RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2014-00147
BRANCH OF SERVICE:  Army	BOARD DATE:  20140918
SEPARATION DATE:  20041025

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (31B/Military Police) medically separated for chronic pain in her bilateral wrist and bilateral ankle.  The CI’s bilateral wrist and ankle conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS).  The CI was able to perform an alternate event for the Army physical fitness test.  She was issued a permanent U3/L2/S1 profile and referred for a Medical Evaluation Board (MEB).  The bilateral wrist and ankle conditions, characterized as “wrist pain bilateral”, “right ankle pain”, and “bilateral, left ankle mild osteoarthritis” were forwarded to the Physical Evaluation Board (PEB) as not meeting retention standards IAW AR 40-501.  No other conditions were submitted by the MEB.  The PEB adjudicated “chronic pain, bilateral wrists and bilateral ankles” as unfitting, rated at 10% citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  “I had a couple of ratings that were 0% when I first was released then the changed some of the ratings later.”

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.  In addition, the CI was notified by the Army that her case may eligible for review of the military disability evaluation of her MH condition in accordance with Secretary of Defense directive for a comprehensive review of Service members who were referred to a disability evaluation process between 11 September 2001 and 30 April 2012 and whose MH diagnoses were changed during that process.  

The CI is also eligible for PDBR review of other conditions evaluated by the PEB and has elected review by the PDBR.  The rating for the unfitting bilateral wrist and ankle condition is addressed below.  In addition, in accordance with Secretary of Defense directive for a comprehensive review of MH diagnoses that were changed during the Disability Evaluation System (DES) process, the applicant’s case file was reviewed regarding diagnosis change, fitness determination, and rating of unfitting mental health diagnoses in accordance with the VA Schedule for Rating Disabilities (VASRD) §4.129 and §4.130.  No additional conditions are 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:

Service IPEB – Dated 20040916 | VA - (1 Week Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Chronic Pain, Bilateral Wrists and Bilateral Ankles | 5099-5003 | 10% | Right Wrist Strain | 5215 | 0% | 20041101
| | | Left Wrist Strain | 5215 | 0% | 20041101
| | | Right Ankle Sprain | 5271 | 0% | 20041101
| | | Left Ankle Sprain | 5271 | 0% | 20041101
No Service PEB entry | Post-Traumatic Stress Disorder | 9411 | 30% | 20041104
Other x 0 (Not in Scope) | Other x 7 | 20041101
Combined:  10% | Combined:  30%
Derived from VA Rating Decision (VARD) dated 20041223 (most proximate to date of separation)
VARD 20130328 increased DC 9411 to 70% from 20121210.

ANALYSIS SUMMARY:  The PEB combined the chronic pain, bilateral wrists and bilateral ankles 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.  The Board must follow suit (IAW DoDI 6040.44) 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 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.  However, since most exams considered all four joints together (wrists and ankles), the evidence for the left/right wrist and left/right ankle conditions are discussed together with attendant recommendations regarding their separate unfitness.  This is followed by a rating analysis for each joint condition, if such is indicated.

Bilateral Wrist and Ankle Condition.  The CI complained of pain of both wrists and left ankle with a history of twisting her right ankle while preparing for deployment.  Bilateral wrist pain started while typing and performing strenuous tasks.  She reported that she had pain and aches with prolonged typing and repetitive motion of both wrists.  The CI described her pain as insidious and recalled no specific single traumatic event.  A rheumatology consultation dated 4 March 2004 noted the CI had bilateral wrist pain aggravated with repetitive use.   The CI reported that while deployed to Iraq “where she had to manhandle the .50 cal M2 machinegun into the turret of the MP vehicle repeatedly,” she experienced pain with the extremes of flexion and dorsiflexion, without warmth, swelling or redness.  There were no generalized arthritic symptoms.  The right ankle sprains were marked by minimal radiographic evidence of degenerative change.  There was no hint of synovitis on the X-ray images, other than minimal tenderness at the dorsum or radial area, along the ulnar sides of the wrists. 

At the MEB examination in July 2004, the CI reported “wrist hurt all the time and was first seen for wrist pain in August 2003.  She also noted arthritis in the right ankle and foot pain that felt like her “bones crack.”  She had a history of right ankle fracture at age 5 years old.  During the physical exam, the examiner indicated full range-of-motion (ROM) of the wrists with tenderness at the right ankle without instability.  Chronic ankle pain and chronic wrist pain were noted to be significant or disqualifying defects.  

The commander’s performance statement dated 20 July 2004 indicated that the CI ability to adequately perform her duties associated with military police was limited by her U3/L2profile ( profile excluded CI from carrying or firing her assigned weapon; prohibited her from carrying a fighting load, construct an individual fighting position nor run or jump).  The NARSUM dated 
30 July 2004 indicated that examination of the wrists revealed no swelling and mild tenderness to palpation dorsally.  The ulnar grind test was slightly positive, with no radioulnar instability and no crepitance.  Examination of the ankles revealed no varus-valgus instability, no anterior draw, although there was mild hypermobility.  There was no joint effusion.  Bilaterally tenderness to palpation, just distal to the medial malleolus of the ankle was evident.   X-ray images revealed mild osteoarthritis in the right ankle, a normal wrist series and an MRI of both wrists were normal.  Lifting was limited to 5 pounds and she was unable to stand greater than 30 minutes without ankle pain.  Pain was present when she fired her weapon or held it for any length of time and she had trouble rotating the 50-caliber weapon.  She was unable to do push-ups and sit-ups.  Wearing her Kevlar protective equipment caused pain from her neck to the wrists and she was unable to carry a rucksack weighing greater than 15 pounds.  As a result of those aforementioned limitations she was nondeployable and unable to perform the duties of a military police.

During the VA Compensation and Pension examination dated 1 November 2004 (performed a week after separation), the CI reported bilateral wrist pain while typing and doing strenuous activity.  Day-to-day activities were not affected, but heavy weight lifting caused some pain in the wrists.  She reported a fracture of the right ankle during childhood and since then has had sprains on-and-off of the right ankle that’s treated with local ice and wraps.  She had the same pain in the left ankle region and was treated with Tramadol.

The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Wrist ROM
(Degrees)

Ortho ~7 Mo. Pre-Sep

MEB ~3 Mo. Pre-Sep

VA C&P ~1 Wk. Post-Sep

| Left | Right | Left | Right | Left | Right
Dorsiflexion (70 Normal) | 75 | 70 | 80 | 80 | 70 | 70
Palmar Flexion (80) | 65 | 60 | 85 | 85 | 80 | 80
Ulnar Deviation (45) | 50 | 50 | Not measured | Not measured | 45 | 45
Radial Deviation (20) | 20 | 25 | Not measured | Not measured | 20 | 20
Comment | Wrist Brace | Wrist Brace | Tender; + sl. ulnar grind | “Repeated and resisted motion did not cause any change in the range of motion”
§4.71a Rating | 0% | 0% | 0-10% | 0-10% | 0% | 0%

Ankle ROM
(Degrees)

MEB ~3 Mo. Pre-Sep

VA C&P ~1 Wk Mo. Post-Sep

| Left | Right | Left | Right
Dorsiflexion (20 Normal) | 15 | 15 | 20 | 20
Plantar Flexion (45) | 60 | 60 | 40 | 40
Comment | Tender; R ankle mild osteoarthritis x-ray | Negative DeLuca
§4.71a Rating | 0% | 10%? | 0% | 0%

As noted above, the Informal PEB found the CI unfit for chronic pain, bilateral wrists and bilateral ankles rated as slight/frequent and rated the conditions 10% using code 5099-5003 IAW the USAPDA policy/guidance.  The VA unbundled and rated each joint separately as right wrist strain at 0% using code 5215; left wrist strain at 0% using code 5215; right ankle sprain at 0% using code 5271; and left ankle sprain at 0% using code 5271.

The Board first considered if each wrist and each ankle, having been de-coupled from the combined PEB adjudication, remained itself unfitting as established above.  In this case, both wrists and both ankles were considered to fail retention standards; all four joints were implicated by the NARSUM and in the commander’s statement; and, all four joints were profiled.  The U3 profile (bilateral wrist pain) limitations from carrying or using a weapon, as well as difficulty performing deployed and administrative tasks, firmly implicated both wrists as reasonably unfitting.  Although the permanent profile for the ankles was L2, nevertheless there were restrictions on running and jumping which were duty-limiting.  Members agreed that the functional limitations in evidence justified the conclusion that each ankle and each wrist was reasonably integral to the CI’s inability to perform her MOS and, accordingly a separate rating for each wrist and each ankle joint was evaluated.

	Right and Left Wrist:  The CI’s wrists ROM measurements were near normal during the MEB’s examination and were normal during the VA’s examination.  The MEB findings of a “slightly positive ulnar grind test” of each wrist was suggestive of painful motion IAW VASRD §4.59 (painful motion) and raised a rating consideration of 10% for each wrist using code 5215.  However, the VA examination within a week post-separation was considered to have a higher probative value based on the temporal proximity to separation.  The VA exam documented normal ROM as well as the notation that repeated and resisted motion did not cause any change in the ROM and did not indicate any painful motion.  The Board majority therefore adjudged that there was insufficient reasonable doubt for any rating higher than 0% for either wrist.

	Right and left Ankle:  Both ankles had near normal ROMs at the MEB examination and normal ROMs at the VA examination.  Only the right ankle had radiologic evidence of mild osteoarthritis.  Neither ankle’s ROM approached the “moderate” limitation to warrant a 10% rating under code 5271 (Ankle, limited motion).  Although the ankles were tender, there was insufficient evidence of painful motion IAW VASRD §4.59 for the minimum compensable rating level (10%) for either ankle.

	Rating Bilateral Wrist and Ankle Condition:  Although each wrist and ankle joint rating standing by itself would not rise to the level of 10%, the combination of two or more major joints with can reasonably be rated at 10% analogously under code 5003, although only the right ankle had abnormal imaging.  There were no episodes of incapacitation noted to support any higher rating.  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 chronic pain, bilateral wrists and bilateral ankles condition.

Contended PEB Condition/MHR condition (PTSD).  The Board’s main charge is to assess whether any MH condition (PTSD) should have been found to be unfitting by the Service.  The Board’s threshold for adding unfit conditions 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.  The CI had a history of sustaining shrapnel wounds to the right side of her face and right arm in May 2003 while deployed in Iraq.  Two weeks later, she was told that her team leader and another member of her unit were killed.  An outpatient psychiatry visit dated 24 October 2003 (a year prior to separation), the CI was diagnosed with an acute stress disorder, resolving and bereavement, resolving.  She had a Global Assessment of Functioning (GAF) of 70 and medications for sleep were changed.  On DD Form 2807-1 stamped RECEIVED Jul 23 2004, she listed trouble sleeping and having nightmares about being and getting hurt in Iraq and she additionally mentioned panic attacks when hearing loud voices or soldiers shooting at the ranges.  The physician who reviewed the form noted the CI was going to group counseling sessions and the problem was lessening.  

No records were available to review relating to the psychiatry counseling post deployment, the care she received in theater, or a pending adverse action statement IAW AR 600–8–2 Personnel-General Suspension of Favorable Personnel Actions in spite of several requests.  PTSD was listed as a significant or disqualifying defect on DD Form 2808 stamped RECEIVED Jul 23 2004 in box #76 along with chronic ankle pain, chronic wrist pain and retained foreign bodies, right cheek.  Form 2808 box #78 Recommendations indicated “Continue Mental Health appointments.”  On Form 2697 dated 21 July 2004, box #21 in response to the question “was patient referred for further evaluation?” neither the yes nor the no response was checked, but MEB-Continue MH visits was written in while box #22 Purpose of Assessment, an X was present in the box labeled Other and MEB was written in.  

Her permanent profile U3,L2,S1 dated 22 July 2004 only addressed bilateral wrist pain and bilateral chronic ankle pain and the commander’s performance statement did not address any MH issue or concerns, however it referred to the profile which excluded her from carrying or firing her assigned weapon.  

A VA Initial Evaluation for PTSD dated 4 November 2004 (10 days post-separation), noted any little noise evoked feeling jumpy and disturbed.  Initially she was bothered by it every other night for 5 to 6 months which decreased to every 2 to 3 weeks.  She became more aggressive, had no patience, did not trust anyone, had difficulty making new friends, became easily angered with verbal outbursts, lost interest in everything, did not laugh as she did in the past, avoided crowded places, liked to be alone, had thoughts of death, lost family members and was afraid of hearing about friends still in Iraq.  Growing up she was abused and assaulted, while in Iraq she saw dead U.S. soldiers in a helicopter crash and she was wounded on the right side of her face and arm for which she received the Purple Heart.  The diagnosis of PTSD was made based on symptoms of intrusive thoughts, nightmares seeing people shot from which she would awaken crying, sleep disturbance, social isolation, avoidance of crowded places, sleep impairment, irritability, outbursts of anger, hypervigilance, an exaggerated startle response, and very minimal functioning.  Her GAF was 48 (serious symptoms).  

The VARD granted a 30% rating for PTSD, which was increased to 70% on 28 March 2013 effective to 10 December 2012.  Although the CI’s contended condition of PTSD was listed on DD Form 2808, she was not referred into the DES for that condition in spite of her writing on Form 2807 about “panic attacks,”  “trouble sleeping having nightmares,” and “counseling.”  She did not have any MH diagnosis on her permanent S1 profile.  This case appears to meet the inclusion criteria in the Terms of Reference of the MH Review Project.

The Board considered the totality of the record for all MH diagnoses and symptoms proximate and preceding the CI’s date of separation including the VA records.  There was not a formal DES MH diagnosis and there was insufficient evidence to recommend any change in MH diagnosis noted in the record.  PTSD was not profiled (S1) or considered as not meeting standards by the MEB.  There was no indication in the commander’s statement that any MH symptoms interfered with duty performance.  There was insufficient performance based evidence from the record that PTSD, or any MH condition regardless of diagnosis, significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend that PTSD or any MH diagnosis was unfitting and so no additional disability rating is recommended.

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 chronic pain, bilateral wrists and bilateral ankles was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the chronic pain, bilateral wrists and bilateral ankles condition and IAW VASRD §4.71a, the Board majority recommends no change in the PEB adjudication.  In the matter of the contended PTSD (or any MH) condition, the Board unanimously agrees that it cannot recommend it for additional disability rating.  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.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140102, 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, AR20150006846 (PD201400147)

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						     XXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA

PD-2014-00147