AF | PDBR | CY2011 | PD2011-00334
PTSD Condition . There was no VA spine exam proximate to TDRL exit. Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.
AF | PDBR | CY2011 | PD2011-00338
PTSD Condition . There was one brief VA outpatient treatment note 9 months prior to separation (TDRL exit) that indicated continued PTSD and depressive symptoms and the assigned GAF was 45, the same (serious) range exams prior to TDRL. The Board considered all mental disorder symptoms IAW §4.130, and the CI’s axis I major depressive disorder was included in the PTSD rating.
AF | PDBR | CY2011 | PD2011-00339
The most proximate source of comprehensive evidence on which to base the permanent rating recommendation in this case are the TDRL narrative summary (NARSUM), performed eleven months prior to TDRL exit, the FPEB testimony recorded on the FPEB rationale, the VA psychiatric exam performed four months after TDRL exit, and several VA outpatient notes within one year of TDRL exit that contribute to the CI’s impairment picture at final separation. The examiner diagnosed major depressive disorder...
AF | PDBR | CY2011 | PD2011-00342
Low Back Condition . Flexion (90⁰ Normal)65⁰40⁰Combined (240⁰ Normal)155⁰Incomplete§4.71a Rating10%20%Although the physical therapy ROM was slightly more proximal to separation and did provide measurements in all planes, the Board considered the Physical Medicine exam to be more probative for rating in that it was more comprehensive of ratable parameters and performed by a specialist. I have carefully reviewed the evidence of record and the recommendation of the Board.
AF | PDBR | CY2011 | PD2011-00344
1207A, rated 10% IAW the Veterans Administration Schedule for Rating Disabilities (VASRD); and adjudicated the chronic left shoulder pain condition as unfitting, rated 0% with application of the US Army Physical Disability Agency (USAPDA) pain policy. An examination by a consulted civilian neurosurgeon (on 14 August 2006) 10 months after separation also showed a “full ROM” of the left shoulder with a normal motor and sensory exam; it appeared that the neurologist considered the CI’s...
AF | PDBR | CY2011 | PD2011-00346
The CI was then medically separated with a 0% disability rating. Right Shoulder Pain . In the matter of the neck and right shoulder condition, for a separation rating after TDRL, the Board unanimously recommends that it be rated as two separate unfitting conditions with rating, by a vote of 2:1, as follows: a cervical spine condition coded 5290 and rated 10%; and, a right shoulder condition coded 5099-5003 and rated 10%; both IAW VASRD §4.71a.
AF | PDBR | CY2011 | PD2011-00348
Nevertheless, given the CI’s history of starting college prior to separation, employment after separation, and normal performance on tests of “intellectual abilities, memory, executive control, language, and visual-spatial functioning,” the Board agreed that the CI’s level of functioning at separation best fit the VASRD §4.130 10% criteria, “occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only...
AF | PDBR | CY2011 | PD2011-00352
As noted above, the Army PEB found him unfit due to bilateral knee pain and he was separated with 10% disability. The Army PEB combined left knee pain and right knee pain as a single unfitting condition. The Board determined therefore that the back condition was not subject to service disability rating.
AF | PDBR | CY2011 | PD2011-00353
The Board evaluates DVA evidence proximal to separation in arriving at its recommendations, but its authority resides in evaluating the fairness of DES fitness decisions and rating determinations for disability at the time of separation. Neither the MEB nor the VA exam documented compensable ROM impairment of the left knee under 5260, limitation of flexion, coding. Service Treatment Record
AF | PDBR | CY2011 | PD2011-00354
The Board evaluates DVA evidence proximal to separation in arriving at its recommendations, but its authority resides in evaluating the fairness of DES fitness decisions and rating determinations for disability at the time of separation. In the matter of the spinal fusion (L4-L5) condition, the Board unanimously recommends a permanent service disability rating of 20%, coded 5241 IAW VASRD §4.71a. Service Treatment Record Exhibit C. Department of Veterans' Affairs Treatment...
AF | PDBR | CY2011 | PD2011-00355
The CI experienced right knee pain with running and was periodically issued physical profiles from May 2001 to May 2002. The C&P examination 14 months after separation recorded complaint of right knee pain with walking and stairs. The Board does not have the authority under DoDI 6040.44 to render fitness or rating recommendations for any conditions not considered by the DES.
AF | PDBR | CY2011 | PD2011-00356
The Board also acknowledges the CI’s contention that suggests service ratings should have been conferred for other conditions documented at the time of separation. The VA’s rating of 10% is justified based on the full but painful ROM recorded in the VA exam with application of §4.59 (painful motion). Several additional non-acute conditions or medical complaints were also documented.
AF | PDBR | CY2011 | PD2011-00358
Right Ankle Condition . All evidence considered, the Board recommends no change from the PEB’s rating decision for the right ankle condition. The neurological exam was normal.
AF | PDBR | CY2011 | PD2011-00363
CI CONTENTION : “I was more disabled than the military rated me for and my leg conditions are more disabling. The NARSUM, dated 3 months prior to separation (9 months post-operative) stated the CI’s “foot and ankle ROM is normal with good strength in all planes bilaterally, and his compartments are soft.” The CI was taking no medications for the condition. No other conditions were service-connected with a compensable rating by the VA within 12 months of separation or contended by the CI.
AF | PDBR | CY2011 | PD2011-00365
Degenerative joint disease of the cervical spine and mechanical low back pain were forwarded to the Physical Evaluation Board (PEB) as medically unacceptable conditions IAW AR 40-501. The Board also noted that both the PEB and VA ratings were based on this exam, and that there was no subsequent VA data within the DoDI 6040.44 prescribed 12-month period in evidence. Other PEB Conditions .
AF | PDBR | CY2011 | PD2011-00368
The PEB adjudicated the chronic mechanical LBP condition as unfitting, rated 10%, with application of the Department of Defense Instruction (DoDI) 1332.39 and the Veterans’ Administration Schedule for Rating Disabilities (VASRD). The Board evaluates DVA evidence proximal to separation in arriving at its recommendations, but its authority resides in evaluating the fairness of DES fitness decisions and rating determinations for disability at the time of separation. However, a C&P examination...
AF | PDBR | CY2011 | PD2011-00369
Other PEB Conditions. The degree of limitation of motion in the shoulder was not compensable under the specific joint coding, however the loss of mobility was considered in the overall rating for the CI’s unfitting shoulder condition. Any scar impairment to the limitation of motion was considered in the above shoulder rating.
AF | PDBR | CY2011 | PD2011-00377
BRANCH OF SERVICE: air force CASE NUMBER: PD1100377 SEPARATION DATE: 20080721 BOARD DATE: 20120119 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty member, SRA/E- 4 (3E851, EOD Journeyman), medically separated for spondylopathy (an arthritis-like condition). The PEB adjudicated the spondylopathy condition as unfitting, rated 20%, with application of the Veterans Administration Schedule for Rating Disabilities...
AF | PDBR | CY2011 | PD2011-00380
CI CONTENTION : “The Army’s PEB determined that I was unfit due to chronic pain and instability for my right and left shoulders; rated at 20% disability; to be separated with disability severance pay. Shoulder Conditions . The Board, therefore, has no support for recommending any unfitting psychiatric condition for Service rating.
AF | PDBR | CY2011 | PD2011-00381
Chronic low back pain secondary to lumbosacral spondylolysis and spondylolisthesis was forwarded to the Physical Evaluation Board (PEB) as medically unacceptable IAW AR 40-501. The PEB adjudicated the low back condition as unfitting, rated 10%, with application of the Veterans Administration Schedule for Rating Disabilities (VASRD). The Board determined therefore that neither of the stated conditions was subject to service disability rating.
AF | PDBR | CY2011 | PD2011-00384
SCOPE OF REVIEW : The Board’s scope of review, as defined in DoDI 6040.44, is limited to those conditions which were determined by the PEB to be unfitting for continued military service; or, when requested by the CI, those condition(s) identified but not determined to be unfitting by the PEB. Left hip condition . At his Army MEB exam, the CI reported that he was having some left hip pain.
AF | PDBR | CY2011 | PD2011-00386
The PEB adjudicated the lumbar condition as unfitting, rated 10%, with presumptive application of the US Army Physical Disability Agency (USAPDA) pain policy. The MEB exam followed a pre-separation VA Compensation and Pension (C&P) exam performed two months earlier; at which the CI had related significantly more severe pain with bilateral radiation, and more significant physical limitations. In the matter of the pes planus with plantar fasciitis condition, the Board unanimously recommends...
AF | PDBR | CY2011 | PD2011-00388
He was issued a permanent P3/H3 profile and underwent a Medical Evaluation Board (MEB). The Informal PEB (IPEB) adjudicated the chronic left mastoiditis, vertigo (following erosion of horizontal canal), and hearing loss conditions as unfitting, rated 10%, 10% and 0% respectively, with application of the Veterans’ Administration Schedule for Rating Disabilities (VASRD). In the matter of the vertigo and the hearing loss conditions, the Board unanimously recommends that the conditions be...
AF | PDBR | CY2011 | PD2011-00389
The Board evaluates DVA evidence proximal to separation in arriving at its recommendations, but its authority resides in evaluating the fairness of DES fitness decisions and rating determinations for disability at the time of separation. The multiply-operated left knee with anteromedial knee pain, subjective instability and mechanical symptoms condition, analogously coded 5299-5003, per VASRD direction, would warrant a 10% rating as given by the PEB and the VA. With non-compensable ROM...
AF | PDBR | CY2011 | PD2011-00390
The Board must then determine the most appropriate fit with VASRD 4.130 criteria at 6 months for its permanent rating recommendation. As for the permanent disability rating, the Board noted that at the time of the VA C&P evaluation the CI had no complaints of tibial pain. In the matter of the right and left tibial stress fracture conditions, the Board unanimously recommends an initial TDRL rating of 10% for each coded 5262; and a 0% permanent rating for each at 6 months IAW VASRD §4.71a.
AF | PDBR | CY2011 | PD2011-00392
Right Knee Condition . No other conditions were service-connected with a compensable rating by the VA within 12 months of separation or contended by the CI. The Board therefore has no reasonable basis for recommending any additional unfitting conditions for separation rating.
AF | PDBR | CY2011 | PD2011-00395
The Board evaluates VA evidence proximal to separation in arriving at its recommendations, but its authority resides in evaluating the fairness of DES fitness decisions and rating determinations for disability at the time of separation. The MEB physical exam was performed on 30 September 2002, over five months prior to separation. The Board noted the physical therapy ROM results and considered whether a higher rating was supported by rating under diagnostic code 5292, limitation of motion...
AF | PDBR | CY2011 | PD2011-00397
These other conditions include left ilioinguinal strain (claimed as left hip pain), meralgia paresthetica, lumbar radiculopathy, synovial herniated pit (left) as documented by VA, and other sources, as well as pubic synthesis dysfunction, lumbargo, symptoms of all began during Basic, AIT, yet ignored, never diagnosed, or fully examined, just discharged from Army. Left Hip Condition . The Board does not have the authority under DoDI 6040.44 to render fitness or rating recommendations for...
AF | PDBR | CY2011 | PD2011-00398
CI CONTENTION : The CI states: “I was only rated for Narcolepsy. All evidence considered, there is not reasonable doubt in the CI’s favor supporting recharacterization of the PEB fitness adjudication for the low back pain condition. The C&P examiner stated that the CI was able to perform normal activity during a headache.
AF | PDBR | CY2011 | PD2011-00399
Motor function of the legs was normal. The VA Schedule for Rating Disabilities (VASRD) coding and rating standards for the spine, which were in effect at the time of separation, were changed to the current §4.71a rating standards in September 2003. 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.
AF | PDBR | CY2011 | PD2011-00401
The PEB adjudicated the chronic left shoulder instability condition as unfitting, rated 20% with application of the Veterans Administration Schedule for Rating Disabilities (VASRD). The contended conditions adjudicated as not unfitting by the PEB was intermittent back pain associated with mild degenerative disc disease. Medical hold was approved for completion of treatment for his left shoulder condition and the CI underwent left shoulder surgery in June 2005 followed by MEB evaluation.
AF | PDBR | CY2011 | PD2011-00402
The PEB adjudicated the right knee condition as unfitting, rated 10%, referencing the US Army Physical Disability Agency (USAPDA) pain policy. Several additional non-acute conditions or medical complaints were also documented. RECOMMENDATION : The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows:
AF | PDBR | CY2011 | PD2011-00403
Back Condition . Service Treatment Record I have carefully reviewed the evidence of record and the recommendation of the Board.
AF | PDBR | CY2011 | PD2011-00404
PHYSICAL DISABILITY BOARD OF REVIEW After due deliberation, the Board unanimously recommends a disability rating of 10% for the back pain condition. Physical Disability Board of Review
AF | PDBR | CY2011 | PD2011-00406
The Board, therefore, has no reasonable basis for recommending any additional unfitting conditions for separation rating. In the matter of the OSA, history of right ankle fracture, acne or any other condition eligible for Board consideration, the Board unanimously agrees that it cannot recommend any findings of unfit for additional rating at separation. I have carefully reviewed the evidence of record and the recommendation of the Board.
AF | PDBR | CY2011 | PD2011-00409
Flex (0-45)No goniometrics45° (50°, 52°, 56°)35⁰*Ext (0-45)No goniometrics45° (50°, 50°, 52°)45⁰R Lat Flex (0-45)No goniometrics35° (35°, 40°, 45°)40⁰*L Lat Flex (0-45)No goniometrics35° (35°, 40°, 45°)40⁰*R Rotation (0-80)No goniometrics50° (52°, 54°, 56°)80⁰L Rotation (0-80)No goniometrics50° (52°, 54°, 56°)60⁰*COMBINED (340)260⁰300⁰C-spine MRI- degenerative disc disease, osteoarthropathyTenderness centrally C3-7; Mild paraspinal tenderness; sharp pain with lateral left bending; Mild pain...
AF | PDBR | CY2011 | PD2011-00410
The MEB examiner noted that the CI had constant tingling to the lateral aspect of the right lower extremity; weakness and fatigue; a right foot drop secondary to peroneal nerve injury; an AFO was required to hold the foot up to allow for walking along with a cane to provide balance; the right leg was 1.5 cm shorter and a right heel lift was required to assist with balance; there was right calf atrophy; and an inability to stand on toes due to right ankle weakness. The DD Form 2808 noted...
AF | PDBR | CY2011 | PD2011-00411
The PEB adjudicated the right shoulder condition as unfitting, rated 10%, referencing the US Army Physical Disability Agency (USAPDA) pain policy. The Board evaluates DVA evidence proximal to separation in arriving at its recommendations, but its authority resides in evaluating the fairness of DES fitness decisions and rating determinations for disability at the time of separation. Right Shoulder Condition .
AF | PDBR | CY2011 | PD2011-00412
The MEB examiner documented normal gait, mild spinal tenderness, and “some” range-of-motion (ROM) limitations “secondary to pain in all axes.” There are no formal ROM measurements identified in the service file. 5292 Spine, limitation of motion of, lumbar: The VA ROM limitations cited above (50% of normal) are reasonably characterized as “moderate;” an opinion shared by the VA rater.
AF | PDBR | CY2011 | PD2011-00415
A January 2004 clinic encounter during a flare of LBP and the April 2004 orthopedic NARSUM indicated normal or near normal motion without muscle spasm while the March 2004 MEB examination recorded significantly reduced ROM. Other PEB Conditions . The Board does not have the authority under DoDI 6040.44 to render fitness or rating recommendations for any conditions not considered by the DES.
AF | PDBR | CY2011 | PD2011-00416
The PEB adjudicated the left shoulder condition as unfitting, rated 10%, citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy. Left Shoulder Neuropathy Condition . In addition to the intrinsic joint pathology contributing the CI’s unfitting “left shoulder pain” condition, there was a contribution from a separately ratable peripheral nerve injury (as per the VA rating) which the Board must consider in this case.
AF | PDBR | CY2011 | PD2011-00421
Right Hip Condition . It may be safely concluded that the VA C&P exam findings (reflecting the response to surgery) were more probative to the impairment at separation than was the pre-operative MEB exam; and, that the intermittent symptoms and normal findings recorded in that exam were correctly rated 0% by the VA. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a separation rating of 0% for the right wrist...
AF | PDBR | CY2011 | PD2011-00424
Hip Condition . In the matter of the hip condition, the Board unanimously recommends permanent separation rating of 10% for each hip, coded 5299-5255 IAW VASRD §4.40, §4.45, §4.59, and §4.71a. Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.
AF | PDBR | CY2011 | PD2011-00425
SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty member, SSG/E-7 (96B, Intelligence Analyst), medically separated for a cervical condition. My condition has not gotten better nor will it. No other conditions were service connected with a compensable rating by the VA within 12 months of separation or contended by the CI.
AF | PDBR | CY2011 | PD2011-00426
Back Condition . After due deliberation, considering all of the evidence the Board recommends a separation rating of 20% for the chronic LBP condition absent the addition of any ratable radiculopathy. No other conditions were service connected with a compensable rating by the VA within twelve months of separation or contended by the CI.
AF | PDBR | CY2011 | PD2011-00427
Chronic back pain and scoliosis were forwarded to the Physical Evaluation Board (PEB) as separate medically unacceptable conditions IAW AR 40-501. The PEB adjudicated chronic back pain as unfitting, rated 10%, citing criteria from the Veterans Administration Schedule for Rating Disabilities (VASRD). The Board readily agreed that the 5293 code (intervertebral disc syndrome) was not applicable in this case since no data in evidence suggested that the CI suffered incapacitating episodes per...
AF | PDBR | CY2011 | PD2011-00430
A 20% rating requires muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position, and a 40% rating requires severe lumbosacral strain 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 osteoarthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion. Both the NARSUM and VA...
AF | PDBR | CY2011 | PD2011-00432
PHYSICAL DISABILITY BOARD OF REVIEW The CI appealed to the Formal PEB (FPEB) who considered expert specialty opinion that the migraines were not related to the pituitary microadenoma and rated the unfitting migraine headache condition at 10%, with application of the US Army Physical Disability Agency (USAPDA) pain policy. Migraine Headaches .
AF | PDBR | CY2011 | PD2011-00433
The Board’s authority as defined in DoDI 6044.40, however, resides in evaluating the fairness of DES fitness determinations and rating decisions for disability at the time of separation. The Board’s role is confined to the review of medical records and all evidence at hand to assess the fairness of service rating and fitness determinations at separation, as elaborated above. In the matter of the lumbar spine condition, the Board unanimously recommends a service disability rating of 20%,...
AF | PDBR | CY2011 | PD2011-00434
Right Foot Drop Condition . The NARSUM did note an absent right Achilles reflex (L5/S1 nerve root) and “a possible mild degree of ankle dorsiflexor weakness on the right.” The MEB neurology consultant noted that “the right foot becomes weak the more he walks,” and several clinical entries (as well as the CI himself in his rebuttal letter) document the onset of foot drop and bilateral leg numbness with exertional activities; not as a baseline. After considerable deliberation it was agreed...