year aggravated by weight bearing activities.  The CI was given orthotics but she did not wear them because they made her foot worse.  She was treated extensively without relief of her heel pain.

At the MEB examination, approximately 8 months prior to TDRL entry, the CI reported right heel pain with walking or standing for long periods.  The MEB physical exam noted TTP of the bottom of the right heel, without swelling.  Foot and ankle ROM was full.  There were no skin changes present and the foot was neurovascular intact.  The NARSUM noted that imaging studies of the foot, including bone scan, were normal.

There was no VA C&P examination of the right foot condition within 12 months following TDRL entry in the record.  At the earliest VA C&P examination in the record addressing the foot condition on 15 July 2003, the CI reported pain on the bottom of both of her feet, worse on the right, always present but increased with weight bearing activities.  She reported being unable to stand or walk for long periods.  The CI had foot orthotics which partially relieved the pain.  On examination the CI had normal gait and posture.  There was no pes planus or evidence of abnormal weight bearing on the feet.  Examination of the right foot noted painful motion.  A second C&P examination for the feet was performed on 16 October 2004 and the CI reported right foot surgery in February 2004 for fascial release and heel spur removal.  The CI reported continued foot pain and numbness of the great toe following surgery.  On examination a limp was noted, without evidence of abnormal weight bearing.  There was tenderness of the right foot and bilateral mild hallux valgus (great toe bends inward) present, without other abnormalities.  Heel and foot X-rays noted only the mild hallux valgus and were otherwise normal.

At the TDRL foot evaluation on 7 December 2004 the CI reported chronic daily bilateral foot pain with walking and standing, worse in the left than the right.  The CI reported minimal pain relief from her right foot surgery or any other treatment modality.  There was no TDRL foot examination.  The examiner indicated that significant improvement in her chronic plantar fasciitis was unlikely in the near future.

At the VA C&P General examination dated 7 February 2005 the CI reported bilateral heel pain aggravated by walking and standing partially improved with shoe inserts.  On examination the CI was noted to have a right-sided limp, without signs of abnormal weight bearing.  There was TTP of the bottom of both feet at the heel, without other foot deformity noted.  At another VA C&P general examination dated 31 August 2005 the CI reported right heel pain following foot surgery, aggravated by walking and standing.  On examination there was mild TTP of the bottom of the foot bilaterally, without painful motion.  The examiner noted no use of corrective footwear, good alignment of the Achilles tendon, and no other foot abnormalities.  Right foot X-ray was negative.

The Board directs attention to its rating recommendation on the above evidence at TDRL entry and TDRL exit.  The PEB rated chronic plantar fasciitis 0%, coded 5399-5310 (analogous to muscle injury Group X, forefoot and toes, an analogous code for plantar fasciitis) at TDRL entry and TDRL exit.  The VARD dated 18 September 2003 indicated that the VA rated the right PF 10%, coded 5299-5276 (analogous to acquired flatfoot).  The 6 January 2006 VARD indicated that the rating was returned to 10% following convalescence from right foot surgery.  At examinations at TDRL entry and at TDRL exit, the CI had persistent right heel pain with standing or walking, not relieved by orthotics.  The Board agreed that the right foot pain on use met a 10% rating coded analogous to acquired pes planus 5299-5276 due to pain on use of her feet at both TDRL entry and TDRL exit, but did not meet a higher evaluation with any applicable code IAW VASRD §4.71a.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the chronic plantar fasciitis condition at TDRL entry and TDRL exit.

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 chronic right wrist and hand pain condition, the Board unanimously recommends no change in the PEB adjudication at TDRL entry and a disability rating of 40% at TDRL exit coded 8799-8713 IAW VASRD §4.124a.  In the matter of the endometriosis condition  the Board unanimously recommends a disability rating of 30% at TDRL entry and 30% at TDRL exit, both coded 7629 IAW VASRD §4.116.  In the matter of the left shoulder condition the Board unanimously recommends a disability rating of 10% at TDRL entry and 10% at TDRL exit, both coded 7629 IAW VASRD §4.71a.  In the matter of the chronic plantar fasciitis condition the Board unanimously recommends a disability rating of 10% at TDRL entry and 10% at TDRL exit, both  coded 5299-5276 IAW VASRD §4.116.  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; and, that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:

UNFITTING CONDITION | VASRD CODE | RATING
| | TDRL | PERMANENT
Right Hand and Wrist Pain | 8799-8713 | 20% | 40%
Endometriosis | 7629 | 30% | 30%
Left Shoulder Impingement | 5299-5201 | 10% | 10%
Chronic Plantar Fasciitis | 5299-5276 | 10% | 10%
COMBINED | 60% | 70%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131031, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				
XXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXX, AR20150002604 (PD201301977)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to  constructively place the individual on the Temporary Disability Retired List (TDRL) at 
60% disability rather than 30% for the period 1 January 2002 to 21 April 2005 and then following this TDRL period recharacterize the individual’s separation as a permanent disability retirement with the combined disability rating of 70%.

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

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of temporary disability effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the day following the six month TDRL period.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, provide 60% retired pay for the constructive temporary disability retired period effective the date of the individual’s original medical separation and then payment of permanent disability retired pay at 70% effective the day following TDRL period.  

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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						     XXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA

PD-2013-01977