AF | PDBR | CY2013 | PD-2013-02252
The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of theVeterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. RATING COMPARISON : IPEB – Dated 20050727VA* -Based on Service Treatment Records(STR)ConditionCodeRatingConditionCodeRatingExam Chronic Non-Radiating Low Back Pain…52370%Chronic Low Back Strain523710%STROther x 0 (Not...
AF | PDBR | CY2013 | PD-2013-02258
The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. Left Ankle Condition . 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...
AF | PDBR | CY2013 | PD-2013-02260
The examiner also noted that the CI had a normal gait, no muscle spasm and pain rating was recorded as moderate / intermittentIAW the American Medical Association.The MEB’s history and physical examinationdocumenteddecreased ROM of the lumbar spine with tenderness to palpation and decreased sensation in the right lower extremity.The MEB NARSUM physical exam findings were summarized in the chart above.The VA Compensation and Pension (C&P) examination (performed a month post separation),...
AF | PDBR | CY2013 | PD-2013-02265
SEPARATION DATE: 20040831 Pre-Separation) ConditionCodeRatingConditionCodeRatingExam Discogenic Low Back Pain523710%Thoracolumbar Spine Strain523710%20040628L4/L5 HNPCategory 2No VA EntryOther x 0 (Not is Scope)Other x 11 Rating: 10%Combined: 30%Derived from VA Rating Decision (VARD)dated 20041013 ( most proximate to date of separation) ANALYSIS SUMMARY :IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations. At the MEB...
AF | PDBR | CY2013 | PD-2013-02268
The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of theVASRD standards to the unfitting medical condition at the time of separation. Post-Separation)ConditionCodeRatingConditionCodeRatingExam Chronic Thoracic Spine Pain…5299-523710%Thoracic Spine Injury523720%20051207Other x 0 Other x 5 RATING: 10%RATING: 30% *Derived from VA Rating Decision (VARD)dated 20060228(most proximate to date of separation...
AF | PDBR | CY2013 | PD-2013-02270
Both nerve ratings (median and ulna) under incomplete paralysis are equivalent for the “mild” (10%; independent of hand-dominance) and “moderate”(20% non-dominant and 30% dominant hand)severity levels.The Board considered if another VASRD-compliant bilateral code was applicable, or if the unfitting left arm and unfitting right arm conditions rated separately would better depicted the CI’s disability condition IAW VASRD §4.7 (higher of two evaluations).All evidence considered there is no...
AF | PDBR | CY2013 | PD-2013-02272
The Informal PEB adjudicated “major depressive disorder”as unfitting, rated 10%with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation. The VA Compensation and Pension (C&P) exam performed 2 months after separation, noted the CI missed...
AF | PDBR | CY2013 | PD-2013-02273
RATING COMPARISON : Service IPEB – Dated 20041027VA - Based on Service Treatment Records (STR)ConditionCodeRatingConditionCodeRatingExam Chronic Neck and Shoulder Pain with Right Arm Numbness5237 -871610%Cervical Disc Herniation at C5-C6 with RUE Radiculopathy5342-871610%STROther x 0 (Not in Scope)Other x 3 STR Combined: 10%Combined: 10%Derived from VA Rating Decision (VARD)dated 20050506 ( most proximate to date of separation [DOS]). In the matter of the Service-combined cervical spine and...
AF | PDBR | CY2013 | PD-2013-02274
The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation. The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. I direct that all the Department of the Army records of the...
AF | PDBR | CY2013 | PD-2013-02277
Chronic Left Shoulder Pain Condition .The CI complained of left neck muscle spasmsseveralhours following his second AVA in the left arm on 1 August 2003.He reported that spasms and radiation of left arm pain had increased over the months,but he was asymptomatic at the 20May 2004 demobilization exam. Chronic Neck Pain Condition .An 18 February 2005 cervical spine MRIshowed a left disc protrusion at C6-7 causing stenosis and contacting the spinal cord and left-sided nerve root.The subjective...
AF | PDBR | CY2013 | PD-2013-02279
Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate. The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities standards to the unfitting medical condition at the time of separation. Treatment records were silent going forward until January 2005...
AF | PDBR | CY2013 | PD-2013-02281
Service IPEB – Dated 20041221VA - (At Separation)ConditionCodeRatingConditionCodeRatingExam Chronic Back Pain523710%Degenerative Disc Disease (DDD), Lumbar Spine523710%VARD*No Additional MEB/PEB ConditionOther x1 Combined: 10%Combined: 10% *VARD dated 20050418 based the rating on evidence found in the evidence & VA C&P dated 20010117 which was not available for review ANALYSIS SUMMARY :IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability...
AF | PDBR | CY2013 | PD-2013-02284
The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of theVASRD standards to the unfitting medical condition at the time of separation. Pre-Separation) ConditionCodeRatingConditionCodeRatingExam Fibromyalgia (includes Cervical DDD)502520%Fibromyalgia502520%20040614Cervical Spine Degenerative Disc Disease524320%20040614Other MEB/PEB Conditions x 5 (Not In Scope)Other x 11 RATING: 20%RATING: 60% *Derived...
AF | PDBR | CY2013 | PD-2013-02285
Sensation was decreased over the entire left foot (non-anatomical).A week later,she was evaluated in the pain clinic and noted to have normal motor and sensory examinations with one painful maneuver which was not expected to cause pain for this particular condition; three such maneuvers were again positive for painthe following day on re-examination.During the physical therapy Maneuvers not expected to cause pain werepositive.A primary care provider examination on 15 November 2004, the...
AF | PDBR | CY2013 | PD-2013-02287
The ankle condition, characterized as “posttraumatic arthritis of the left ankle” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E. CI CONTENTION : “Broken left ankle; arthritis in left ankle; hardware in left ankle” Physical Disability Board of Review
AF | PDBR | CY2013 | PD-2013-02289
The MEB only referred “chronic neck pain” and “chronic low back pain” to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB physical examination noted decreased range-of-motion (ROM) of the cervical areas and tenderness with spine palpation.The narrative summary (NARSUM) dated 7 April 2004 noted the CI could not perform the duties of his MOS secondary to chronic low back and neck pain.A permanent profile U3/L3dated 12 May 2004 was issued for neck pain, CTS and a chronic lower back...
AF | PDBR | CY2013 | PD-2013-02291
The first record in evidence is a primary care note dated 26 April 2004 in which the CI reported LBP for a month without recorded trauma (but later recorded as after performing a “flutter kick”). At the MEB examination on 12 January 2005, 5 months prior to separation, the CI reported back pain since physical training. The primary care note on 13 July 2005, several weeks after separation, documented that the neurological examination had “no gross motor and sensory deficits.” The C&P...
AF | PDBR | CY2013 | PD-2013-02293
Foot Condition . It documented hallux valgus and pes cavus (claw foot, congenital) deformitiesof both feet and full ROM of the right ankle and hindfoot.That note itself did not reference trauma, but a follow-up orthopedic entry provided a history of injury to the right foot only. The podiatry addendum 8 months prior to separation documented pain rated “6/10 progressing to 9/10 on his right foot;” with no rest pain of the left foot, but 5/10 pain with activity.
AF | PDBR | CY2013 | PD-2013-02295
SEPARATION DATE: 20050615 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. Left Lower Extremity Condition .
AF | PDBR | CY2013 | PD-2013-02297
The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation. A provider note from April 2005 (10 months prior to separation) states, “Achilles symptoms are self-manageable per patient, but primary complaint is surgical site foot pain.” TheAchilles condition was never profiled. RECOMMENDATION : The Board, therefore, recommends...
AF | PDBR | CY2013 | PD-2013-02298
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 (BCMR).The Board acknowledges the opinion of the CI’s treating physician in his letter to the FPEB that service mal-treatment contributed to the disability. The Board agreed that no rating could be recommended under this code. I have carefully reviewed the evidence of record and the...
AF | PDBR | CY2013 | PD-2013-02299
Post-Separation) ConditionCodeRatingConditionCodeRatingExam Chronic Neck Pain…524310%Degenerative Disc Disease, Cervical Spine5299-524210%20060731Chronic Low Back Pain…524310%Degenerative Disc Disease, Lumbar Spine524210%20060731Other x 0 (Not In Scope)Other x 7 RATING: 20%RATING: 20% *Derived from VA Rating Decision (VARD)dated 20070215(most proximate to date of separation [DOS]). At pain management visit dated 10 May 2004 the CI reported increased neck and right upper back pain with...
AF | PDBR | CY2013 | PD-2013-02301
The VA increased their radiculopathy rating, but maintained the 40% back rating until a subsequent exam in 2012 led to a decreased spine rating of 20%. 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 his prior medical separation: XXXXXXXXXXXXXXX President Physical Disability Board of Review
AF | PDBR | CY2013 | PD-2013-02304
The physical therapy MEB ROM examination on 12 April 2006, is recorded in the chart. At the VA Compensation and Pension (C&P) examination performed on 7 December 2006, 2 months after separation, the CI reported continued activity limiting low back pain with radiation to the right leg without weakness. The limitation of motion documented in the MEB examinations and the VA C&P examination proximate to separation support a 20% rating under the VASRD General Rating Formula for Diseases and...
AF | PDBR | CY2013 | PD-2013-02307
Rated at 0% for pain. Even though the PEB’s analogous coding and rating of 20% under VASRD application of the Diseases of the Peripheral Nerves is equivalent to the same rating if it was coded under 4.71a ROM impairment, the Board still considered whether a separate and additional rating could be recommended under a peripheral nerve code, as conferred by the VA, for the residual upper extremity radiculopathy at separation. Additionally, the knee condition was not specifically implicated in...
AF | PDBR | CY2013 | PD-2013-02308
He rated his pain at 4/10. Deluca criteria§4.71a Rating10%* (PEB 10%)10% (VA 10%) invalid font number 31502 *IAW VASRD §4.59, Painful motion invalid font number 31502 The Board directed attention to its rating recommendation based on the above evidence.The PEB coded the chronic LBP secondary to L5-S1 HNP without neurologic deficit condition 5243 (Intervertebral Disc Syndrome) and rated at 10%. RECOMMENDATION : The Board, therefore, recommends that there be no re-characterization of the...
AF | PDBR | CY2013 | PD-2013-02311
The BLEconditions, characterized as “quadriceps tendinopathy” and “stress reaction tibia” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.No other conditions were submitted by the MEB.The Informal PEB adjudicated “bilateral knee pain with right greater than left chronic quadriceps tendon insertional pain,” and “bilateral leg pain consistent with posteromedial tibial stress reaction,”as unfitting, rated at 10%, with application of the US Army Physical Disability Agency...
AF | PDBR | CY2013 | PD-2013-02313
The CI was started on hydroxychloroquine (specific drug therapy for Sjogren’s syndrome) with some improvement in her symptoms.Notes in the STRproximate to separation indicated the CI’s condition was stable,with no evidence of incapacitating episodes in the previous 12 months.At the MEB examination dated 31 October 2002, 6 months before separation, the CI reported pain in her shoulders, elbows, wrists, hands, and knees.The MEB NARSUM cited the DD Form 2808, Report of Medical Examination for...
AF | PDBR | CY2013 | PD-2013-02314
SEPARATION DATE: 20050420 The left handcondition characterized as “pain in the hand and weakness in the left upper extremity” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.The Informal PEB adjudicated “chronic pain with diminished grip strength, left (non-dominant) hand”as unfitting rated at 10%with application of the US Army Physical Disability Agency (USAPDA) pain policy. Despite therapy, the CI’s hand painwith weakness,continued,which impaired his...
AF | PDBR | CY2013 | PD-2013-02316
The shoulder condition, characterized as “persistent right shoulder postoperative pain” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.The MEB also identified one other condition.The Informal PEB adjudicated “chronic pain, right shoulder”as unfitting, rated 0%citing the US Army Physical Disability Agency (USAPDA) pain policy. Right shoulder pain . After reviewing the evidence, all Board members agreed that a rating of 10% was appropriate for the right shoulder condition.
AF | PDBR | CY2013 | PD-2013-02318
The PEB adjudicated the bilateral knee pain condition using codes 5099-5003 (chronic joint disease) rated alternatively as degenerative arthritis, ruling a rating of 10% using the USAPDA pain policy.The VA rated the right knee condition 10%, coded 5260 (leg, limitation of flexion), for painful motion.The Board considered using code 5260 or 5261 (leg, limitation of extension) noting that the threshold for a rating could not be achieved with the ROMs in evidence. RECOMMENDATION : The Board,...
AF | PDBR | CY2013 | PD-2013-02319
Neither the MEB nor the PEB documented the left hip, the left knee orthe lower back conditions for disability evaluation and therefore these contended conditions are not within the Board’s scope of review. However, the CI hip pain remained constant following surgery and she was not able to return to full duty.A permanent L3 profile was issued on 14 December 2004 for right hip fracture (right knee pain P2 injury) which precluded the CI from most military activities.At the MEB examination...
AF | PDBR | CY2013 | PD-2013-02320
Right snapping hip with right hip pain was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. 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 right hip condition was operant in this case and the...
AF | PDBR | CY2013 | PD-2013-02321
The eye conditions, characterized as “mild traumatic cataract,” “decreased vision,” and “cystoid macular edema” of the left eye, were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.No other conditions were submitted by the MEB.The Informal PEBcombined the MEB diagnoses as a single unfitting condition, rated 10% under criteria of the VA Schedule for Rating Disabilities (VASRD). The Board also acknowledges the CI’s information regarding the occupational impediments due to his...
AF | PDBR | CY2013 | PD-2013-02323
Cervical spine MRI on 20 January 2005 noted lower cervical spine disc herniation with spinal stenosis and general degenerative disc disease.As noted above, a note in the STR indicated “EMG/NCS-no evidence of radiculopathy.”Notes in the STR near the date of separation noted continued neck pain with intact ROM and normal strength and sensation.At the MEB examination on 27 May 2004, (approximately 5 months prior to separation)the CI reported neck pain. RECOMMENDATION : The Board, therefore,...
AF | PDBR | CY2013 | PD-2013-02325
The Board noted that the C&P exam, which was almost 3 years after separation, documented that the CI did not have any recurrent dislocations. 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...
AF | PDBR | CY2013 | PD-2013-02326
He denied hospitalization for diabetes or diabetic complications and had a full-time job.At a C&P exam on 13 June 2007(14 months after TDRL placement) the CI reported that if “he runs or does any type of activities he will have hypoglycemia.” He therefore restricted his activities. The Board directs attention to its rating recommendationbased on the above evidence.Both at the time of placement on the TDRL and at the time of permanent disability disposition and removal from the TDRL, the...
AF | PDBR | CY2013 | PD-2013-02327
The Board acknowledges the CI’s contention that suggests a higher service rating should have been granted on the unfitting medical condition documented at the time of separation. The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on ratable severity at the time of separation; and, to review those fitness determinations within its scope (as elaborated above)...
AF | PDBR | CY2013 | PD-2013-02329
The only other bilateral coding choice is 5276 under which the VA conferred separate ratings; but, the code provides for 30% and 50% bilateral ratings. Members agreed that the 5284 code (offering no rating advantage) was less applicable because of the absence of any specific injury to the foot; but, concluded that both tibial neuropathy (code 8725) and plantar fasciitis (code 5310)were significant contributors to the unfitting foot pain. In the matter of the combined bilateral foot...
AF | PDBR | CY2013 | PD-2013-02331
There was no change in range-of-motion (ROM) with three repetitions. Board members agreed that, based on the limitation of motion in evidence on the respective exams, the corresponding ratings by the PEB and VA were appropriate. RECOMMENDATION : The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.
AF | PDBR | CY2013 | PD-2013-02333
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. Furthermore, the VA examination did not elicit any associated abnormal muscular findings or secondary pain as one would expect in a bilateralmuscle strain condition.The VARD’s comment of“no significant abnormalities in the lower extremities”clearly indicated the minimalist...
AF | PDBR | CY2013 | PD-2013-02334
The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of theVASRD standards to the unfitting medical condition at the time of separation. The §4.97 criteria for a 30% rating are “FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication;” and, those for 10% are “FEV-1 of 71- to 80-percent...
AF | PDBR | CY2013 | PD-2013-02335
The VA rated the shoulder condition 10%, for a code not available for review by the Board.The Board directs attention to its fitting and rating recommendations based on the above evidence. Right and Left knee conditions .The Board will discuss the clinical findings of both conditions together, as they are combined in the record, but then separate them for fitting and rating considerations.The CI had a long history of bilateral knee pain, the right greater than the left, with an associated...
AF | PDBR | CY2013 | PD-2013-02337
RECORD OF PROCEEDINGSPHYSICAL DISABILITY BOARD OF REVIEWNAME: XXXXXXXXXXXXXXXXXCASE: PD-2013-02337BRANCH OF SERVICE: Army BOARD DATE: 20140912 The syncope condition characterized as “recurrent syncopal episodes likely secondary to hyperventilation syndrome” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.No other conditions were submitted by the MEB.The Informal PEBadjudicated syncope as unfitting rated at 20%citing criteria of theVeterans Affairs Schedule for Rating...
AF | PDBR | CY2013 | PD-2013-02341
SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) was an active dutyE-4 (Infantryman) medically separated for chronic pain of the left leg. The Informal PEB adjudicated “chronic pain left leg” as unfitting, rated 10%, with cited application of the US Army Physical Disability Agency (USAPDA) pain policy. The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence...
AF | PDBR | CY2013 | PD-2013-02342
At that point I was sent to the medical review board to see what my options were. The VA rated the right ankle and foot at 10% coded 5284 (Foot injuries, other; “moderate symptoms”) with two additional 0% ratings for 5276 (Flatfoot, acquired [pes planus] “Mild”) and 5280 (hallux valgus).The Board considered that the disability conditions of the foot had overlapping symptoms and considered a possible higher rating-level under 5284 (considering all foot/ankle conditions) or 5310 (muscle...
AF | PDBR | CY2013 | PD-2013-02345
The back condition and anemia, characterized as “mechanical low back pain (LBP)” and “anemia,” were the only conditions forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. A neurosurgical examination on 23 August 2004 (10 months prior to separation) showed normal spine contour and normal gait. RECOMMENDATION : The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.
AF | PDBR | CY2013 | PD-2013-02346
Spasm was absent.At the MEB examination dated 4 November 2004, the CI reported lower back surgery on 23 July 2004. Thoracolumbar ROM (Degrees)MEB ~3 Mo. However, the Board does not recommend a rating lower than that adjudicated by the PEB.
AF | PDBR | CY2013 | PD-2013-02349
The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation. After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines...
AF | PDBR | CY2013 | PD-2013-02350
The CI was prescribed a combined steroid (Advair) and BD inhaler twice daily and follow-up PFT in three months was recommended.A follow up PC visit 29 March 2004 noted that the CI had no symptoms and was not using the BD inhaler “at all.”At the MEB exam 29 March 2004, the CI reported asthma, denied any SOB or chest tightness, but still had occasional coughing spells.The medications list included Advair twice daily “started today.” The MEB physical exam noted a normal lung exam. However, a...