RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY 

CASE NUMBER: PD1200626 SEPARATION DATE: 20020808 

BOARD DATE: 20130315 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty SSG/E-6 (11B30/Infantryman), medically separated 
for chronic pain of the mid and low back, status post (s/p) compression fracture; chronic right 
shoulder pain and bilateral ankle pain with instability. In 1995, after an airborne jump, he 
landed hard and experienced pain in the low back and mid back region and also in the right 
ankle and right shoulder. He was found to have a T12 vertebral fracture. He was treated 
conservatively with physical therapy (PT), medications, and duty restrictions. The CI returned 
to full duty, including active jump status, but developed recurrent symptoms about a year prior 
to separation. The CI did not improve adequately with treatment to meet the physical 
requirements of his Military Occupational Specialty or satisfy physical fitness standards. He was 
issued a permanent U3L3 profile and referred for a Medical Evaluation Board (MEB). The MEB 
referred the back, right shoulder and bilateral ankle conditions to the Physical Evaluation Board 
(PEB) as medically unacceptable; no other conditions were forwarded by the MEB. The PEB 
adjudicated the chronic pain, mid and low back, s/p compression fracture; chronic pain right 
shoulder; and, chronic pain bilateral ankles with instability as unfitting and rated them at 10% 
with application of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made 
no appeals and was medically separated with a 10% disability rating. 

 

 

CI CONTENTION: “All issues including right shoulder, fracture vertebrate [sic], left and right 
ankle.” The Board noted an undated letter from the CI addressed “To whom it may concern” in 
which he reported that he suffered from depression and shame, tinnitus, sleep disturbance, 
knee pain, shin splints and plantar fasciitis. 

 

 

SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 
6040.44, Enclosure 3, paragraph 5.e. (2) is limited to those conditions which were determined 
by the PEB to be specifically unfitting for continued military service; or, when requested by the 
CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings 
for unfitting conditions will be reviewed in all cases. The back, right shoulder and bilateral 
ankles, as requested for consideration, meet the criteria prescribed in DoDI 6040.44 for Board 
purview; and, are addressed below. 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 Army Board for Correction of Military Records. 

 

 

RATING COMPARISON: 

 

Service IPEB – Dated 20020529 

VA (2 Mos. Post-Separation) – All Effective Date 20020809 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Chronic Pain, …back…R 
shoulder …bil ankles 

5099 5003 

10% 

Right Shoulder Sprain 

5299-5201 

0% 

20021015 

Recurrent Ankle Sprains, Bil 

5299-5271 

0% 

20021015 

Status-Post Fracture of Spine … 

5010-5292 

0% 

20021015 

.No Additional MEB/PEB Entries. 

0% x 4 

20021015 

Combined: 0% 

Combined: 10% for multiple, noncompensable disabilities 



The back, shoulder and both ankles were rated at 10% each, effective 20090730, based on post-separation treatment records. 


ANALYSIS SUMMARY: The PEB combined the back, right shoulder and bilateral ankle conditions 
as a single unfitting condition, coded analogously to 5003, degenerative arthritis, and rated it 
0%. The PEB may have relied on AR 635.40 (B.24 f.) and/or the USAPDA pain policy for not 
applying separately compensable Veterans Affairs Schedule for Rating Disabilities (VASRD) 
codes. The Board must apply separate codes and ratings in its recommendations if 
compensable ratings for each condition are achieved IAW VASRD §4.71a. If the Board judges 
that two or more separate ratings are warranted in such cases, however, it must satisfy the 
requirement that each unbundled condition was unfitting in and of itself. Not uncommonly this 
approach by the PEB reflects its judgment that the constellation of conditions was unfitting and 
that there was no need for separate fitness adjudications rather than a judgment that each 
condition was independently unfitting. Thus, the Board must exercise the prerogative of 
separate fitness recommendations in this circumstance, with the caveat that its 
recommendations may not produce a lower combined rating than that of the PEB. Review of 
the service treatment records shows that the CI was first seen for left ankle pain after sprain in 
November 1990, 6 months after accession. He was treated conservatively with return to full 
duty. In June 1991, he sprained his right ankle, but was again returned to full duty. He was 
seen several more times for his right ankle in 1995, 1996, and 2000. During this time, he 
apparently remained on jump status. In October 1995, he made a bad landing after a jump 
with injury to his back, right shoulder and right ankle. A bone scan a month later showed a 
fracture at T12 and mild post traumatic change of the right ankle with a stress reaction at the 
base of the first right metatarsal. The Board noted that the history for an X-ray of the left ankle 
on 13 April 2001 documented that the CI had left ankle pain since a parachute jump the 
previous night. Also, the record showed that on 15 June 2001, the CI scored a 265 (300 
maximum) on a record physical fitness test, exceeding requirements for sit ups, pushups and 
the two mile run. 

 

Mid and Lower Back Pain, S/P Compression Fracture Condition. On 18 September 2001, 11 
months prior to separation, the CI reported morning stiffness of his back while at a family 
practice appointment for his right shoulder. This was his first recorded evaluation for the back 
pain since 1995. He had full range-of-motion (ROM), negative provocative testing for radicular 
irritation and a normal neurological examination and gait. X-rays that day showed a 
compression fracture at T12 with 20% reduction in height; otherwise, these were 
unremarkable. He was again seen 2 weeks later with a continued normal examination. An 
examination in PT a month later was again normal. He was treated by PT without improvement 
in his pain. He was referred to orthopedics and seen 4 February 2002, 6 months prior to 
separation. The CI was noted to have a 10% compression fracture, seven degrees of scoliosis, 
tenderness to palpation over the thoracolumbar junction, painful extension , some flattening 
and spasm with right less than left side bend. At the MEB examination on 17 March 2002, just 
under 5 months prior to separation, the CI reported that the back pain had continued since the 
parachute accident in 1995. The MEB physical examination was silent regarding the back. The 
narrative summary (NARSUM) was dictated 29 March 2002, 4 months prior to separation. The 
CI reported chronic, but slight pain. On examination, there was no sensory or motor deficit or 
muscle atrophy. Reflexes were noted as 1-2+ without further specification. He was able to heel 
and toe walk. The ROM was slightly reduced in all planes with most reduction in flexion at 50 
degrees. It was noted that he had a desk job without organized physical fitness training. The CI 
was issued an U3L3 profile on 23 April 2002 and was limited to lifting 40 pounds, marching four 
miles, and walking and running at his own pace and distance. The VA Compensation and 
Pension (C&P) examination was on 15 October 2002, 2 months after separation. The CI 
reported back pain rated at 7 out of 10 associated with weakness, stiffness, fatigability, and lack 
of endurance. He denied flare ups or the use of assistive devices. He worked as a school 
teacher. His only limitation in daily activity was the use of Motrin. The ROM exceeded normal 
values without pain. The back musculature was normal. There was no evidence of spasm, 
weakness, or tenderness. He could walk on both his heels and toes. Reflexes were normal and 
provocative testing for nerve root irritation was negative. X-rays showed disc space narrowing 


(location not defined) and degenerative changes in the T11-12 area. A second examination (by 
the same examiner) that day documented a normal gait. The Board first considered if the back 
pain condition was separately unfitting. It noted that the CI had injured his back in 1995, but 
had returned to jump status and had an excellent fitness test a year prior to separation. He had 
chronic pain, but the back, including ROM, was normal on most examinations including the C&P 
examination which was the most proximate to separation. There was no history of intervening 
trauma in the record to account for the increased symptoms the final year of active service. 
The Board noted that the CI had a U3L3 profile and that the MEB determined the back pain to 
be medically unacceptable, but that his profile permitted marching for four miles and lifting 40 
pounds with unlimited walking and running at his own pace and distance. The commander 
noted that he was fully able to meet his duties in an office setting and had limited capacity to 
meet field duties for a limited time. The Board noted that while there was evidence which 
would argue for the condition being separately unfitting, that the condition would not rate at 
higher than a 0% disability rating, providing no advantage to the CI. After due deliberation, 
considering all of the evidence and mindful of VASRD §4.3 (Resolution of reasonable doubt), the 
Board concluded that there was insufficient cause to recommend a change in the PEB 
adjudication for the back condition. 

 

Right Shoulder Condition. There is no record of visits for the right shoulder after the 1995 
parachute accident until the CI was seen in family practice on 19 September 2001, 11 months 
prior to separation. He reported increased pain for the past few months and was unable to 
throw a ball overhead. The examination was normal including ROM. An X-ray was negative, 
but a magnetic resonance imaging (MRI) exam on 25 October 2001 showed a mild increased 
signal of the rotator cuff which was not full thickness and thought to be consistent with early 
tendon degeneration. At a PT examination on 8 November 2001, the CI reported insidious 
onset of pain over the prior several years with an increase the past year. The ROM was full, but 
painful between 120 and 160 degrees. Strength was reduced at 4/5 for abduction at 30 
degrees. The CI was treated with PT without subjective benefit. Rotator cuff testing was 
positive for pain, but there was no impingement. At the MEB examination on 17 March 2002, 
just under 5 months prior to separation, the CI reported that continued pain in the right 
shoulder. The examiner noted normal ROM and strength, but pain with abduction. The 
narrative summary (NARSUM) was dictated 29 March 2002, 4 months prior to separation. The 
CI reported pain with hyperextension and overhead throwing, but no limitation in ROM. The 
neurological examination was normal and no atrophy noted. There was slight pain with 
hyperextension and mild limitation with internal rotation compared to the left. X-rays were 
normal. The profile restricted the CI to lifting 40 pounds and no pushups although swimming 
was permitted. The C&P examination was on 15 October 2002, 2 months after separation. The 
right dominant CI reported pain rated 8 out of 10, stiffness, instability, fatigability and a loss of 
endurance. He subjectively assessed a 40% loss of function. The ROM was normal including 
internal rotation. No muscle atrophy was noted. The Board first considered if the right 
shoulder condition was separately unfitting. It noted that the CI had injured his shoulder in 
1995, but had returned to jump status and had an excellent fitness test one year prior to 
separation including pushups. He had chronic pain, but the right shoulder, including ROM, was 
normal on most examinations including the C&P examination which was the most proximate to 
separation. There was no history of intervening trauma or a change in activity in the record to 
account for the increased symptoms the final year of active service. The Board noted that the 
CI had a U3L3 profile and that the MEB determined the shoulder pain to be medically 
unacceptable, but that his profile permitted marching for four miles and lifting 40 pounds with 
swimming permitted. The commander noted that he was fully able to meet his duties in an 
office setting and had limited capacity to meet field duties for a limited time. As noted in the 
discussion for the back, while there is evidence to support a separate unfitting determination, 
the shoulder condition would not achieve a disability rating higher than 0%, providing no 
advantage to the CI. After due deliberation, considering all of the evidence and mindful of 


VASRD §4.3 (Resolution of reasonable doubt), the Board concluded that there was insufficient 
cause to recommend a change in the PEB adjudication for the right shoulder condition. 

 

Bilateral Ankle Condition. On 13 April 2001, 16 months prior to separation, the CI presented 
with a complaint of left ankle pain since a parachute jump the previous night. The examination 
and X-rays were negative for fracture. That June, the CI had an excellent physical fitness test 
including the run. His next documented visit was in orthopedics on 24 January 2002, 7 months 
prior to separation, at an appointment requested by PT to evaluate his shoulder. He reported 
lateral instability and was found to have a pain and crepitance on an anterior drawer test and a 
positive talar tilt, tests for ligamentous stability. At the MEB examination on 17 March 2002, 
just under 5 months prior to separation, the CI reported that bilateral ankle pain since the 
parachute accident in 1995. The examiner noted bilateral pes planus (flat feet), but made no 
comment on the ankles. The narrative summary (NARSUM) was dictated 29 March 2002, 4 
months prior to separation. The CI reported a history of multiple bilateral sprains. The profile 
restricted the CI to running and walking at his own distance and pace. On examination, there 
was no swelling and the ROM was normal and symmetric bilaterally. No muscle atrophy was 
observed. Heel and toe walk was normal. The C&P examination was on 15 October 2002, 2 
months after separation. The CI endorsed fatigability, lack of endurance, stiffness, and pain, 
but denied instability or locking. He subjectively assessed a 40% loss of function, but did not 
use a brace or assistive device. The ROM was reduced in flexion. No muscle atrophy was 
noted. Heel and toe walk were normal as was the gait. X-rays were normal bilaterally. The 
Board first considered if either ankle condition was separately unfitting. It noted that the CI 
had injured his right ankle in 1995, but had returned to jump status and had an excellent fitness 
test one year prior to separation including the run. He had chronic pain, but both ankles, 
including ROM, were normal on most examinations. There was no history of intervening 
trauma or a change in activity in the record to account for the increased symptoms the final 
year of active service. The Board noted that the CI had a U3L3 profile and that the MEB 
determined the bilateral ankle pain to be medically unacceptable, but that his profile permitted 
marching for four miles and walking or running at his own pace and distance. The commander 
noted that he was fully able to meet his duties in an office setting and had limited capacity to 
meet field duties for a limited time. The Board determined that the preponderance of evidence 
does not support a finding that either ankle condition was separately unfitting. After due 
deliberation, considering all of the evidence and mindful of VASRD §4.3 (Resolution of 
reasonable doubt), the Board concluded that there was insufficient cause to recommend a 
change in the PEB adjudication for the bilateral 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 
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 back, right shoulder, and bilateral ankle 
conditions was operant in this case; these were adjudicated independently of that policy by the 
Board. In the matter of the back, right shoulder and bilateral ankle conditions, the Board is 
prohibited from lowering the PEB rating; therefore, the board unanimously recommends no 
change in the PEB adjudication. 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, as follows: 

 

UNFITTING CONDITION 

VASRD CODE 

RATING 

Chronic Pain, Mid and Low Back, Status-Post Compression 
Fracture, Right Shoulder (Pain) and Bilateral Ankles with Instability 

5299-5003 

10% 

RATING 

10% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120604, w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

 XXXXXXXXXXXXXXXXXXXXX, DAF 

 Acting Director 

 Physical Disability Board of Review 

 


SFMR-RB 


 

 

MEMORANDUM FOR Commander, US Army Physical Disability Agency 

(TAPD-ZB / xxxxxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 

 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for 
xxxxxxxxxxxxxxxxxxxxxxx, AR20130006866 (PD201200626) 

 

 

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 xxxxxxxxxxxxxxxxxx 

 Deputy Assistant Secretary 

 (Army Review Boards)