RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2013-01971		
BRANCH OF SERVICE:  Army	Separation Date:  20060123

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E-6 (Armor Crewman) medically separated for right knee and right shoulder pain.  These conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent U3L3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic right knee pain post meniscus tear” and “chronic right shoulder pain with acromioclavicular degenerative joint disease (DJD),” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated his right knee and right shoulder as unfitting, rated 10% and 10%, citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The PEB forwarded the findings and ratings to the United States Army Physical Disability Agency (USAPDA) for review and approval.  The USAPDA made an administrative change to the VASRD diagnostic code for the right knee condition, citing application of the USAPDA pain policy.  The CI made no appeals and was medically separated.  

CI CONTENTION:  The CI elaborated no specific contention in his application.

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 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:  

USAPDA Admin – Dated 20060110	VA* - (~5 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Knee Pain…	5099-5003	10%	Residuals of Right Knee Injury	5099-5014	10%	20060629	
Osteoarthritis of the Right Shoulder Joint…	5010	10%	Right Shoulder Arthritis…	5201-5010	10%	20060629	
Other x 0 (Not In Scope)	Other x 7	
COMBINED RATING:  20%	COMBINED RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20060824 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Chronic Right Knee Pain Condition.  The CI injured his right knee (and right shoulder) as a result of a motorcycle accident on 3 November 2004.  A right knee MRI (magnetic resonance imaging) done in November 2004 showed a lateral meniscal tear, large joint effusion and fracture (of the fibular head with ligament and tendon disruption).  The CI underwent right knee arthroscopic surgery with partial lateral menisectomy on 16 November 2004.  Despite extensive physical therapy (PT), orthopedic evaluations and medications, the CI continued to experience knee pain with activities.  A repeat knee MRI done in July 2005 showed a cyst in the meniscus with a meniscal tears.  The CI underwent a second right knee arthroscopic surgery with partial lateral menisectomy in August 2005.  

The MEB Narrative Summary (NARSUM) exam, approximately 3 months prior to separation, documented that there was no significant improvement in knee pain despite the second arthroscopic surgery.  There was pain with weight-bearing or at extremes of range-of-motion (ROM).  The CI had functional limitations of an inability to perform the APFT aerobic event, an inability to run or walk a significant distance and an inability to perform vehicle maintenance.  The MEB and PT physical exam findings are summarized in the chart below.  

The VA Compensation and Pension (C&P) exam, approximately 5 months after separation, documented that the CI had a knee brace and complained of knee pain and stiffness without swelling, instability, giving way or locking.  The VA C&P physical exam findings are summarized in the chart below.  

There were goniometric ROM evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.  

Right Knee ROM
(Degrees)	MEB/PT ~3 Mo. Pre-Sep	VA C&P ~5 Mo. Post-Sep	
Flexion (140 Normal)	140	98	
Extension (0 Normal)	4	0	
Comment:  Surgery ~6 Mo. Pre-Sep	Antalgic gait; painful motion; lateral joint line tenderness; no effusion; “ligaments are stable”	Knee brace; antalgic gait; no instability or giving way; Deluca decreased ROM by 5 degrees	
§4.71a Rating	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the right knee condition as analogous to 5003 (arthritis, degenerative [hypertrophic or osteoarthritis]) and rated at 10% with application of the USAPDA pain policy.  The VA coded the right knee condition as analogous to 5014 (osteomalacia) and rated at 10%.  Both the MEB and VA exams proximate to separation showed painful motion (IAW VASRD §4.59) without evidence of instability.  There was no ROM limitation for higher than a 10% rating under any specific knee code (flexion limited to 30 degrees or extension limited to 15 degrees).  Alternative coding analogous to 5259 (cartilage, semilunar, removal of, symptomatic) would rate no higher than 10% and there was insufficient evidence of frequent episodes of “locking,” pain, and effusion into the joint to justify a higher rating under code 5259 (also meniscal coding).  Meniscal coding includes painful or pain-limited motion, and with consideration of §4.14 (avoidance of pyramiding), there was insufficient evidence for dual rating of the knee.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right knee condition.  
Osteoarthritis of the Right Shoulder Joint…Condition.  The CI is right hand dominant.  The CI injured his right shoulder as a result of an accident in 2004 (as noted above) and had a grade II acromioclavicular (AC) separation, partial rotator cuff tear and positive labral tear.  A shoulder MRI done in July 2005 showed degenerative changes in the humeral head, capsular hypertrophy, osteoarthritis at the AC joint, and tendinitis of the muscle.  An orthopedist evaluation on 18 August 2005, approximately 5 months prior to separation, documented positive impingement and instability signs (+Neer, +Hawkins, +O’Brien tests) as well as slight motor weakness (4+/5).  There was no muscle atrophy.  Forward flexion was 160 degrees (normal 180).  The orthopedist scheduled a surgical repair; however, the CI subsequently declined surgery since the physician opined that the CI would continue to have chronic pain even with surgery.  

The MEB exam approximately 3 months prior to separation documented that the CI had constant right shoulder pain with reaching overhead or behind his neck and rated the pain at baseline 4-5/10 which increased to 8/10 with movements.  The MEB physical exam and PT findings are summarized in the chart below.  

The VA C&P exam approximately 5 months after separation documented that the CI had stiffness and pain in the shoulder.  The VA C&P physical exam findings are summarized in the chart below.  

The ROM evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation, are summarized in the chart below.  

Right Shoulder ROM
(Degrees)	MEB/PT ~3 Mo. Pre-Sep	VA C&P ~5 Mo. Post-Sep	
Flexion (180 Normal)	134, 133, 134	178	
Abduction (180)	111	178	
Comments:  
Right Hand Dominant	Atrophy with prominent distal clavicle, tenderness to palpation (TTP); +Neer, +Hawkins +O’Brien tests; sharp pain reaching overhead/above head	No pain with ROM; no instability; no change with repetition	
§4.71a Rating	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the right shoulder condition as 5010 (arthritis, due to trauma, substantiated by X-ray findings) and rated at 10%.  The VA coded the right shoulder condition as 5201 (arm, limitation of motion of) with 5010 (arthritis, due to trauma, substantiated by X-ray findings) and rated at 10%.  All evidence proximate to separation showed limited ROM and/or pain-limited motion.  VASRD §4.71a specifies for the 5003 criteria (that applies for code 5010) that satisfactory evidence of objectively confirmed limited motion warrants application of a 10% rating “for each such major joint ….”  The MEB exam also documented painful motion and VASRD §4.59 (painful motion) would provide an alternate justification for a 10% rating.  The Board considered alternative coding under 5201; however, there was insufficient evidence that motion was limited to “at shoulder level (~90 degrees)” to meet the minimum 20% rating criteria.  There was no evidence of dislocations or loose motion and the right shoulder condition could not be reasonably rated higher than 10% using any exam proximate to separation or any alternate rating schema.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right shoulder 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, reliance on the USAPDA pain policy (AR 635-40) for rating the knee condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the right shoulder condition and IAW VASRD §4.71a, 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 20131027 w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXX, AR20150018689 (PD201301971)

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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA