AF | PDBR | CY2013 | PD2013 00821
In addition to that diagnosis, he also listed diagnoses of chronic pain syndrome, bilateral foot pain, bilateral shoulder pain with right shoulder arthrosis, low back pain status-post surgery and chronic bilateral knee pain with retropatellar pain syndrome.At the MEB exam on 14 May 2001(7 months prior to entry on TDRL),the CI reported that he could not perform his duties because of pain in his upper back, lower back, shoulders, hips, legs, knees, feet, hands and neck.At the VA Compensation...
AF | PDBR | CY2013 | PD2013 00826
The Board reviews medical records and other available evidence to assess the fairness of PEB rating determinations, using the VASRD standards, based on ratable severity at the time of separation. Contended PEB Conditions : The Board noted that no MH condition was referred into the DES. invalid font number 31502 RECOMMENDATION : The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows:
AF | PDBR | CY2013 | PD2013 00849
No other conditions were submitted by the MEB.The PEB found the LBP condition unfitting, and rated it 0% with likely application of the US Army Physical Disability Agency (USAPDA) pain policy.The CI made no appeals at that time, and was medically separated with a 0% disability rating. Low Back Pain (LBP) . Neurological exam showed normal sensation, normal reflexes, and normal motor strength.
AF | PDBR | CY2013 | PD2013 00860
SEPARATION DATE: 20050526 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. A pain management note dated 5 April 2005 documented that the CI received good pain relief from the RFA for about 6 months and then underwent repeat RFA with another 6 months of pain relief.
AF | PDBR | CY2013 | PD2013 00863
The PEB adjudicated chronic back pain as unfitting, rated 10%, with likely application of the US Army Physical Disability Agency (USAPDA) pain policy.The remaining conditions were determined to be not unfitting.The CI made no appealsand was medically separated. 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...
AF | PDBR | CY2013 | PD2013 00864
SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSGT/E-6 (3381/Food Service Specialist) medically separated for recurrent deep venous thrombosis (DVT).The CI reportedly had his first episode of DVT (a clot in a large leg vein), left lower extremity (LLE), in 1985. The Board determined that the DVT in either leg, in the presence of the requirement for lifelong anti-coagulation, was separately unfitting and...
AF | PDBR | CY2013 | PD2013 00867
A 24 January 2007 clinic record entry reflected the CI reported medication was working well for his headaches but had recurred when he ran out of medication.At a VA C&P examination, dated 23 July 2007, 5 months after separation, the CI reported two headaches per week, but added that he was not incapacitated by headaches, and had lost “no time from work due to headache.”The Board directs attention to its rating recommendation based on the above evidence. The PEB found the headaches unfitting...
AF | PDBR | CY2013 | PD2013 00871
Bilateral Achilles Tendinitis Status Post Haglund’s Resection Left Foot with Haglund’s Deformity Right Foot :The first entry in the service treatment record is from 27 January 1997troop medical clinic, when the CI presented with a 3-day history of pain on the outside of her right ankle down to heel during and after running PT and with walking. She had continuing pain and an X-ray of the right ankle for pain was normal. The final diagnoses were (1) bilateral Achilles tendinitis, (2) status...
AF | PDBR | CY2013 | PD2013 00892
SEPARATION DATE: 20060426 Post-Separation) ConditionCodeRatingConditionCodeRatingExam Heat Exhaustion7999-79000%Isolated Episode of Heath Intolerance7999-7900NSC*20070511Low Back Pain with L5 Mild RadiculopathyNot UnfittingLumbar Strain523710%20070511Migraine HeadachesNot UnfittingMigraines81000%20070511Antisocial Personality DisorderNot UnfittingPTSD and Antisocial Personality Disorder9411NSC**20070529No Additional MEB/PEB EntriesOther x 220070529 Rating: 0%Combined Rating: 30%Derived from...
AF | PDBR | CY2013 | PD2013 00923
Post hospitalization note, 29 December 2008, recorded improvement in mood symptoms, noted stability of symptoms with medication, and recorded a diagnosis of “cognitive deficits NOS”, PTSD chronic, with a rule out of psychotic depression. 3 June 2009, approximately 1-year after separation, the VA increased disability rating to 70% for the conditions of psychosis with cognitive disorder and residuals of brain lesion (claimed as dermoid cyst, cognitive problems, speech problems, traumatic...
AF | PDBR | CY2013 | PD2013 00925
The “chronic pain, multiples cites [ sic ]”characterized as “mechanical thoracic and lumbar back pain,, “right knee pain,” “right ankle pain,” “right foot sesamoiditis and metatarsalgia,”“left knee pain,” and “left foot and ankle pain,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. Bilateral knee condition . X-rays were normal for both knees.
AF | PDBR | CY2013 | PD2013 00935
The PEB combined the MEB referred conditions of FM and bilateral plantar fasciitis and pes cavus and rated them as one unfitting condition of FM coded at 5025, specified by the VASRD as “with widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesia, headaches, irritable bowel symptoms, depression, anxiety, or Raynaud’s-like symptoms.” The PEB cited avoidance of pyramiding IAW VASRD §4.14 for not rating the plantar...
AF | PDBR | CY2013 | PD2013 00988
Right knee pain secondary to patellar tendonitis and shrapnel injury was diagnosed.The PT noted the need for ambulation with a cane and knee brace with strength limited by pain. The Board reviewed the MH conditions for “fitness” and possible rating (under VASRD 4.130) if determined to be “unfitting” for military service. Physical Disability Board of Review
AF | PDBR | CY2013 | PD2013 01001
A physical therapy (PT) entry a month later, however, documented flexion limited to 30 degrees (normal 90 degrees) and, the MEB physical exam a month after that (3 months pre-separation) noted “limited” ROM and antalgic gait.An earlier entry of April 2006 (7 months pre-separation) documented flexion “20%” (unclear if % reduction or % normal) but, no other STR entries documented grossly decreased ROM or abnormal gait (one specifying normal gait and anothernormal ROM). There is thus no...
AF | PDBR | CY2013 | PD2013 01020
The chest painand headache conditions, characterized as “chronic costochondritis” and “migraines with aura,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.No other conditions were submitted by the MEB.The PEB adjudicated “chronic costochondritis and migraine headaches”as unfitting, rated 10% and 0%,referencing the US Army Physical Disability Agency (USAPDA) pain policy for chronic costochondritis and DoDI 1332.39 for migraine headaches.The CI made no appealsand was...
AF | PDBR | CY2013 | PD2013 01030
RATING COMPARISON : Service IPEB – Dated 20071212VA -(based on Service Treatment Records (STR)ConditionCodeRatingConditionCodeRatingExam Chronic Low Back Pain Rated Analogously to Lumbrical Strain with Atraumatic Onset5299-523710%Back Injury5237NSC*STROther x 0NSC x 3STR Combined: 10%Combined: 0%Derived from VA Rating Decision (VARD)dated 20090225 ( most proximate to date of separation [DOS]). The STR noted a gymnastic accident resulting in an L-5 compression fracture prior to service entry...
AF | PDBR | CY2013 | PD2013 01034
The rating for the unfitting chronic mid back pain condition is addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board.However, the CI additionally was notified by the Army that his case may be eligible for a review of the military disability evaluation of any mental health (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...
AF | PDBR | CY2013 | PD2013 01054
Based on an interview and a review of psychological testing, the examiner diagnosed an undifferentiated somatoform disorder. The VA coded the somatoform disorder as 9421, somatization disorder and rated at 0%, specifically citing “…this condition is currently not causing impairment in a social or occupational setting.” Documentation throughout the service treatment record (STR)consistently diagnosed the CI with a somatoform disorder. Physical Disability Board of Review
AF | PDBR | CY2013 | PD2013 01059
The headache condition, characterized as “chronic refractory migraine;” the neck condition, characterized as “cervicalgia;”and two other conditions (“imbalance secondary to cervicalgia” and “mild right cubital tunnel syndrome”) were forwarded to the Physical Evaluation Board (PEB) as failing retention standards.No other conditions were forwarded by the MEB.The PEB adjudicated “chronic neck pain” and “chronic headaches, occurring daily, non-prostrating”as unfitting, rated 10% and 0%...
AF | PDBR | CY2013 | PD2013 01060
The MEB narrative summary (NARSUM) accomplished 2 months prior to separation documented continued numbness in the ring and small fingers of his left hand as well as the posterior aspect of his forearm along with left elbow pain and stiffness. Physical Disability Board of Review SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
AF | PDBR | CY2013 | PD2013 01068
After a thorough review of the evidence, the Board determined that a disability rating of 10% was appropriate. On MSE, the CI’s orientation, appearance, hygiene, behavior and eye contact were all normal. 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...
AF | PDBR | CY2013 | PD2013 01073
The MEB also identified and forwarded three other conditions for PEB adjudication.The PEB adjudicated “chronic low back pain….L5/S1 discectomy”as unfitting, rated 10%, with likely application of the VA Schedule for Rating Disabilities (VASRD).The remaining conditions were determined to be medically acceptable and were determined to be not unfitting, therefore not ratable. The back was too painful for ROM to be measured. RECOMMENDATION : The Board, therefore, recommends that there be no...
AF | PDBR | CY2013 | PD2013 01076
CI CONTENTION :“PEB rating of 20% w/disability discharge should have been at least 30% - VA Disability Rating of 30% upon review of military records.” Slight instability of the medial collateral ligament of the left and right knee was reported. 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...
AF | PDBR | CY2013 | PD2013 01078
The PEB adjudicated “left hand numbness…,” rated 10%,citing criteria of the VA Schedule for Rating Disabilities (VASRD).The remaining conditions were determined to be not unfitting.The CI made no appeals and was medically separated. The narrative summary was dated 24 January 2006, 3 months prior to separation, and noted that the CI had persistent left elbow pain and numbness in the left 5th and 4th fingers. These included full range-of-motion of the left shoulder and elbow with normal grip...
AF | PDBR | CY2013 | PD2013 01079
In addition, the CI was notified by the Army that his case may eligible for review of the military disability evaluation of his 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 performance of the CI was stellar prior to the onset of anxiety related to a future deployment and...
AF | PDBR | CY2013 | PD2013 01090
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 VA Schedule for Rating Disabilities (VASRD) standards, based on ratable severity at the time of separation; and, to review those fitness determinations within its scope (as elaborated above) consistent with performance-based criteria in evidence at separation. No evidence of spondylolysis or pars defect.”At the MEB medical examination...
AF | PDBR | CY2013 | PD2013 01104
The CI was permanently profiled and continued on conservative management and physical therapy. Members agreed, therefore, that the pain of the rib cage and upper abdomen (costochondritis, aponeurotic neuritis and diastasis of abdominal rectus) conditions were not reasonably justified as separately unfitting; and, accordingly, they cannot be recommended for separate disability rating. BOARD FINDINGS : IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines...
AF | PDBR | CY2013 | PD2013 01106
The PEB adjudicated the right-shoulder condition as unfitting rated at 10%, citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD);the bilateral knee, right-ankle and lumbar diagnoseswere consolidated as a single unfitting condition coded analogously to 5003 (degenerative arthritis)rated at 10%, with likely application ofthe U.S. Army Physical Disability Agencypain policy and/or AR 635-40 (B.24.f). There are multiple STR entries reflecting normal or nearly normal...
AF | PDBR | CY2013 | PD2013 01110
SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve component active duty second lieutenant (prior-enlisted)/O-1E (66H00/Registered Nurse) medically separated for chondromalacia of the left knee, diagnosed on arthroscopy, present several years, and for “major depressive disorder, atypical, known to have existed prior to service (EPTS) by history, without permanent service aggravation (PSA).”The CI enlisted in 1996 at...
AF | PDBR | CY2013 | PD2013 01118
The PEB combined the two MEB back conditions and adjudicated “chronic back pain” as unfitting, rated 10% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).The CI made no appeals and was medically separated with thatdisability rating. While spasm was noted on second VA examination and in the diagnosis part of the initial VA examination, the gait was noted to be normal (but stiff) as was the posture. RECOMMENDATION : The Board, therefore, recommends that there...
AF | PDBR | CY2013 | PD2013 01125
Right Ankle Condition . The examiner referred to the profile for physical limitations. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record
AF | PDBR | CY2013 | PD2013 01127
The condition, characterized as “diabetes type I requiring insulin” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The Informal PEB adjudicated “diabetes mellitus type I”as unfitting, rated 20%.The remaining condition was determined to be not unfitting and not rated.The CI made no appeals, and was medically separated. RECOMMENDATION : The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows:
AF | PDBR | CY2013 | PD2013 01140
There were no periods of incapacitation.At the MEB narrative summary (NARSUM) examination,performed 5 months prior to separation, the CI endorsed“tolerable back pain (with medication use), unless exacerbated by activity.”The examination was limited and revealed tendernessand guarding. Although the service and VA titled the unfitting back condition differently, they both used similar codes of 5242 (degenerative arthritis of the spine) at 10% and 5243 (intervertebral disc disease) at 20%,...
AF | PDBR | CY2013 | PD2013 01141
Chronic Back Condition . He complained of chronic 2/10 back pain at rest and 6/10 pain with activity and lifting. Physical Disability Board of Review
AF | PDBR | CY2013 | PD2013 01157
It was likewise agreed that even if a recommendation for a change in service MH diagnosis was conceded, there would be insufficient evidence for recommending it as unfitting and eligible for rating; noting that no psychiatric impairment was judged to fail retention standards, that the profile wasS1, that the commander did notidentify any MH limitations on performance, and that there is a lack of any performance-based evidence in the service record suggesting that such limitations existed. ...
AF | PDBR | CY2013 | PD2013 01160
Although the CI elaborated no contention related to any MH condition, it is noted that he received a post-separation VA rating for posttraumatic stress disorder (PTSD) and listed that condition (along with sleep apnea) on his application as a VA rated condition.Accordingly, the case file was reviewed for potentially unfavorable diagnosis change, fitness determination, applicability of VA Schedule for Rating Disabilities (VASRD) §4.129, and rating (via VASRD §4.129 or §4.130 as appropriate)...
AF | PDBR | CY2013 | PD2013 01166
RECORD OF PROCEEDINGSPHYSICAL DISABILITY BOARD OF REVIEWNAME: XXXXXXXXXXXXXXXXXX CASE: PD1301166 BRANCH OF SERVICE: Army BOARD DATE: 20140304 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. The Board considered whether the totality of the evidence at the time of separation met the criteria for a higher than 10% disability rating.
AF | PDBR | CY2013 | PD2013 01191
The CI is also eligible for PDBR review of other conditions evaluated by the PEB and has elected review by the PDBR.The ratings for the unfitting right anterior knee pain with early chondromalacia but no chondral defects condition is addressed below. While depression and anxiety were noted on the MEB examination by a Family Medicine doctor, and it was also noted in the second NARSUM by the MEB physician (an orthopedic)that he had a past history of PTSD evaluated by psychiatry, this was not...
AF | PDBR | CY2013 | PD2013 01195
After a thorough review of the evidence, the Board determined that a disability rating of 10% was appropriate. 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...
AF | PDBR | CY2013 | PD2013 01197
The bilateral foot condition, characterized as “chronic left and right foot pain (pes planus)” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The requested knee, back, weight gain, mental health, and substance abuse conditions were not identified by the PEB, and thus are not within the DoDI 6040.44 defined purview of the Board.The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected condition continues to burden...
AF | PDBR | CY2013 | PD2013 01198
The examination was normal and mood was not specifically described. The NARSUM clearly noted that the MH symptoms were present prior to deployment as well as after, indicating the CI was “fit” to deploy. After due deliberation in consideration of the preponderance of the evidence, the Board concluded there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions, so no additional disability ratings are recommended.
AF | PDBR | CY2013 | PD2013 01211
RATING COMPARISON : Service IPEB – Dated 20030511Based on VA and Service Treatment Records(STR)ConditionCodeRatingConditionCodeRatingExam Low Back Pain, Without Neurologic Abnormality5299-529510%Chronic LBP w/DDD523710%STR & 20040818Muscle Atrophy Right Thigh and Right Leg, Etiology UndeterminedNot UnfittingRight Lower Extremity Atrophy….w/LBP w/DDD852110%STROther x 1 (Within Scope)Depression/Insomnia9499-9434NSC*STROther x 4 NSC Combined: 10%Combined: 20%*Derived from VA Rating Decision...
AF | PDBR | CY2013 | PD2013 01212
The rating for the unfitting MH condition isaddressed below. 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 MDD condition and IAW VASRD...
AF | PDBR | CY2013 | PD2013 01221
Originally diagnosed with back pain due to muscle spasms, the pain worsened and extended into his left leg within 4 months. Bilateral Shoulder Condition . RECOMMENDATION : The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination.
AF | PDBR | CY2013 | PD2013 01230
To that end, the evidence for the left hip neuritic post-op pain and right greater trochanteric bursitis conditions are presented separately; with attendant recommendations regarding separate unfitness and separate rating if indicated.The Board first considered if the right greater trochanter bursitis condition, having been de-coupled from the combined PEB adjudication, remained itself unfitting. He continued to complain of right hip pain; however, his left hip pain was much more severe. ...
AF | PDBR | CY2013 | PD2013 01235
Post-Separation) ConditionCodeRatingConditionCodeRatingExam Right Shoulder Pain…5099-500310%Right Shoulder S/P Acromioplasty5201-502410%20040907 Rating: 10%Rating: 10%Derived from VA Rating Decision (VARD)dated 20040930 ( most proximate to date of separation [DOS]). The VA’s 10% rating under code 5201 (limitation of motion), coded as 5024 (tenosynovitis), is compatible with the ROM evidence from the C&P examiner. BOARD FINDINGS : IAW DoDI 6040.44, provisions of DoD or Military Department...
AF | PDBR | CY2013 | PD2013 01236
The examiner specifically noted, “…this [CI] is continuing to have TIAs.” Again, there was no comment on his functional ability; however, the permanent profile of 9 April 2004 limited only assignment or deployments to areas with definitive medical care, but that his activities were otherwise unrestricted.At afollow-up neurology note of 16 June 2004, the CI endorsed occasional subtle numbness of both the left upper and lower extremities for 30 minutes once a month.The examination was normal...
AF | PDBR | CY2013 | PD2013 01246
The PEB adjudicated “right, dominant, shoulder pain… ,” “right hip pain,” and “bilateral heel pain and right ankle pain” as unfitting, rated 10%, 0% and 0% (respectively), citing criteria of the VA Schedule for Rating Disabilities (VASRD). Post-Separation)ConditionCodeRatingConditionCodeRatingExam Right Shoulder Pain…5099-500310%Right Shoulder Arthritis5010-520110%20091125Right Hip Pain…5099-50030%Right Hip Bursitis5024-525210%Bilateral Heel Pain and Right Ankle Pain…52840%Stress Fracture,...
AF | PDBR | CY2013 | PD2013 01270
Left Knee Condition . The CI sustained a fracture of his tibial plateau (top of the lower leg bone at the knee)left knee in a MVA in October 2001 which required surgical fixation with instrumentation.The service treatment record (STR) was void of source documents from 2001, and record documentation began in May 2003 when he re-injured/hyperextended his left knee when he slipped in a water puddle. (Army Review Boards)
AF | PDBR | CY2013 | PD2013 01304
Theratingsfortheunfittinglowbackandright knee conditions are addressed below; and, no additional conditions are within the DoDI SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXX, AR20140007238 (PD201301304) 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.