RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00053
BRANCH OF SERVICE:  Army	BOARD DATE:  20150402
SEPARATION DATE:  20080218

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Petroleum Supply Specialist) medically separated for left knee pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  The CI was permitted to take the walking portion of the alternate Army Physical Fitness Test.  He was issued a permanent L3/H2/S1 profile and referred for a Medical Evaluation Board (MEB).  The left knee condition, characterized as “chronic lt knee pain” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded four other conditions (right shoulder instability, posttraumatic stress disorder [PTSD] chronic, major depressive disorder [MDD], and noise induced sensorineural hearing loss) as not disqualifying for PEB adjudication.  The Informal PEB adjudicated “chronic left knee pain” as unfitting, rated 0%, with likely application of US Army regulations.  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Depression.  PTSD.  Chronic Low Back Strain, Tinnitus Concussion.  Left Knee injury.  Right Shoulder injury.”

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:

Service IPEB – Dated 20071127	VA - (1 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain	5099-5003	0%	Left Knee Chondromalacia Patella and Medial Meniscus Tear	5099-5024	10%	20080125	
Right Shoulder Instability	Not Unfitting	Right Shoulder Dislocation with Bankart Procedure	5099-5024	10%	20080125	
PTSD Chronic	Not Unfitting	PTSD with Major Depressive Disorder	9434-9411	30%	20080125	
Major Depressive Disorder	Not Unfitting					
Hearing Loss	Not Unfitting	Tinnitus	6260	10%	20080126	
		Bilateral Hearing Loss	6100	0%*	20080126	
Other x 0 (Not In Scope)	Combined:  70%	
Combined:  0%		
Derived from VA Rating Decision (VARD) dated 20080317 (most proximate to date of separation [DOS]).
* DC 6100 was a deferred rating on original VARD, which was later changed per VARD 20080728 to 0%, effective 20080219 

ANALYSIS SUMMARY:

Left Knee.  The narrative summary (NARSUM) noted that the CI developed left knee pain in 2005 after an airborne operation.  He complained of some catching and symptoms of instability.  Arthroscopy in March 2007 (11 months prior to separation) revealed chondromalacia (softening) of the patella (kneecap), no other cartilage damage (intact menisci), and intact ligaments.  Follow-up examinations by physical therapy (PT) on 26 April 2007 and 6 June 2007 recorded full range-of-motion (ROM) with normal gait and no locking.  The MEB orthopedic evaluation on 7 September 2007 (5 months prior to separation) showed “full range of motion,” crepitus (grating) with ROM, pain with palpation of the patella, no ligamentous laxity, and normal strength.  The CI reported a catching sensation but no locking.  The MEB physical exam on 28 September 2007, 4 months prior to separation, reported in the NARSUM noted tenderness of the patella, positive patellar grind, and negative ligamentous laxity.  ROM done by PT on 30 October 2007, 4 months prior to separation, was active extension 8 degrees to 100 degrees (normal 0 degrees to 140 degrees) indicating 8 degrees loss of extension.  Passive extension was 2 degrees indicating no mechanical loss of extension.  Orthopedic clinic examinations on 21 September 2007, 23 October 2007, and 4 December 2007 recorded full active left knee ROM (“full AROM”; active ROM) and no locking or giving out.  

At the VA Compensation and Pension (C&P) exam performed a month prior to separation, the CI reported constant pain in his knee, that he wore a brace at all times, that the knee swelled at times, that the knee locked significantly to where he had to use his arms to get the knee to move again and that the knee occasionally gave-way.  On examination, there was significant edema around the knee, exquisite point tenderness over the medial joint line, positive McMurray's test (suggestive of meniscus problem), no locking or clunking with manipulation, and no evidence of ligamentous laxity.  Gait displayed some mildly decreased weight-bearing on the left knee during ambulation.  ROM was 0 degrees to 100 degrees (normal 0 degrees to 140 degrees) before pain limited further motion.  There was no mention of additional functional impairment with repetitive use.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition analogously to code 5003 (Arthritis, degenerative) at 0%, noting that ROM was limited by pain.  The VA rated the condition analogously to code 5024 (Tenosynovitis) at 10%, citing painful or limited motion.  The Board noted that the ROM examinations considered by the PEB and VA would both result in a rating of 10% under §4.59 (Painful motion) and the respective codes under §4.71a.  The Board noted that the 8 degrees limitation of extension measured by PT for the MEB exam would warrant a 10% rating under code 5261 (Leg, limitation of extension of), with no additional benefit to the CI.  The Board reviewed the VA’s diagnosis of left medial meniscus tear, and considered whether this would support a separate rating under code 5258 (cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion into the joint).  Although the CI reported a history of occasional locking and giving-away of the knee in his VA exam, and the examiner reported a positive McMurray’s sign, these findings are not definitive for a meniscus tear, and the CI was found to have an intact meniscus at surgery just 11 months prior to separation, with no interval history of another injury.  Therefore, the preponderance of evidence did not support a separate diagnosis of medical meniscus tear or a rating under the associated code (5258).  The Board also noted that a higher rating was not supported under the diagnostic code for recurrent subluxation or lateral instability (5257), compensable limitation of motion (flexion), or impairment of the tibia or fibula (with nonunion or malunion).  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 the left knee condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that right shoulder instability, PTSD, MDD, and noise induced sensorineural hearing loss were not unfitting.  The Board’s threshold for countering fitness determinations is “preponderance of evidence,” which is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

Right Shoulder.  The NARSUM noted that the CI dislocated his right shoulder (dominant side) during combat training in March 2006, and that it was soon reduced in the Troop Medical Clinic.  In June 2007 (8 months prior to separation) he had shoulder surgery (arthroscopic anterior capsulorraphy and posterior labral repair).  On 7 September 2007 (3 months after surgery and 5 months prior to separation) at the orthopedic MEB evaluation, the CI reported that his shoulder pain had “greatly improved” and that he had no symptoms of instability.  On examination he had well-healed incisions, no pain with palpation, normal strength with shoulder movement, and intact neurovascular status.  “His shoulder appears to be very stable with load shift.”  The ROM was flexion to 130 degrees (normal 180 degrees) and 100 degrees abduction (normal 180 degrees).   At the MEB NARSUM on 28 September 2007, 3 months after surgery, 5months prior to separation examination, the CI reported that he had done very well with his shoulder over the course of the last few months, that his pain had greatly improved, and that he had no symptoms of instability.  On examination he had no tenderness on or around the joint.  The examiner stated that the shoulder condition was non-disqualifying.  On 30 October 2007 (4 months prior to separation), PT reported that the right shoulder had 145 degrees flexion and 145 degrees abduction.  At an orthopedic clinic visit on 4 December 2007 (2 months prior to separation), the CI reported excellent results with his right shoulder surgery and “no problems.”  At a PT visit 8 days later, flexion and abduction were “within normal limits,” but push-ups were limited by pain and fatigue.  The commander’s statement did not address any specific physical condition.  The medical conditions listed in a physical profile on 2 November 2007 were left knee chondromalacia and hearing loss, but not the shoulder.  The actual restrictions (no lower body weight training, running, jumping, squatting, and ruck marching) referred to lower body issues only.  The MEB and PEB classified the shoulder condition as not disqualifying.  

At the VA C&P exam on 25 January 2008, a month prior to separation, the CI stated that he had no further dislocations, but reported that he continued to have significant pain in his shoulder on an intermittent basis; every 3-4 days he would have pain that lasted for a couple of hours that he rated as a 4/10 in intensity.  He also had limitations in motion, especially internal rotation of the shoulder.  On examination he had some tenderness over the anterior aspect of the shoulder, pain and pulling with abduction, severe pain and tightness limiting internal rotation, but no instability.  Examination of the right shoulder revealed some mild tenderness over the anterior aspect of the shoulder, no instability, forward flexion 180 degrees (normal), and abduction 160 degrees (normal 180 degrees) with painful motion.  Although the CI did have some shoulder symptoms at the time of separation, they improved after surgery, did not result in specific duty restrictions, and did not engender any specific comments from the commander.  The orthopedic and MEB examining physicians, the MEB, and the PEB all characterized the condition as “not disqualifying.”  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 right shoulder condition.  

Posttraumatic Stress Disorder/Major Depressive Disorder.  According to the MEB psychiatry consult, the CI reported two significant events in which he witnessed the death of others while deployed to Baghdad from May 2003 to July 2004 and developed PTSD symptoms after returning to his home base.  He received counselling and reported that he continued to experience some symptoms to a lesser degree.  The CI incurred a concussion in November 2005 during a parachute landing and was subsequently diagnosed with post-concussive syndrome manifesting with concentration and memory problems.  Clinic record entries noted absence of active psychological symptoms such as depression or anxiety.  Clinic notes in November 2006 indicated the CI had recently graduated from SERE school (survival, evasion, resistance and escape training).  The CI was evaluated in the psychology clinic, 15 December 2006 complaining of difficulty sleeping and slow processing of information since the November 2005 head injury.  He denied problems with depression, anxiety but indicated some problems at work or home and some interpersonal relationship problems.  The CI was referred for neuropsychological testing.  The neuropsychological testing (report 13 March 2007), was inconclusive regarding cognitive problems due to head injury, but instead indicated depressive symptoms thought to be causing the symptoms.  Mental status examination was recorded as normal on 26 March 2007 and at a clinic follow up 11 May 2007 noted improved symptoms on medications.  At the time of a neurology evaluation, 3 May 2007 the mental status examination was normal including memory, speech, and language.  A 15 May 2007 psychology examination recorded symptoms of anxiety, nightmares, loss of interest, social withdrawal, and passive suicidal thoughts.  The diagnosis was adjustment disorder.  At the time of follow up in the psychology clinic, 24 October 2007, the CI reported feeling greatly improved but still reported sleep problems and memory and concentration problems.  The diagnosis was adjustment disorder with mixed emotional features.  The psychologist noted, “Scores on the Brief Symptom Inventory today were all in the Average range indicating that the patient reports no significant symptoms.  …  With most symptoms in remission at this time.  Problems with sleep and low energy remain, but these may be related to chronic pain.”  The psychiatric MEB NARSUM, written one week later (31 October 2007), noted the CI endorsed a history of traumatic events, symptoms of re-experiencing nightmares, avoidance, hypervigilance, and feeling detached.  The CI reported he continued to experience nightmares and avoidance but to a lesser degree along with depressive symptoms.  The examiner stated, “He has been seen just a few times in Behavioral Health since presenting there in December 2006.  He states he has not previously reported his symptoms as extensively as today.”  He did not endorse other symptoms of anxiety, mood or thought disorders.  On mental status examination he had no psychomotor abnormalities; fluent speech with regular rate and rhythm; good recall, calculations, and abstractions; linear and goal-directed thought; and no expression of suicidal/ homicidal ideation or auditory/ visual hallucinations; and fair insight/ judgment.  The examiner assigned a Global Assessment of Functioning (GAF) of 60 for moderate symptoms.  The diagnoses were PTSD and MDD, and the examiner concluded that the CI had no impairment for further military duty, met Army retention criteria.  The CI’s commander stated that he had performed all tasks and light duties assigned, appeared to be compliant with his treatment plan, and has displayed a good attitude.  The physical profile did not reflect any limitations due to his mental health status.  

At the VA C&P mental health exam performed a month prior to separation on 25 January 2008, the CI endorsed moderate symptoms of PTSD and depression including persistent re-experiencing, avoidance and increased arousal having a mild to moderate impact on his current quality of life.  On mental status examination the CI demonstrated no impairment of thought process or communication; demonstrated eye contact and interaction within normal limits; denied any suicidal or homicidal thoughts; endorsed a good history of maintaining minimal personal hygiene and other basic activities of daily living; endorsed some short term memory problems; stated that he obsessively checked his wallet; had normal rate and flow of speech; denied panic attacks; and stated that he had been struggling with depression since Iraq on a daily basis (feeling sad, losing interest and pleasure in things, and gaining weight).  He denied impaired impulse control and stated that he slept less than 4 hours per night, “with energy that is weak during the day.”  Regarding going back to work, the CI stated, “I don't know if I can handle the surroundings, co-workers, it's hard to tell.”  The examiner assigned a GAF of 60 denoting moderate symptoms and opined that the CI’s mild to moderate PTSD and depression would pose mild to moderate vocational limitations.  According to the MEB psychiatry consult and service treatment records, the CI had symptoms since 2004, which did not interfere with performance of duties.  There was an apparent increase in depressive symptoms in January 2007 and neuropsychological testing for cognitive problems due to head injury was inconclusive except for depressive symptoms.  Service treatment records indicated improvement with treatment (“most symptoms in remission”).  The MEB psychiatry consult indicated the chronic symptoms were improved since 2004 and met retention standards.  The Board also noted the CI’s contention for residuals of head injury (concussion) in 2004 and November 2005.  Neuropsychological testing in March 2007 did not demonstrate cognitive deficits independent of the depressive symptoms.  Neither the mental health symptoms nor cognitive symptoms possibly related to concussion were profiled or implicated in the commander’s statement.  There was no performance based evidence from the record that the mental health conditions or residuals of head injury (concussion) significantly interfered with satisfactory duty performance.  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 mental health conditions.  

Hearing Loss.  A clinic note on 3 August 2007, 6 months prior to separation, stated that the CI had tinnitus (ringing in the ears) for 4 months, and he denied any preceding exposure to gunshot or other loud noise.  At an audiology evaluation on 29 October 2007 (4 months prior to separation), the CI noted intermittent problems with bilateral hearing loss (worse in left ear), difficulty understanding speech, tinnitus (ringing in the ears) in both ears, and overall “sounding tinny” that came and went.  The audiologist noted bilateral moderately severe high frequency hearing loss that met Army H-2 standards (based on hearing loss), no evidence of inner ear pathology, and that the hearing was stable since 2005.  The NARSUM, MEB, and PEB categorized the noise induced sensorineural hearing loss as non-disqualifying.  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 hearing loss 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.  In the matter of the left knee condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5024 IAW VASRD §4.71a.  In the matter of the contended right shoulder, mental health, and hearing loss conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration. 

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Left Knee Pain  	5099-5003	10%	
RATING	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131226, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

				
XXXXXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXXXXX, AR20150015525 (PD201400053)

1.  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 to modify the individual’s disability rating to 10% without recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     XXXXXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA