53

Returning to Duty After Major Limb Loss and the US Military Disability System

Chapter 4

RETURNING TO DUTY AFTER MAJOR 

LIMB LOSS AND THE US MILITARY 

DISABILITY SYSTEM

JEFF GAMBEL, MD*; ERIC DESSAIN, MD†; PAUL FOWLER, DO, JD‡; ANDREW RHODES, DO§; and MARIA MAYORGA, MD¥

INTRODUCTION

RETURNING TO DUTY

Factors Involved 

US Army Process

PHYSICAL DISABILITY EVALUATION SYSTEM 

Overview

Medical Evaluation Board

Medical Military Occupational Specialty Retention Board

Physical Evaluation Board

Continuation on Active Duty 

RETIREMENT AND DISABILITY COMPENSATION

VETERANS AFFAIRS BENEFITS

WAY FORWARD

SUMMARY

*

Colonel, Medical Corps, US Army; Physician, Department of Orthopaedics and Rehabilitation, Walter Reed Army Medical Center, 6900 Georgia Avenue, 

NW, Washington, DC 20307

†

Lieutenant Colonel, Medical Corps, US Army; Physician, Chief, Physical Disability Evaluation Service, Walter Reed Army Medical Center, 6900 

Georgia Avenue, NW, Washington, DC 20307

‡

Senior Medical Evaluation Board Disability Advisor; Physician-Attorney, Command Group, Walter Reed Army Medical Center, 6900 Georgia Avenue, 

NW, Washington, DC 20307

§

Captain, Medical Corps, US Army; Physician, Medical Evaluation Board, Physical Disability Evaluation Service, Walter Reed Army Medical Center, 

6900 Georgia Avenue, NW, Washington, DC 20307

¥Colonel (Retired), Medical Corps, US Army; Physician, Past Chief, Physical Disability Evaluation Service, Walter Reed Army Medical Center; Currently, PhD Candidate, Sweden 
54

Care of the Combat Amputee

INTRODUCTION

In recent decades, returning to duty after major limb 

loss has been a rare event in the US military. Today’s 

military service member who wishes to remain on 

active duty after major limb loss commonly finds a 

more receptive atmosphere, if not strong encouragement from his or her chain of command. This support 

is well-founded given advances in amputee care that 

make it possible for such service members to effectively 

meet and exceed rigorous performance standards for a 

wide range of military occupations. This chapter will 

describe some of the key factors that service members 

with major limb loss and their families might consider 

when deciding whether to pursue return to duty or 

transition into civilian life. The military disability system, with the US Army’s system as the prime example, 

will also be described.

RETURNING TO DUTY

Factors Involved

The severity of limb loss, as well as the nature and 

extent of associated injuries, has a dramatic impact on 

an injured service member’s ability to return to active 

military duty. History has many examples of soldiers 

with major limb loss returning to active duty, including the Invalid Corps of the Union Army during the 

US Civil War1 and approximately 1,500 World War II 

veterans who were recalled to active duty to support 

the Korean War.2 While serving as junior officers in 

Vietnam, General (Retired) Eric Shinseki (a partial 

foot amputee) and General (Retired) Frederick Franks 

(a transtibial [below-knee] amputee) suffered major 

limb loss, yet retired after full active duty, reaching 

the highest positions of leadership in the US Army.3

Despite these examples, a study by Kishbaugh et al4

found that only 11 of 469 US soldiers with limb loss 

(2.3%) returned to duty in the 1980s, with amputation 

levels including partial foot, partial hand, and transtibial. More recently, during the global war on terror 

(GWOT), injured service members from Afghanistan 

and Iraq with more proximal levels of amputations, 

including transfemoral (above-knee) and transradial 

(below-elbow), have remained on active duty and continue to serve successfully.5 From the onset of GWOT 

through 2008, approximately 17% to 20% of injured 

service members with major limb loss, across all US 

military services, have completed their respective 

medical board process and been retained on active 

duty or reserve status.6,7

Many factors associated with the traumatic event 

(commonly a blast injury) responsible for the amputation can make healing and realistic decision-making 

about return to duty more complex. Some of these 

factors include complications with the healing limb,8

multiple limb loss, ongoing residual limb (stump) pain, 

uncomfortable and limited prosthetic use, decreased 

functional abilities,9 traumatic brain injury, delayed 

psychological adjustment to limb loss,10 and impaired 

confidence in one’s ability to resume normal-life activities (self-efficacy).11

Traits characteristic of amputees who seek to remain 

on active duty include strong individual motivation for 

continued military service, anticipated ability to meet 

the performance standards of their military occupational specialty (MOS), solid support from close family 

members and friends, and possession of highly valued 

military-specific skills. In addition, service members 

most likely to return to duty are those who had strong 

service records prior to injury and can expect robust 

unit and command backing, especially after a trial of 

duty with their previous unit. It is particularly helpful if the unit has special MOS-related needs that the 

service member can fill. Also, service members are 

usually wise to remain flexible, with the willingness to 

consider the possibility of training in another MOS that 

can better match their current abilities with a valued 

military job. Amputee service members report that 

speaking with peer amputee visitors and veterans who 

have personal experience with the return-to-duty process provides helpful information to guide their own 

decision making.12 The Web addresses of organizations 

with useful resources for injured service members are 

listed in Table 4-1.

US Army Process

In the US Army, many injured soldiers, especially 

those returning from overseas, are either assigned or 

attached to a medical holding company such as the 

one at Walter Reed Army Medical Center while recovering from their injuries. More recently, such units 

have been called warrior transition units (WTUs). The 

WTU acts as the medical and administrative facilitator 

between the hospital clinicians and the physical evaluation board liaison officer. The WTU further ensures 

administrative accountability for all soldiers receiving 

care by assigning a case manager or social worker to 

support them and their families. The range of support 
55

Returning to Duty After Major Limb Loss and the US Military Disability System

TABLE 4-1

WEB SITE ADDRESSES OF ORGANIZATIONS HELPFUL TO INJURED SERVICE MEMBERS

Activity Internet Address

US Army Publication Directorate www.apd.army.mil

Walter Reed Army Medical Center www.wramc.amedd.army.mil

Amputee Coalition of America www.amputee-coalition.org

Department of Veterans Affairs www.index.va.gov

Disabled Soldier Support System www.ArmyDS3.org

Disabled American Veterans www.dav.org

Paralyzed Veterans of America www.pva.org

Veterans of Foreign Wars www.vfw.org

American Legion www.legion.org

Military Order of the Purple Heart of the USA www.purpleheart.org

American Veterans www.amvets.org

National Amputation Foundation www.nationalamputation.org

National Military Family Association www.nmfa.org

Combat Related Special Compensation www.crsc.org

Physical Disability Agency www.hrc.army.mil/site/active/tagd/pda/pdapage.htm

provided includes logistics (lodging), pay and allowances, convalescent and ordinary leave, and military 

orders. The WTU team of professionals makes certain 

that patients receive timely clinical appointments 

and that all required administrative documentation 

is properly processed.

The WTU also serves as a coordinator between the 

soldier and the transition office. The transition office 

prepares the discharge document, DD214, which 

verifies all periods of military service and character 

of discharge. The DD214 is required for Department 

of Veterans Affairs (VA) benefits to begin. In most 

situations, the soldier’s transition out of the unit, and 

ultimately out of the Army, involves an administrative 

process that may take weeks, up to several months. For 

those who are able to return to duty, new orders will 

direct the soldiers to their next duty station. The length 

of time a soldier remains with the WTU depends upon 

his or her unique healthcare situation, individual resources, support system, and administrative needs.

PHYSICAL DISABILITY EVALUATION SYSTEM

Overview

Each branch of the Department of Defense (DoD) 

has specific standards by which it determines whether 

or not an injured or ill member will be continued on 

active duty, based upon the severity of the condition 

and the imposed functional limitations. The ensuing 

text will focus on the US Army physical disability 

evaluation system (PDES), and specifically the active 

duty soldier with major limb loss who must navigate 

the system. The rules and regulations for the reserve 

soldier, in relation to disability compensation, are different than those for the active duty soldier. However, 

in terms of the medical evaluation mechanics, once entered into the PDES, active duty, reserve, and National 

Guard soldiers all flow through the Army disability 

system in the same manner.

For example, soldiers with major limb loss may be 

medically retired from the US Army for a physical 

impairment if it renders them physically unfit for duty. 
56

Care of the Combat Amputee

Fitness for duty is evaluated as a function of the reasonably expected ability to perform the duties of the soldier’s 

primary MOS.13(p14) To get to this point, the Army must 

utilize the medical evaluation board (MEB) and physical 

evaluation board (PEB). The MEB determines “retention,” 

per Army Regulation (AR) 40-501, Chapter 3.14 The PEB 

determines “fitness,” based upon MOS. This distinction 

is extremely important, because the medical treatment 

facility (MTF) does not and should not comment on the 

“fitness” of a soldier, but rather whether the amputee 

meets retention standards, regardless of MOS, based 

solely on AR 40-501, Chapter 3.14 

If the soldier’s medical condition could potentially 

be found to not meet the medical retention standards, 

as outlined in AR 40-501, Chapter 3, it is the treating 

physician’s responsibility to refer the soldier to the 

MEB. The MEB physician, who receives specialized 

disability training, then reviews all clinical and administrative evaluations. The MEB physician (civilian 

or military) is directly employed by or assigned to 

the MTF, working under the authority of the MTF 

commander, through the deputy commander for 

clinical services. The MEB physician’s key role is to 

determine whether or not the referred soldier’s medical conditions meet the retention standards of AR 

40-501, Chapter 3, regardless of MOS. If the soldier 

fails to meet retention standards and cannot satisfactorily perform his or her military duties, he or she 

is referred to the PEB. The PEB, under the authority 

of the US Army Physical Disability Agency, which 

manages the Army’s PDES and acts on behalf of 

the secretary of the Army, will consider the recommendations of the MEB and make the determination 

of fitness or unfitness, rendered with the soldier’s 

MOS in mind.14

Developing and implementing a system to best 

benefit the soldier, while providing for the overall 

good of the Army, whose “paramount mission is 

to maintain a fit fighting force,” is a difficult and 

daunting endeavor.15 A pilot program was established in November 2007 to streamline the process, 

improve overall customer satisfaction, and rely on 

the VA for disability rating purposes.16 This joint 

effort was born out of the President’s Commission 

on Care for America’s Returning Wounded Warriors [Dole-Shalala], which provided an “agenda 

for moving forward.”17 The goal of the pilot is to 

streamline and improve the disability evaluation 

process by providing one medical examination and 

a single-sourced (VA) disability rating, making for 

a seamless transition from the care, benefits, and 

services of the DoD to the VA system, measured by 

customer satisfaction (Figure 4-1).16 The PDES Joint 

Pilot Program was first put into practice at the three 

Washington, DC-area triservice facilities: Walter 

Reed Army Medical Center, National Naval Medical 

Center, and Malcolm Grow Medical Center. The plan 

has been to expand the pilot program throughout the 

DoD, worldwide. Army-wide rollout of the pilot has 

begun with Fort Meade, Maryland, and Fort Belvoir, 

Virginia, on October 1, 2008. 

Medical Evaluation Board

Current Legacy System

To understand the Army’s proposed changes to the 

PDES, a closer look at the legacy system is necessary. 

Currently, an Army infantry soldier with major limb 

loss found by the MEB to not meet retention standards 

is referred to the PEB for a fitness determination. When 

the PEB determines that the limb loss renders the 

soldier unfit for his or her infantry MOS, a disability 

rating is generated by the PEB using the VA Schedule 

for Rating Disabilities (VASRD).15 Soldiers who receive 

at least a 30% disability rating from the Army, which 

is often the case with major limb loss, and do not want 

to continue in service are medically retired, either 

temporarily or permanently.15

For the now retired soldier to receive disability 

compensation from the VA with the same limb loss 

diagnosis already rated by the Army, he or she must 

restart the medical evaluation process with a new set 

of clinical examinations by the VA medical providers. 

After reexamination, the VA, using the same VASRD 

criteria used by the Army, rates the soldier’s serviceconnected disability, often at a higher percentage. 

Soldiers may be left wondering (a) why they received 

two separate and different ratings, one from the Army 

and one from the VA, for the same impairment, and 

(b) why the process takes so long. These two problems 

with the legacy system deserve further discussion. 

First and foremost, the legacy system allows for a 

discrepancy in the final disability rating, rendered by 

both the Army and the VA, irrespective of one another, 

on the exact same diagnoses. The primary reason for 

this discrepancy is that the two departments follow 

different rules. The Army is tasked with rating each 

diagnosis that the MEB found “unacceptable” or “not 

meeting retention standards” and the PEB also found 

“unfitting,” preventing the soldier’s performance 

within his or her specific military job training.15 Furthermore, the Army rates an “unfitting condition for 

present level of severity,” much like a snapshot of 

the soldier’s condition, at the time the MEB is conducted.15 The VA, on the other hand, rates any and 

all “service-connected conditions,” keeping in mind 

future progression of the disease or injury process, 
57

Returning to Duty After Major Limb Loss and the US Military Disability System

Figure 4-1. Disability evaluation system Joint Pilot Program timeline overview. This graphic is part of the mass briefing 

provided to WTU members at Walter Reed Army Medical Center by the physical evaluation board liaison officer. Note that 

the treating physician, who generates the permanent “3” or “4” profile, which initiates the PDES, is distinct from the MEB 

physician, who administratively helps process the MEB.

AC: active component

DES: disability evaluation system

DoD: Department of Defense

MEB: medical evaluation board

PDES: physical disability evaluation system

PEB: physical evaluation board

RC: reserve component

VA: Veterans Administration

1

Reserve component member entitlement to VA disability compensation begins upon release from active duty or separation.

with respect to the condition’s “adverse impact on 

employability within the civilian job sector.”15 These 

distinctions in laws and regulations allow for significantly different rating values. The final disability 

rating is expressed as a percentage rating between 

0% and 100%, resulting from all types of diseases 

and injuries encountered as a result of, or incident 

to, military service.18

Second, the legacy MEB/PEB process may involve 

considerable delays for soldiers and their families. 

For soldiers suffering from multiple and complex 

“unacceptable” conditions, each requiring a disability evaluation from a separate MTF specialty clinic, 

delays become inevitable. US Army Physical Disability Agency guidance requires that the disability 

evaluations of unacceptable conditions be performed 

no more than 6 months (30–45 days for psychiatric 

conditions) before submission to the PEB.19 If the MTF 

disability evaluation of an unacceptable condition 

extends beyond the 6-month window before the case 

reaches the PEB, the soldier needs to be seen again 

by the particular MTF specialty clinic for an updated 

assessment and comment on whether or not the 

condition remains unacceptable. This reevaluation, 
58

Care of the Combat Amputee

a repeat of clinical work, places a tremendous strain 

on the specialty clinics.

Proposed Pilot System

Regardless of whether they enter the pilot program 

or remain in the legacy system, wounded soldiers 

returning from the battlefield are assessed by their 

inpatient treatment team prior to discharge from the 

hospital. During transition to the outpatient setting, 

the soldiers are placed into an established WTU to be 

cared for safely outside the hospital, since they are 

not well enough to return to their units. A physicianmember of each soldier’s interdisciplinary treatment 

team, serving as a competent medical authority, must 

determine whether the soldier’s conditions are medically stable.20 Once medically stable, the soldier may 

be considered for referral to the MEB. For referral, 

the soldier must have a permanent “3” or “4” profile.20 A “3” designator signifies that the individual 

has “significant limitations”; whereas a “4” indicates 

that his or her “physical defects are to such a severity 

that performance of military duty must be drastically 

limited.”14(ch7) For PDES purposes, the “3” and “4” 

designators are synonymous, meaning the soldier will 

not receive additional disability benefit in having a 

permanent “4” versus a permanent “3.” 

Once the permanent profile has been generated by 

the treating physician and signed by the designated 

approving authority, the soldier is recommended for 

referral into the Joint Pilot Program.21

An MEB physician reviews the permanent profile 

and ultimately determines if the soldier is a suitable 

candidate for entry into the pilot program, based on a 

completely new referral standard:

When a competent medical authority determines a 

service member has one or more condition(s) which is 

suspected of not meeting medical retention standards, 

he or she will refer the service member into the DES at 

the point of hospitalization or treatment when a member’s progress appears to have medically stabilized 

(and the course of further recovery is relatively predictable) and when it can be reasonably determined that 

the member is most likely not capable of performing 

the duties of his office, grade, rank, or rating. Referral 

will be within 1 year of being diagnosed with a medical condition(s) that does not appear to meet medical 

retention standards, but may be earlier if the examiner 

determines that the member will not be capable of 

returning to duty within 1 year.20

A condition is unstable when it has the potential, 

within 1 year of treatment intervention, to improve 

to such a degree that the soldier meets medical retention standards.19 Examples of treatment interventions 

are condition-improving surgery or medication titrations, warranting a trial of duty prior to stabilization 

determination. If the MEB physician believes that a 

medical treatment intervention may improve the soldier’s condition to such a degree that he or she will 

meet retention standards, then the soldier should be 

maintained on a temporary profile, valid for 3 months, 

and extendable up to 12 months, prior to consideration 

of permanency.14(ch7) The MEB physician must review 

all conditions for determination of medical stability 

before the soldier enters the MEB pilot program. Under 

no circumstances should any soldier with major limb 

loss be issued a permanent profile within 4 months of 

the amputation, per AR 40-501, Chapter 3.14

In a hypothetical example of the DES process, a male 

soldier with a right above-knee (transfemoral) amputation has had his permanent “3” profile reviewed 

by the MEB physician, and is ready for the pilot program MEB entry. The soldier meets with his assigned 

physical evaluation board liaison officer (Figure 4-2), 

who helps the soldier navigate through the disability 

process, helping him understand the procedural intricacies of the PDES. Next, the soldier is scheduled 

for medical evaluation with the VA clinical examiners 

at the regional VA facility. The VA examiners evaluate all conditions claimed by the soldier as well as all 

chronic conditions and those that have the potential 

to render the soldier militarily unfit.22 After the VA 

clinical examinations, VA worksheets are generated to 

Figure 4-2. PEBLO counseling session: Mr Aaron Clemmons 

(left), Senior PEBLO, meets with SSG Juan Roldan to review 

all MEB administrative documents and answer procedural 

questions, prior to forwarding MEB case file to the PEB.

MEB: medical evaluation board

PEB: physical evaluation board

PEBLO: physical evaluation board liaison officer
59

Returning to Duty After Major Limb Loss and the US Military Disability System

Figure 4-3. MEB physician encounter: Dr Andrew Rhodes, 

CPT, MC, USA (center), resolves discrepancy in soldier’s 

medical record by examining SSG Juan Roldan (left), with 

consultation from Dr Eric Dessain, LTC, MC, USA (right), 

Disability Evaluation Service Chief, before finalizing the 

DoD/VA consolidated narrative summary.

DoD: Department of Defense

MEB: medical evaluation board

VA: Department of Veterans Affairs

document focused subjective complaints and objective 

findings, resulting in a final diagnosis for each claimed 

condition. The worksheets are returned to the MEB 

physician, who then prepares a consolidated narrative 

summary (NARSUM). The NARSUM must resolve 

any inconsistencies between the soldier’s electronic 

medical record and the VA worksheets (Figure 4-3). 

The NARSUM also provides the physician with the 

opportunity to comment on each VA-generated diagnosis, with respect to whether or not the soldier meets 

retention standards, per AR 40-501, Chapter 3. 

In generating the consolidated NARSUM, it is 

important that the MEB physician is knowledgeable 

about retention standards.14 In the case of the soldier 

with an above-knee amputation, the MEB has no discretion; it must find that the soldier does not meet retention standards, per AR 40-501, Chapter 3, paragraph 

13a(1b).14 Paragraph 12a lists the specific impairment 

criteria for upper extremity limb loss.14

After the soldier with the above-knee amputation 

has returned from the VA and met with the MEB physician to review his consolidated NARSUM, his case 

is then officially referred to the MEB, an all-physician 

panel of at least two doctors, who review the entire case 

and make the final determination as to whether or not 

the soldier’s conditions meet retention standards, per 

AR 40-501, Chapter 3.14,23 The membership composition 

of the MEB, PEB, and medical MOS retention board 

(MMRB) is the same, regardless of whether the MTF 

is involved in the pilot program. Soldiers found by 

the MEB to have conditions that do not meet retention 

standards are referred to the PEB for determination 

of fitness.

Soldiers who do not agree with MEB findings have 

a new option for further evaluation. A policy memorandum, issued by the under secretary of defense 

on October 14, 2008, describes the possibility of an 

independent medical review of MEB findings, prior 

to submission to the PEB:

E3.P1.2.6.1.2. Upon request of a Service member referred into the DES, an impartial physician or other 

appropriate health care professional (not involved 

in the Service member’s MEB process) is assigned 

to the Service member to offer a review of the medical evidence presented by the narrative summary or 

MEB findings. In most cases, this impartial health 

professional should be the Service member’s primary care manager (PCM). The impartial health professional will have no more than 5 calendar days to advise the Service member on whether the findings of 

the MEB adequately reflect the complete spectrum 

of injuries and illness of the Service member.

. . .

E3.P1.2.6.1.3. After review of findings with the assigned impartial health care professional, a Service 

member shall be afforded an opportunity to request a 

rebuttal of the results of the MEB. A Service member 

shall be afforded 7 calendar days to prepare a rebuttal 

to the convening medical authority. The convening 

medical board authority shall be afforded 7 calendar 

days to consider the rebuttal and return the fully documented decision to the Service member...The fully 

documented rebuttal will be included with the MEB 

information sent to the PEB.24

Medical Military Occupational Specialty Retention 

Board 

There are a few instances in which a soldier with 

limb loss can meet retention standards, including the 

loss of toes or fingers. In the case of amputated toes, 

to fail to meet retention standards, the impairment 

must preclude the soldier’s “abilities to run or walk 

without a perceptible limp and to engage in fairly 

strenuous jobs,” as listed under 3-13a(1a).14 In the 

case of lost fingers, to be considered as not meeting 

retention standards, the loss must be greater than or 

equal to: “a) a thumb proximal to the interphalangeal 

joint; b) two fingers of one hand, other than the little 

finger, at the proximal interphalangeal joints; [or] c) 

one finger, other than the little finger, at the metacarpophalangeal joint and the thumb on the same hand at 
60

Care of the Combat Amputee

the interphalangeal joint,” as defined under 3-12a(1ac).14 An infantry soldier missing the trigger and little 

fingers on the same hand, resulting from a traumatic 

blast injury, is by regulation, if no other impairments 

exist, still able to meet retention standards.14 Since this 

soldier requires “significant functional limitations,” 

specifically being unable to fire a weapon, the soldier 

is issued a permanent “3” profile. However, because 

the soldier meets retention standards, he or she should 

be referred to an MMRB.14(ch7)

Soldiers may be referred to an MMRB if they have 

at least a permanent “3” designator for a condition 

that meets retention standards.14(ch7) The MMRB has the 

option of returning the soldiers to their units, placing 

them on medical probationary status, reclassifying 

them into another MOS, or referring them to the MEB.25

The MMRB consists of five members, some voting 

and some nonvoting. The voting members include 

a colonel, either in combat arms, combat support, or 

combat service-support, serving as president; a field 

grade Medical Corps officer or MTF commanderdesignated civilian medical doctor; and an additional 

voting member who, if possible, is in the same branch, 

specialty, or primary MOS as the soldier appearing 

before the board.25 The nonvoting members are a 

personnel advisor and recorder.25 Treating physicians 

should be familiar with the options available for their 

injured soldiers. 

Physical Evaluation Board

The Army PEB is composed of three voting members: a colonel, serving as the board president; a field 

grade personnel management officer; and a senior 

physician, either a Medical Corps officer or an Army 

civilian doctor.24 The PEB first meets informally, 

meaning the soldier is not present, and also that the 

recommendations made at this meeting may later be 

changed. The three board members determine fitness 

by majority vote, taking into consideration the following: clinical evidence presented in the soldier’s MEB; 

performance standards of the soldier’s primary MOS; 

and the soldier’s personnel records, including but not 

limited to his or her record brief, evaluation reports, 

and commanders’ statements.15 Under the pilot program, the PEB records its informal factual findings 

for each diagnosis, along with its recommendation 

for fitness determination, on DA Form 199 (Election to 

Formal Physical Evaluation Board Proceedings).15 No 

rating determinations appear on Form 199; rather, for 

those conditions labeled as unfitting, the form has an 

explanation of the condition followed by a qualifier, 

signifying that the rating generated for the unfitting 

condition is to be completed by the VA. The VA rating board then evaluates the soldier’s referred and 

claimed conditions, providing a rating percentage 

with rationale to the PEB within 15 calendar days of 

notification by the PEB that a soldier is unfit.22 At this 

time, the soldier must request a copy of his or her VA 

rating for each claimed condition (generated by a VA 

regional office).22 

In the pilot program, the Army is bound by the 

VA rating for those conditions found to be unfitting. 

In other words, if the Army finds the soldier unfit 

for a particular condition, the rating for that condition is determined by the rating provided by the 

VA.22 For example, the soldier with the right aboveknee amputation, whose only condition is major 

limb loss, is found to not meet retention standards, 

per AR 40-501, Chapter 3, Paragraph 13a(1b).14 The 

soldier’s primary MOS is 11B, infantry. He is found 

unfit for service, based on his injury and inability to 

satisfactorily perform the duties within his primary 

MOS. A soldier is physically unfit when a medical 

impairment prevents reasonable performance of the 

duties required of the soldier’s office, grade, rank, or 

rating.15 In this example, the soldier’s residual limb 

length, as measured from the perineum, is found to 

be one-third of the distance from perineum to knee 

joint, when compared to the left, unaffected side. Thus, 

the right above-knee amputation transects the upper 

third of the femur bone. Per disability code 5161, as 

found in the VASRD, the VA rates his condition at 

80% disability.18 Under the pilot program, the Army 

is now bound by this 80% disability rating, whereas 

in the legacy disability system, the Army provides a 

disability rating independent of the VA rating. 

After the informal PEB has convened and rendered 

DA Form 199, the soldier is entitled to governmentappointed legal counsel (if not already obtained24) and 

has the following election options: (a) concur with the 

informal findings and recommendations; (b) request a 

formal administrative hearing, either with or without 

a personal appearance; or (c) nonconcur and submit 

a written appeal in lieu of proceeding with a formal 

board.15 The formal PEB is administrative, fact-finding, 

and nonadversarial, meaning no government representative appears to oppose or counter the soldier’s 

position at the hearing.15 Because the informal PEB 

recommendations may be changed, the soldier may 

be found fit with a condition previously considered 

unfitting. Soldiers typically request a formal hearing 

to argue that conditions found to be fitting should be 

reconsidered as unfitting. Also, some soldiers found 

unfit for service request a formal hearing to argue that 

they are fit for duty, based upon duty performance, as 

substantiated by their chain of command.15 Thus, before a soldier requests a formal hearing, it is extremely 

important for him or her to understand the VA rating, 

which will ultimately drive the subsequent Army dis-
61

Returning to Duty After Major Limb Loss and the US Military Disability System

ability disposition. 

The end result is that the soldier receives a disability 

rating from the VA and a disability disposition from 

the Army. The VA rates all claimed service-connected 

conditions based upon its evaluations. The Army 

renders a disposition of the soldier, based upon the 

VA rating, for those conditions found unfitting by 

the PEB. If the soldier has less than 20 years of active 

federal service and reaches at least a 30% disability 

rating, the Army may place the soldier on either permanent disability retirement (PDR) or the temporary 

disability retirement list (TDRL). PDR applies when 

the soldier’s condition is stable and not expected to 

improve or deteriorate in the next 18 months. TDRL 

applies to those conditions where the converse is 

believed to be clinically true: the condition will likely 

change in the next 18 months.15 Soldiers on the TDRL 

are reexamined at 12 to 18 months following Army 

discharge. The soldier can be maintained on TDRL 

for a maximum of 5 years, with reexaminations at the 

3- and 5-year marks, if the condition remains unstable 

and continues to meet the minimum criteria for at least 

a 30% rating.15 If the soldier’s unfitting condition has 

not stabilized in 5 years, the PEB will provide a disability rating based upon the level of severity at that 

point in time.15 The legacy disability system applies to 

the TDRL, in that the reevaluations are conducted at 

the MTF and the disability rating can be adjusted by 

the PEB, independent of the VA. 

Soldiers who are found unfit by the PEB but receive 

a combined VA rating of less than 30% for their serviceconnected conditions are separated with a one-time, 

lump-sum, severance payment.15 The exact disability 

rating, whether 0%, 10%, or 20%, makes no difference 

in the calculation of severance pay. The disability 

severance payment amount is calculated by doubling 

the soldier’s monthly basic pay, multiplying it by the 

number of combined years of federal service (not to 

exceed 12 years), and then adding this number to the 

inactive duty points, per AR 635-40, Appendix C.

Continuation on Active Duty 

The Army provides an administrative procedure—

continuation on active duty (COAD)—to determine 

whether or not the unfit soldier suffering major limb 

loss should be continued on active duty. The study 

by Kishbaugh et al,4 which found that only 2.3% of 

soldiers in the 1980s remained on active duty after 

amputation, did not discern whether the soldiers remaining on active duty were found fit or were granted 

a continuation on active duty. However, it is important 

to note that none of the 79 soldiers with above-knee 

amputations were retained on active duty.4 “Soldiers 

with hand and/or finger amputations (54.5%) constituted the majority of the return-to-duty group, with 

the remainder made up of foot and/or toe amputees 

(27.3%) and below-knee amputees (18.2%).”4 

Over the past year, all soldiers with combat-related 

limb loss referred by the Walter Reed Army Medical 

Center MEB who failed to meet retention standards 

(per AR 40-501, Chapter 3) were found unfit. AR 

635-40, Chapter 6, prescribes the criteria by which 

soldiers with major limb loss who have been found 

unfit by the PEB may be continued on active duty or 

on active reserve status.13(ch6)

In the example of the active duty soldier with 

above-knee amputation, to be considered for COAD, 

he must meet one of the following criteria:

• have 15, but less than 20, years of active federal service, or 

• be qualified in a critical skill or shortage 

MOS, or

• possess a disability resulting from combat or 

terrorism. 13(ch6)

Per Army Regulation, the soldier does not have 

an inherent or vested right to continuation on active 

duty; the primary objective of the COAD program is to 

conserve personnel by effective use of needed skills or 

experience. 13(ch6) If approved by the Human Resources 

Command, the COAD for soldiers with major limb loss 

lasts for any period of time up to the last day of the 

month in which they obtain 20 years of active federal 

service. 13(ch6) If the disability precludes continuation 

in a limited duty status within the soldier’s current 

primary MOS, the soldier may request reclassification 

into another MOS, listing three alternatives, in order of 

preference.13(ch6) A soldier approved for COAD longer 

than 6 months is referred to the PDES before the continuance expires.13(ch6) During the final PDES evaluation, 

soldiers whose disabilities have healed or improved to 

such a degree that they are capable of performing their 

primary MOS may be found fit; however, the ability 

to perform duties with prostheses does not constitute 

healing or improvement of a soldier’s condition for 

purposes of a fit finding. 13(ch6)

RETIREMENT AND DISABILITY COMPENSATION

Soldiers considering a return to duty should clearly 

understand the nuances of a COAD and reaching regular/longevity retirement after a minimum of 20 years 

of active duty service. If a COAD is approved and the 

soldier retires after at least 20 years, the soldier must 

be reevaluated with a new MEB at the time of retire-
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Care of the Combat Amputee

¢ a special adaptive housing grant (up to 

$50,000),

¢ an automobile grant (up to $11,000),

¢ automobile adaptive equipment,

¢ annual clothing allowance, and

¢ aide and attendant’s care.

ment or separation. The same applies for soldiers with 

an approved continuation on active reserve (COAR) 

and 20 qualifying years for reserve retirement. The 

final MEB/PEB does not affect longevity retirement 

benefits, to which every soldier with over 20 years of 

service is entitled. However, the percentage of retirement pay may be increased because of a disability 

causing unfitness for duty, and receipt of additional 

VA disability compensation as well as potential taxfree military retirement monies may be affected, as 

described below.

Retired amputee service members may be eligible to 

receive both military retirement and VA disability compensation (known as concurrent receipt [CR]), if they 

are found by a PEB to have at least 30% disability, or 

if their COAD or COAR is approved and they qualify 

for longevity retirement. A longevity retirement, which 

requires completion of at least 20 years of active duty 

service, or 20 years of accumulated required retirement points for reserve or National Guard service, 

is the basis for either CR or combat-related special 

compensation (CRSC). Service members may also be 

eligible for CR if they have over 20 years of active duty 

service and are retiring because of disability, without 

ever having a COAD or COAR. 

Military retirement pay is taxable income unless the 

soldier’s injuries are combat-related as determined by 

the PEB. All VA benefits are nontaxable. Current law 

requires that military retirement pay (taxable income) 

be reduced dollar-for-dollar for each dollar of VA compensation (nontaxable income) paid. However, CR and 

CRSC are designed to replace that offset. To qualify for 

CR, a veteran must retire with 20 or more years of service and be rated with a 50% or more service-connected 

disability by the VA. CR increases taxable retirement 

pay, but not nontaxable VA compensation. Payment 

of CR is automatic for qualified retirees; however, the 

benefit is being phased-in over a 10-year period, and 

full CR will not be achieved until January 2014. CRSC 

is a DoD program designed to correct the offset when 

all or some of the service-connected conditions are the 

result of combat or combat-type injuries or illnesses. 

Veterans must apply to their service for CRSC after 

they receive a disability rating from the VA. CRSC does 

not increase or replace retirement pay; it is a special 

nontaxable compensation. Qualifying veterans have 

the choice of either CR or CRSC, and both programs 

are capped at the amount equal to full retirement pay. 

Service members and veterans should contact the Defense Finance and Accounting service or a VA benefits 

counselor for specific information about their situation. 

Amputee service members who do not qualify for 

longevity retirement still qualify for VA benefits.

Reserve component amputee service members 

whose COAR is approved face unique challenges with 

benefits. While in inactive status, they have no personal or family TRICARE benefits or military income. 

Healthcare can be received at any MTF, but only with 

a line-of-duty statement. Travel to and from an MTF is 

generally not reimbursed. COAR-approved amputee 

service members can apply for VA benefits and receive 

VA compensation and medical care, but their monthly 

VA disability compensation is offset by their monthly 

military compensation. 

VETERANS AFFAIRS BENEFITS

Besides understanding the PDES, service members 

with major limb loss should also be familiar with the 

range of potential VA benefits available to them as they 

consider whether or not to remain on active or reserve 

duty (see Chapter 3, Department of Veterans Affairs System of Care for the Polytrauma Patient). VA counselors 

are available to discuss each of the following benefits:

• compensation and pension payments,

• home loan guaranty (VA loan funding fee 

waived for disabled veterans),

• life insurance,

• tuition assistance,

• vocational rehabilitation and employment 

opportunities,

• medical care for all service-connected conditions,

• civil service preference, and

• special grants (some available to active duty 

disabled service members and retired veterans 

alike), such as: 

Vocational rehabilitation benefits (see Chapter 6, 

Vocational Rehabilitation of the Combat Amputee) 

are especially important, for service members with 

major limb loss will at some time likely transition to 

the civilian workforce. Assessment of service members’ 

vocational aptitudes and interests, as well as individual 

training services, can start while they are still on active 

duty; however, the financial stipend cannot be paid 

until a DD214 is issued and a VA service-connected 

disability rating is obtained. Specific training benefits 

include tuition, books, fees and supplies, a monthly 

stipend, transportation support, and any necessary 

adaptive equipment.
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Returning to Duty After Major Limb Loss and the US Military Disability System

According to the Armed Forces Amputee Care 

Program database at the time of this writing, the US 

Army retained over 15% of soldiers with major limb 

loss in uniform. Further research is required to more 

fully assess this cohort and the significant factors that 

influenced their decisions to stay in the military, the 

duration and quality of their subsequent military 

service, and their eventual transition to civilian life. 

In addition, studies to compare the amputee care 

treatment and policies related to military retention 

between US military personnel with major limb loss 

and their counterparts in allied militaries may lead to 

further improvements in US military healthcare and 

personnel systems. 

The PDES pilot program is the first attempt to 

merge complicated and separate military and VA 

disability systems across the entire DoD. Soldiers in 

the pilot program no longer have to repeat Army disability evaluations at the VA. This relieves some of 

the burden of the MTF specialty clinics; without sole 

responsibility for providing the disability evaluation, 

they are able to focus more on soldiers’ treatment and 

continuity of care. 

Challenges remain, including differences in VA and 

military disability terminology and the responsibilities 

assigned to an already overburdened VA disability 

system. The pilot program has not yet reformed the 

compensation system. The Dole-Shalala Commission 

recommended that service members found unfit because of their combat-related injuries should receive 

comprehensive healthcare for themselves and their 

dependents through the DoD TRICARE program, 

regardless of rating percentage.17 The Commission 

also recommended that the VA reform the VASRD to 

reflect current understanding of the impact of disability on quality of life, such as described in the civilian 

American Medical Association Guides to Evaluation of 

Permanent Impairment.

17

Another proposed idea is to shorten the time soldiers remain on TDRL by having the VA clinicians, 

rather than MTF physicians, provide the medical determination of whether a condition is stable, once, at 

18 months after retirement, as opposed to numerous 

times. In October 2008 a change was made to TDRL 

policy for service members found unfit secondary to a 

WAY FORWARD

mental disorder sustained from a traumatic stress, the 

prime examples being posttraumatic stress disorder 

and traumatic brain injury with its resultant sequelae; 

a rating of not less than 50% is assigned and the soldier 

is automatically placed into TDRL, with reevaluation 

within 6 months.24 Reworking the entire TDRL policy 

will allow for greater efficiency, consistency, and overall patient-provider satisfaction. 

Customer satisfaction is the driving force behind the 

PDES pilot program, as evidenced by the Report to Congress on the Current Status of the Department of Defense 

and Department of Veterans’ Affairs Disability Evaluation 

System Pilot Program, prepared by the Wounded, Ill, 

and Injured Overarching Integrated Product Team on 

November 20, 2008.26 This team was established by an 

oversight committee cochaired by the deputy secretaries of DoD and VA, which also developed eight workgroups to focus on specific care areas for wounded, 

injured, or ill service members entering the PDES, 

within each service. The care areas ranged from case 

management and disability evaluation of service members to compensation and benefits to overall collaboration between the DoD and VA. Process and outcome 

measures were established, with the evaluation and 

assessment of the pilot program based on a balanced 

score card approach, focusing on four dimensions: (1) 

process improvement, (2) customer satisfaction, (3) 

financial management, and (4) learning and growth.

To determine measurable results that can be used to 

assess the program’s success, specific parameters have 

been established, including a continuing process improvement effort, a cost-benefit analysis, participant 

and stakeholder surveys, and a mechanism to track 

the duration of the process for service members, in 

relation to their location and DoD/VA regional treatment facilities.Feedback initiatives that provide service 

members and their families a voice throughout the 

disability process are intended to improve the overall 

satisfaction and understanding of the process.An online data-capturing tool has been implemented to track 

each service member through the process, allowing for 

management review and oversight.Preliminary indications are favorable that the pilot program is improving 

the disability system, yet data is limited and further 

efforts to collect information are needed.26

SUMMARY

Soldiers who sustain traumatic injuries, including 

major limb loss, are challenged with a complex recovery process that unfolds over weeks to years. The 

personal decision of whether to pursue return-to-duty 

or transition into civilian life requires a realistic appraisal of one’s clinical, psychological, and functional 

progress, in light of the demands of self, family, and 

ultimate reentry into a military or civilian occupation. Effectively navigating the PDES requires an 

awareness of the military and VA disability systems. 
64

Care of the Combat Amputee

Through military and VA counseling, self-education, 

and early involvement of military-appointed legal 

counsel or other soldier advocate groups, injured 

soldiers can best understand the options afforded to 

REFERENCES

1. Pelka F, ed. The Civil War Letters of Colonel Charles F. Johnson, Invalid Corps. Amherst, Mass: University of Massachusetts 

Press, 2004: 336.

2. Callison L. Army will call back amputees back to active duty: regulation is break for handicapped. Washington TimesHerald. November 11, 1951:13.

3. Greve F. 50% of Walter Reed amputees want to return to active duty. McClatchy Newspapers. June 22, 2007.

4. Kishbaugh D, Dillingham TR, Howard RS, Sinnott MW, Belandres PV. Amputee soldiers and their return to active 

duty. Mil Med. 1995;160:82–84. 

5. Rozelle D. Back in Action: An American Soldier’s Story of Courage, Faith, and Fortitude. Washington, DC: Regnery Publishing Inc; 2005. 

6. US Army Military Amputee Care Data Base. Washington, DC: Walter Reed Army Medical Center.

7. Wingert P, Gegax T. Back to the front: soldiers who lost limbs in Iraq and Afghanistan are doing the unthinkable, going 

back to battle. Newsweek. 2005;145(11):38–41.

8. Dougherty PJ. Transtibial amputees from the Vietnam War: twenty-eight year follow-up. J Bone Joint Surg Am.

2001;83A:383–389.

9. Steinbach T. Total rehabilitation for amputees in special conditions. Prosthet Orthot Int. 1977;1:125–126.

10. Pasquina PF, Gambel J, Foster LS, Kim A, Doukas WC. Process of care for battle casualties at the Walter Reed Army 

Medical Center: Part III. Physical Medicine and Rehabilitation Service. Mil Med. 2006;171:206–208.

11. Mackenzie EJ, Bosse MJ. Factors influencing outcome following limb-threatening lower limb trauma: lessons learned 

from the Lower Extremity Assessment Project (LEAP). J Am Acad Orthop Surg. 2006;14:S205–210.

12. Gambel J, Mayer J, Lourake A, Downs F. Peer visitor support of recent U.S. military amputees. inMotion. 2004;Nov–

Dec:26–27.

13. US Department of the Army. Personnel Separations: Physical Evaluation for Retention, Retirement, or Separation. Washington, DC: DA, 2006. Army Regulation 635-40. 

14. US Department of the Army. Standards of Medical Fitness. Washington, DC: DA; 2008. Army Regulation 40-501, Chapter 3. 

15. Webb RE, White DC. Physical disability separation. Louisville Law, Kentucky Legal Resources on the Internet. Available at: http://louisvillelaw.com/federal/physical_disbility_sep_1.htm. Accessed June 2006.

16. Mansfield GH, Deputy Secretary of Veterans Affairs; England G, Deputy Secretary of Defense. Department of Defense 

(DoD) and Department of Veterans’ Affairs (DVA) Implementation of Recommendations of the President’s Commission on Care 

for America’s Returning Wounded Warriors (Dole/Shalala Report). DoD/VA Wounded, Ill, and Injured Senior Oversight 

Committee Memorandum, 07 August 2007.

17. Dole R, Shalala D. Serve, Support, Simplify: Report of the President’s Commission on Care for America’s Returning Wounded 

Warriors. Washington, DC: President’s Commission on Care for America’s Returning Wounded Warriors; 2007.

18. 38 CFR, Part 4, § 4.71a.

them and their families. With the commitment of support from the highest levels of the DoD and VA, more 

service members with amputations can be expected 

to successfully return to duty. 
65

Returning to Duty After Major Limb Loss and the US Military Disability System

19. US Department of the Army. US Army Physical Disability Agency. Guidance for medical evaluation board (MEB) 

physicians, guidance for MEB examiners. Available at: https://www.hrc.army.mil/site/Active/TAGD/Pda/pdapage.

htm. Updated November 25, 2008. Accessed January 15, 2009.

20. Chu DSC, Under Secretary of Defense. Policy Memorandum on Implementing Disability-Related Provisions of the National 

Defense Authorization Act of 2008 (Pub L. 110-181). Memorandum for Secretaries of the Military Departments, Chairman of the Joint Chiefs of Staff, General Counsel of the Department of Defense, Inspector General of the Department 

of Defense, 14 October 2008.

21. Chu DSC, Under Secretary of Defense. Policy Guidance for the Disability Evaluation System and Establishment of Recurring 

Directive-Type Memoranda. Memorandum for Secretaries of the Military Departments, Chairman of the Joint Chiefs of 

Staff, General Counsel of the Department of Defense, Inspector General of the Department of Defense, and Director, 

Administration and Management, 03 May 2007. 

22. Under Secretary of Defense. Policy and Procedural Directive-Type Memorandum (DTM) for the Disability Evaluation System 

(DES) Pilot Program. Washington, DC: DoD; 21 November 2007.

23. US Department of the Army. Medical Services: Patient Administration. Washington, DC: DA; 2008. Army Regulation 

40-400: Chap 7.

24. Under Secretary of Defense. Policy Memorandum on Implementing Disability-Related Provisions of the National Defense 

Authorization Act of 2008 (Pub L. 110-181). Washington, DC: DoD; 14 October 2008.

25. US Department of the Army. Physical Performance Evaluation System. Washington, DC: DoD; 2008. Army Regulation 

600-60: Chap 4.

26. Wounded, Ill, and Injured Overarching Integrated Product Team. Report to Congress on the Current Status of the Department of Defense and Department of Veterans’ Affairs Disability Evaluation System Pilot Program. Washington, DC: Department of Defense, Department of Veterans Affairs; 2008. 
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