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AF | PDBR | CY2013 | PD-2013-01720

Original file (PD-2013-01720.rtf) Auto-classification: Denied

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX CASE: PD-2013-01720
BRANCH OF SERVICE: Army BOARD DATE: 20141112

SEPARATION DATE: 20051112

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PFC/E-3 (91W10/Health Care Specialist) medically separated for chronic pain in multiple locations including bilateral peroneal tendon subluxation status post repair on the right, bilateral knee pain and right shoulder pain. These conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards. He was issued a permanent U3/L4 profile and referred for a Medical Evaluation Board (MEB). “Bilateral peroneal tendon subluxation,” “paraspinal muscular pain, cervical,” “bilateral retropatellar pain syndrome” and “right shoulder pain suggestive of tendinopathy,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB adjudicated “chronic pain in multiple locations including bilateral peroneal tendon subluxation status post repair on the right, bilateral knee pain and right shoulder pain” as single unfitting condition, rated 10%, refe rencing application of the US Army Physical Disability Agency (USAPDA) pain policy. The neck pain was determined to be not unfitting and therefore not rated. The CI non-concurred and upon reconsideration the PEB increased the rating to 20%. The CI concurred and withdrew his Formal PEB request and was medically separated with a 20% disability rating.

CI CONTENTION: “Was only rated for RT ankle, other conditions was not looked at by DOD. Depression, shoulder and knees was not rated for fitting conditions.”

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. The rating for the bundled bilateral peroneal tendon, bilateral knees and right shoulder are addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board. The contended depression was not identified by the PEB, and thus is not within the DoDI 6040.44 defined purview of the Board. The cervical condition, identified as not unfitting by the PEB, was not requested for review and thus is not within the defined scope. 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.

IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations. 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.

RATING COMPARISON :

Service Informal Recon – Dated 20050816	VA - (1 Mos. Pre-Separation)
Condition	Code	Rating	Condition	Code	Rating	Exam
Chronic Pain in Multiple Locations Including Bilateral Peroneal Tendon Subluxation s/p Repair on the Right, Bilateral Knee Pain and Right Shoulder Pain	5099-5003	20%	Patellofemoral Pain Syndrome, Right Knee	5099-5014	10%	20051017
			Right Shoulder Biceps Tendonitis	5099-5024	10%	20051017
			Peroneal Tendon Subluxation, Left Ankle	5099-5271	10%	20051017
			Surgical Residuals, Right Ankle	5099-5272	10%	20051017
Other x 0 (Not in Scope)	Other x 6
Rating: 20%	Combined: 60%

Derived from VA Rating Decision (VA RD ) dated 200 60215 ( most proximate to date of separation )

ANALYSIS SUMMARY:

Bilateral Peroneal Tendon Subluxation s/p Repair on the Right. The CI presented on 10 January 2003 with right ankle pain after a twisting injury. He was diagnosed with a right ankle sprain and treated with activity modification and anti-inflammatory medications. The CI was subsequently referred for physical therapy due to persistent ankle pain. A physical therapy note dated 4 March 2003, recorded right ankle pain level at 5/10 that’s constant and throbbing. The physical examination was significant for evidence of right ankle instability (positive anterior draw) and tenderness to palpation at the outside of the right ankle (lateral malleolus). The CI’s pain and ankle instability did not improve with casting, a lace up brace or physical therapy. A magnetic resonance imaging (MRI) study dated 19 July 2003 was suspicious for a peroneus tendon tear and probable anterior talofibular ligament tear. The CI underwent surgical repair of a right ankle peroneus brevis tendon tear. Six months after surgical repair, the CI continued to report right ankle pain, instability, and new onset left ankle pain. A MRI dated 30 January 2004 revealed a partial tear and tenosynovitis (inflammation of the tendon) of the lower portion of the peroneus longus and brevis tendons without tearing away from the bone. Diagnoses of right peroneal tenosynovitis, sural nerve entrapment, and hypertrophic right ankle scar were rendered. The CI underwent a second right ankle surgery and a course of physical therapy for bilateral ankle pain. Despite conservative and surgical intervention the CI’s bilateral ankle pain persisted.

The narrative summary addendum dated 24 June 2005 noted that the CI was wheelchair bound since June 2004. At the time of the examination he had progressed to crutch ambulation with reports of persistent right ankle pain. The physical examination demonstrated mild chronic skin changes over the right lateral malleolus without evidence of edema. The range-of-motion (ROM) was minimally decreased with a soft end point due to subjective pain. There was sensory loss at the site of the surgical scar, but no evidence of edema, atrophy, contracture or deformity. The examiner rendered a diagnosis of right ankle pain and instability.

At the VA Compensation and Pension (C&P) examination performed a month prior to separation, the CI reported constant, daily right greater than left ankle pain requiring continuous use of a brace on the right and brace support with vigorous activity on the left. The physical examination was significant for an antalgic gait and use of a cane. The right ankle examination demonstrated a tender, mildly raised right ankle surgical scar, swelling, tenderness to palpation, and pain limited motion. The left ankle was tender to palpation, snapping sensation of the tendons, and normal ROM.

The Board directs attention to its rating recommendation based on the above evidence. The PEB adjudicated the bilateral peroneal tendon subluxation status post repair on the right as part of a single unfitting condition with cited application of the USAPDA pain policy; 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. IAW DoDI 6040.44, if the PEB combined adjudication is not compliant with VASRD §4.71 and each condition can be reasonably justified as separately unfitting, the Board may recommend separate ratings for separately compensable joints 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. Although the right ankle required surgical intervention, multiple treatment records document bilateral tendon subluxation and ankle pain. Both ankles were implicated in the CI’s inability to ambulate without crutches. Both ankles were profiled. Because the disability associated with each ankle cannot be isolated by the clinical evidence, or segregated based on functional impairment; member consensus was that both ankles were separately unfitting. The Board determined that both ankles met the criterion of painful motion IAW VASRD §4.59, painful motion for a minimum rating of 10% each. The Board considered if there was evidence for a higher than 10% rating for each ankle. There was no evidence of marked ankle limitation of motion, ankylosis, or bony malunion for a 20% rating. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for each peroneal tendon subluxation condition, a combined rating of 20%.

Bilateral Knee Pain. The CI presented on 1 October 2004 with bilateral knee pain for a month. The CI reported he was wheelchair bound for several months due to bilateral ankle pain. In May 2005, an orthopedic consultation was requested. At the orthopedic MEB evaluation dated 17 May 2005 the CI reported an insidious onset of bilateral knee pain with popping. He denied instability. The examiner noted that the CI begun ambulating by crutches one month prior to presenting with knee pain. The physical examination demonstrated negative instability testing, negative patella laxity, and no tenderness to palpation. There was a positive grind test, left greater than right, for patellofemoral pain. A diagnosis of bilateral retropatellar pain syndrome was rendered. The examiner noted that a course of physical therapy and aerobic conditioning could result in improvement of the retropatellar pain.

The VA C&P examination was restricted to evaluation of the right knee. The right knee bursitis (pain) was noted to have been gradual in onset. On physical examination there was no evidence of swelling, effusion, or instability. There was tenderness to palpation along the lateral aspect of the patella with full active ROM with pain from 120-130 degrees. A diagnosis of right knee patellofemoral pain syndrome was rendered.

The Board directs attention to its rating recommendation based on the above evidence. The PEB adjudicated the bilateral knee pain as part of a single unfitting condition. The Board’s initial consideration was directed at determining whether each knee could be reasonably justified as separately unfitting in lieu of the PEB’s combined adjudication. The Board noted that the knee pain was profiled, but was not implicated in the commander’s statement. The CI was wheelchair bound and progressed to crutch ambulation; however there were few treatment notes related to knee pain. The orthopedic evaluation revealed minimal evidence of retropatellar knee pain and no evidence of instability. The VA examination evidenced painful, but full ROM. Members agreed that based on the above evidence there was a questionable basis for arguing that the bilateral knee condition separate from the bilateral ankle condition was separately unfitting. Members agreed, therefore, that the bilateral knee condition was not reasonably justified as separately unfitting; and, accordingly, it cannot be recommended for separate disability rating.

Right Shoulder Pain. The CI initially presented with acute right shoulder pain on 27 November 2004 while using his wheelchair. He was diagnosed with right shoulder strain and treated conservatively. In May 2005 an orthopedic consultation was requested for evaluation of right shoulder pain (rotator cuff ligament subluxation). At the orthopedic MEB evaluation dated 17 May 2005 the CI reported a gradual onset of right shoulder pain beginning in October 2004. He reported subluxation of the tendon; which the examiner noted was confirmed by physical therapy; and occasional tingling in the extremity. The pain was worse with overhead use and at night. The physical examination was positive for pathology of the bicep/labral complex (Speed Test) and mild pain at the acromioclavicular joint. There was full passive ROM without tenderness to palpation. A diagnosis of right shoulder pain suggestive of tendinopathy was rendered. The examiner noted that a course of physical therapy and aerobic conditioning would result in improvement of the shoulder pain. The VA C&P examination noted a diagnosis of right shoulder strain. The CI reported difficulty with torque movements and physical exercises such as push-ups. The physical examination demonstrated tenderness to palpation over the biceps tendon and full ROM with pain on internal rotation and abduction. Radiographic right shoulder impingement series evaluation was normal. A diagnosis of right shoulder biceps tendinitis was rendered.

The Board directs attention to its rating recommendation based on the above evidence. The PEB adjudicated the right shoulder pain as part of a single unfitting condition. The Board’s initial consideration was directed at determining whether right shoulder could be reasonably justified as separately unfitting in lieu of the PEB’s combined adjudication. The Board noted that the shoulder pain was profiled, but was not implicated in the commander’s statement. There were few treatment notes related to shoulder pain. The orthopedic examiner opined that targeted physical therapy and aerobic conditioning would result in improvement of the right shoulder pain. The VA examination evidenced painful, but full ROM. Members agreed that, based on the above evidence, there was a questionable basis for arguing that the right shoulder pain was separately unfitting. Members agreed, therefore, that the right shoulder pain condition was not reasonably justified as separately unfitting; and, accordingly, it cannot be recommended for separate disability rating.

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 in multiple locations including bilateral peroneal tendon subluxation status post repair on the right, bilateral knee pain and right shoulder pain was operant in this case and the conditions were adjudicated independently of that policy. Although the Board majority determined each ankle was separately unfitting, the Board concluded there is no benefit to the CI in unbundling the conditions as separate ratings would not result in a higher than 20% disability rating. Therefore, in the matter of the chronic pain in multiple locations including bilateral peroneal tendon subluxation status post repair on the right, bilateral knee pain and right shoulder pain condition, 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 re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131022, 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, AR20150005538 (PD201301720)

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

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AF | PDBR | CY2013 | PD-2013-01720

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