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AF | PDBR | CY2014 | PD-2014-01777
Original file (PD-2014-01777.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2014-01777
BRANCH OF SERVICE: Army  BOARD DATE: 20150318
SEPARATION DATE: 20080508


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2 (Infantryman) medically separated for multiple somatic complaints. The 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 L3 profile and referred for a Medical Evaluation Board (MEB). The “lumbar strain, cervical strain, right knee patellofemoral pain, left calcaneus stress fracture, and right calcaneus stress fracture” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded one other condition (Hepatitis C infection) for PEB adjudication. The Informal PEB (IPEB) adjudicated the “multiple somatic complaints” as unfitting due to overall effect c iting Department of Defense Instruction (DoDI) 1332.38 and rated it at 0%. The remaining condition was determined to be not unfitting. The CI appealed to the Formal PEB (FPEB) which affirmed the PEB findings and rating and was medically separated.


CI CONTENTION: “Please consider all 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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting. Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records. 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 (VASRD) standards to the unfitting medical condition at the time of separation. The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions. That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws. 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.


RATING COMPARISON :

FPEB – Dated 20080416
 VA* - ~4 months Post-Separation
Condition
 Code Rating Condition Code Rating Exam
Multiple Somatic Complaints 4000 0% Cervical Scoliosis, Chronic … 5237 10% 20080905
DDD L4-5 and L5-Sl 5242 10% 20080905
Right Knee Condition 5260 10% 20080905
Bilateral Heel Stress Fractures 5299-5284 NSC
Hepatitis C Infection Not Unfitting No VA Placement
Other x 0 (Not In Scope)
 Other x 0
RATING: 0%
 COMBINED RATING: 30%
* Derived from VA Rating Decision (VA RD ) dated 200 90116 (most proximate to date of separation [ DOS ] ) .


ANALYSIS SUMMARY: The PEB combined the back, neck, right knee, and bilateral calcaneus conditions under a single disability rating for “overall effect” as permitted by DoDI 1332.38 (E3.P3.4.4). The combination of multiple conditions as a single disability reflects the PEB’s determination that each condition was not separately unfit, but the functional impairment resulting from the conditions when considered together was unfitting. The Board’s initial charge in this case was therefore directed at determining if the PEB’s single overall effect rating was justified in lieu of separate unfit determinations and ratings. 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 as shown by a preponderance of evidence. The Board’s recommendations may not produce a lower combined rating than that of the PEB. The evidence for the back, neck, right knee, and bilateral calcaneus conditions are presented separately; with separate fitness determinations and rating recommendations if indicated.

Neck Pain. The initial narrative summary (NARSUM) was dated 29 January 2008, just over 3 months prior to separation. It recorded that while the CI was in physical therapy and rehab program for bilateral heel and right knee pain, he complained of both back and neck pain. He was treated with physical and chiropractic therapy as well as medications with good relief from the chiropractic treatment. Electrodiagnostic (EDX) studies had been performed 3 weeks earlier and were normal. Cervical spine X-rays were noted as normal other than mild right scoliosis. On examination, the neck muscles were tender to palpation. Motion was reduced to the left for side bend and rotation, but otherwise normal. The motor examination and reflexes were normal. The range-of-motion (ROM) on physical therapy (PT) on 1 February 2008 showed flexion, extension, and right lateral flexion which exceeded VA normal values, with limited motion for left lateral flexion and for rotation bilaterally, left worse than right. An updated NARSUM was dated 10 April 2008, a month prior to separation, and accomplished in orthopedics for the neck and back pain. He reported constant pain, but denied both radicular symptoms and incontinence. He had a normal gait and functionally, a normal ROM. There was no change with repetitive motion. He had mild tenderness over the left side of the neck. Compression of the neck (to elicit pain) was negative. The neurological examination was normal. Heel and toe walk were “without difficulty.” The examiner wrote that “examination of the patient reveals no significant objective pathology of the cervical or lumbar spine.” An MRI of the neck on 14 April 2008 revealed a disc bulge at C5-6. At the VA Compensation and Pension (C&P) exam performed 4 months after separation, the CI reported that he had injured his neck when he fell while carrying a soldier in training. He denied incapacitation. The ROM was noted to be painful and limited in flexion and to the left. The gait and neurological examination were normal.

The Board considered if the neck was separately unfitting. The CI was issued a U3 profile for neck strain and the MEB found that it failed retention standards. The commander’s statement only addressed the back. Both the IPEB and FPEB found the neck to be not unfitting as a separate condition. The orthopedic examination a month prior to separation found no “objective pathology.” The Board determined that the preponderance of evidence is not sufficient to overcome the PEB adjudication that the neck was not separately unfitting.

Back Pain. The first record for the low back pain (LBP) was dated 28 May 2007, 7 days after accession, when he hurt his back as he changed positions from pushups to flutter kicks. The CI subsequently had bilateral calcaneal (a heel bone) stress fractures and was placed on convalescent leave for 30 days. The CI was next seen on 24 August 2007 in PT. He reported that the LBP worsened with sitting. On examination, the ROM and gait were normal. The CI continued PT, but had persistent LBP. An X-ray on 6 September 2007 was significant for mild L5-S1 disc space narrowing. On 8 September 2007, he reported that he re-injured his back doing exercises (presumably for rehabilitation). The ROM was unrestricted and pain free with a normal gait and stance. He was referred to chiropractic therapy with some improvement in his pain. On 7 January 2008, EDX studies were normal. An MRI on 11 January 2008 showed mild degenerative disc disease (DDD) at L4-5. The initial NARSUM recorded that the back was tender to palpation, but the lumbosacral ROM was full with pain at the extremes of motion. It also noted that the CI developed back pain while performing “calf lifts” in the gym as part of his rehabilitation. Gait, stance, and neurological examination were normal. The ROM testing in PT on 1 February 2008 showed marked limitation in flexion, extension, lateral flexion, and left lateral rotation. The updated NARSUM recorded that the CI reported constant pain, but denied both radicular symptoms and incontinence. He had a normal gait and functionally, a normal ROM. There was no change with repetitive motion. He had mild tenderness over the left side of the neck. Compression of the neck (to elicit pain) was negative. The neurological examination was normal. Heel and toe walk were “without difficulty.” Review of a scoliosis (abnormal curvature of the spine to the left or right) was interpreted as non-significant for pathology. The examiner wrote that “examination of the patient reveals no significant objective pathology of the cervical or lumbar spine.” At the VA C&P examination performed 4 months after separation, the CI reported that he had injured his back when he fell while carrying a soldier in training. He denied incapacitation. The ROM was noted to be painful and minimally limited in flexion, extension, and left lateral rotation. The gait and neurological examination were normal.

The Board considered if the back was separately unfitting. The CI was issued a L3 profile for four conditions including back strain and the MEB found that it failed retention standards. The commander’s statement indicated that the back impaired duty. Both the IPEB and FPEB specifically found the back to be not unfitting as a separate condition. The orthopedic examination a month prior to separation found no “objective pathology.” The Board majority determined that the preponderance of evidence is not sufficient to overcome the PEB adjudication that the back was not separately unfitting.

Right Knee Patellofemoral Pain. The CI also began to have right knee pain early in basic training. An X-ray on 8 June 2007 was normal. At the initial NARSUM, the CI reported that he twisted his right knee while running. Flexion and climbing stairs produced pain along the lateral (outside) of the kneecap. The kneecap was tender to palpation and pressure over the kneecap was painful and had palpable crepitus (an abnormal crackling sensation). A sign of degeneration of the kneecap cartilage was also positive (Clarkes sign). The knee was stable and the ROM full and pain free. The gait was normal. At formal ROM testing in PT, flexion was slightly reduced on the right. The orthopedic NARSUM recorded a normal gait, ROM, and neurological examination. The CI was also able to toe and heel walk without difficulty. At the VA C&P examination, the CI reported that he had twisted his knee running up and down stairs in physical training. On examination, the knee was tender and the ROM reduced 10 degrees in flexion and painful. There was no instability present. The gait was normal.

The Board considered if the right knee was separately unfitting. The CI was issued a L3 profile for 4 conditions including the right knee and the MEB found that it failed retention standards. The commander’s statement indicated that only the back impaired duty. Both the IPEB and FPEB specifically found the right knee to be not unfitting as a separate condition. The gait was consistently normal and the ROM normal or near normal. Atrophy, indicative of disuse, was not recorded on any examination. The Board determined that the preponderance of evidence is not sufficient to overcome the PEB adjudication that the right knee was not separately unfitting.

Left Calcaneus Stress Fracture. The CI presented with a 4-day history of bilateral heel pain on 8 June 2007 and was noted to have tenderness on palpation. X-rays of both ankles were normal other than a single metallic pellet in the soft tissues of the lower left leg. A bone scan was ordered, but the CI did not initially get this accomplished as he did not want to be slipped in basic training. He was again directed to obtain this study which, on 13 June 2007, showed bilateral stress fractures of the calcaneus bone (heel bone). Repeat X-rays on 16 July 2007 showed a normal right heel and a healing stress fracture of the left calcaneus. An examination that day was remarkable for continued tenderness over the left heel. However, he had a normal gait without limping. He was placed on convalescent leave for 30 days with apparent resolution. After return to training, he again had pain secondary to activity as noted on the 22 August 2007 PT entry. Repeat X-rays of both feet on 5 October 2007 were normal. At the initial NARSUM, the CI reported continued bilateral heel pain with walking, after work, and when he awoke in the morning. Both heels were tender to palpation, but the ROM of the ankles, gait, and stance were normal. The orthopedic NARSUM recorded a normal gait, ankle ROM, and neurological examination. The CI was also able to toe and heel walk without difficulty. At the C&P examination, the CI reported that the heel symptoms had resolved. On examination, the gait was normal and the feet normal to examination. The condition was noted to be resolved.

The Board considered if the left calcaneus stress fracture was separately unfitting. The CI was issued a L3 profile for four conditions including the left and right calcaneus stress fracture and the MEB found that it failed retention standards. The commander’s statement indicated that only the back impaired duty. Both the IPEB and FPEB specifically found the left calcaneus stress fracture to be not unfitting as a separate condition. The gait was consistently normal and the ROM also normal. The after separation C&P examination noted resolution of the condition. The Board determined that the preponderance of evidence is not sufficient to overcome the PEB adjudication that the left calcaneus stress fracture was not separately unfitting.

Right Calcaneus Stress Fracture. The history for the right calcaneus stress fracture is address above. The Board considered if the right calcaneus stress fracture was separately unfitting. The CI was issued a L3 profile for four conditions including the left and right calcaneus stress fracture and the MEB found that it failed retention standards. The commander’s statement indicated that only the back impaired duty. Both the IPEB and FPEB specifically found the right calcaneus stress fracture to be not unfitting as a separate condition. The gait was consistently normal and the ROM also normal. The after separation C&P examination noted resolution of the condition. The Board determined that the preponderance of evidence is not sufficient to overcome the PEB adjudication that the right calcaneus stress fracture was not separately unfitting.

Contended Hepatitis C Infection. The Board’s main charge is to assess the fairness of the PEB’s determination that Hepatitis C was not unfitting. The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. The Hepatitis C condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards. It was reviewed and considered by the Board. There was no performance based evidence from the record that it significantly interfered with satisfactory duty performance. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended Hepatitis C condition and so no additional disability rating is recommended.


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 for rating purposes. The PEB specified application of DoDI 1332.38 for a determination of overall effect. The Board concluded that there was not a preponderance of evidence showing that any of the conditions (neck, back, right knee, and bilateral calcaneal stress fracture) standing alone would have caused the CI to be referred into the DES or be found unfit, and the Board therefore recommends no change in the PEB overall effect adjudication. In the matter of the contended Hepatitis C condition, the Board unanimously recommends no change from the PEB determination as not unfitting. 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 20140421, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record





XXXXXXXXXXXXXXX
President
DoD 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 XXXXXXXXXXXXXXX , AR20150014169 (PD201401777)

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                                                  XXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)
                                                     
CF:
( ) DoD PDBR
( ) DVA

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