RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00440
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060520

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty O-3 (Chaplain) medically separated for “chronic left knee pain” and “chronic pain with motion in both shoulders, both hips, and right knee” rated 10% and 10%, respectively, with a combined disability rating of 20%.  

CI CONTENTION:  “The speed and severity of the service-connected degenerative joint disease has proven to be much more debilitating than initially led to believe. I was acting on a faulty presupposition and had I known the severity, I would not have resigned my commission.”  The applicant’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 based upon a 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 PEB - 20060215	VARD - 20060607	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain	5003	10%	Degenerative Changes, Left Knee	5003	10%	20060317	
Chronic Pain with Motion in Both Shoulders, Both Hips and Right Knee	5003	10%	DJD Right Shoulder	5003	10%		
			DJD  Left Shoulder	5003	10%		
			Osteoarthritis, Right Hip	5003	10%		
			Osteoarthritis, Left Hip	5003	10%		
			Degenerative Changes, Right Knee	5003	10%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Chronic Left Knee Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left knee pain condition, which was associated with pain in multiple joints, began in 2000 without antecedent trauma.  His pain was improved by medications but persisted and was aggravated by running.  X-rays on 9 August 2005, 9 months prior to separation, showed degenerative joint disease (DJD).  He was unable to meet full duty requirements and referred for MEB.  The MEB forwarded bilateral knee, hip, and shoulder arthritis for PEB adjudication.  At the MEB examination on 16 December 2005, 5 months prior to separation, the CI reported arthritis in multiple joints treated with medications.  The examination noted crepitus (an audible or sensible grating sensation on movement) in both knees with reduced range of motion (ROM).  The MEB NARSUM examination on 12 January 2006, 4 months prior to separation, noted a slow and progressive increase in pain to the bilateral knee, hip, and shoulder joints with the left knee the most symptomatic.  It was prepared by the treating orthopedic surgeon.  On examination, flexion was limited to 110 degrees (VA normal is 140) and painful.  Extension was normal.  The joint was stable and without an effusion (fluid in the joint) or signs of meniscal (a cartilage cushion in the knee) irritation.  At VA Compensation and Pension (C&P) evaluation performed on 17 March 2006, 2 months prior to separation, the CI reported the gradual onset of pain over the previous 4 years.  On examination, his gait was normal but he could not walk briskly.  Extension was normal at (-) 5 degrees and flexion painful and limited to 115 degrees by stiffness.  He was noted to have mild laxity of both knees, but specific testing for instability was recorded as negative.  Signs of meniscal irritation and an effusion were again absent.  The Board noted that testing for instability at the C&Ps accomplished on 16 December 2011 and 6 November 2013 was normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition at 10%, coded 5003 (degenerative arthritis), noting painful loss of motion with a stable knee.  The VA also rated the left knee degenerative changes condition 10% coded 5003, based on the VA C&P examination 2 months before separation, citing limited and painful motion.  The Board considered if the left knee could also be rated for instability.  It noted that the knee was stable to an orthopedic examination 4 months prior to separation.  It also noted that while the C&P examiner recorded mild laxity bilaterally, this was not further specified and specific testing for instability was recorded as normal at this examination and additional C&P examinations remote from separation.  The evidence does not support a finding of instability for rating at separation.  A 10% rating is supported by limited and painful motion in the presence of X-ray evidence of DJD.  No route to a higher rating was found.  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 left knee condition.  

Chronic Pain with Motion in Both Shoulders, Both Hips, and Right Knee.  According to the STRs and MEB NARSUM, the CI also had the insidious onset of pain in both shoulders and hips as well as the right knee 4-5 years prior to separation.  The MEB forwarded bilateral knee, hip, and shoulder arthritis for PEB adjudication.  

Right Knee.  The first record in evidence for the right knee was a whole body bone scan dated 15 January 2004.  It showed uptake in both knees and the left wrist consistent with DJD.  An X-ray report dated 20 January 2004 showed DJD (as did repeat X-rays on 9 August 2005).  The CI passed the run on the final fitness test on 13 May 2005.  The CI was next seen on 28 July 2005 for bilateral hip pain aggravated by running and thought to have osteoarthritis.  He was seen 2 weeks later in orthopedics and reported a 2-3 year history of right hip pain aggravated by running and noted to have a past history of osteoarthritis of the knees.  On examination, the knees were tender, but the examination otherwise normal without instability or pain with motion and with normal ROM.  He was continued on a P2 (no running) profile.  A repeat bone scan showed mild increased uptake in the large and small joints.  He was seen again in orthopedics on 15 December 2005 and MEB initiated for generalized osteoarthritis.  He had been unable to attend the chaplains’ advanced course due to his inability to run, but could still pass the physical fitness test albeit with pain.  At the MEB examination, the CI reported arthritis in multiple joints treated with medications.  The examination noted crepitus in both knees with reduced ROM.  The MEB NARSUM, accomplished by an orthopedic surgeon, showed motion limited to 135 degrees of flexion, but it was pain free.  The knee was stable and without an effusion or signs of meniscal irritation.  No comment was made on the gait implying that there was no significant abnormality.  The commander noted on 24 January 2006 that the CI was unable to meet the physical demands of a Chaplain, but did not attribute the impairment to a particular condition.  The profile was for both shoulders, hips, and knees.  At VA C&P evaluation, the gait was normal but not brisk.  The examination mirrored the left knee.  Subsequent C&Ps showed the right knee to be stable.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee in conjunction with the other joints at 10%, coded 5003.  The VA rated the right knee condition at 10%, coded 5003, noting painful and limited motion on the VA C&P examination.  The Board considered if the right knee was separately unfitting.  The CI was on a profile for no running, but still was able to pass the physical fitness test.  The CI was entered into the MEB process for generalized osteoarthritis rather than for a specific joint.  The Board determined that the right knee could not be reasonably justified as separately unfitting.  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.  

Right Shoulder.  The first record in evidence for the right shoulder was an X-ray report dated 20 January 2004.  It showed DJD.  There were no specific records for the right shoulder until in the MEB process.  The CI scored 98 for push-ups on the final fitness test in evidence which was dated 13 May 2005, 12 months prior to separation.  At the MEB examination, the CI reported arthritis in multiple joints treated with medications.  The examination noted pain in both shoulders with ROM, but did not cite limitations in motion.  The MEB NARSUM showed motion limited to 170 degrees of flexion and abduction (180 is normal) without documented pain.  The shoulder was stable and without atrophy.  Impingements signs were present bilaterally, but atrophy was absent as was an obvious deformity.  Crepitus was present.  The motor examination was normal.  Arthritic changes were noted on X-rays.  As noted above, the commander’s comments were general.  The profile was for both hips, shoulders, and knees.  At VA C&P evaluation, the ROM was reduced to 170 degrees and limited by pain and stiffness.  Crepitus was present.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder in conjunction with the other joints at 10%, coded 5003.  The VA rated the right shoulder condition at 10%, coded 5003, noting painful and limited motion on the VA C&P examination.  The Board considered if the right shoulder was separately unfitting.  The CI was on a profile for no running, but still was able to pass the physical fitness test and scored well on push-ups.  X-rays showed DJD of the right shoulder and there was painful motion.  The CI was entered into the MEB process for generalized osteoarthritis rather than for a specific joint.  The Board determined that the right shoulder could not be reasonably justified as separately unfitting.  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.  

Left Shoulder.  The first record in evidence for the right shoulder was an X-ray report dated 20 January 2004.  It was normal.  There were no specific records for the right shoulder until in the MEB process.  At the MEB examination, the CI reported arthritis in multiple joints treated with medications.  The examination noted pain in both shoulders with ROM.  The MEB NARSUM showed motion limited to 170 degrees of flexion and abduction (180 is normal) without documented pain.  The shoulder was stable and without atrophy.  Impingements signs were present bilaterally, but atrophy was absent as was an obvious deformity.  The motor examination was normal.  Crepitus was present.  It noted that X-rays showed changes consistent with moderate arthritis.  These are not in evidence and no date is provided.  It is not clear from the record if this represents an orthopedic review of the X-rays from 20 January 2004, a new study, or an error.  However, in consideration of VASRD §4.3, it is presumed that there is X-ray evidence of arthritic changes of the left shoulder.  As noted above, the commander’s comments were general.  The profile was for both hips, shoulders, and knees.  At VA C&P evaluation, the ROM was reduced to 170 degrees and limited by pain and stiffness.  Crepitus was present.  It noted that the X-ray report in evidence was normal, but cited the MEB NARSUM comment in the rating recommendation.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder in conjunction with the other joints at 10%, coded 5003.  The VA rated the left shoulder condition at 10%, coded 5003, noting painful and limited motion on the VA C&P examination.  The Board considered if the left shoulder was separately unfitting.  The CI was on a profile for no running, but still was able to pass the physical fitness test and scored well on push-ups.  X-rays possibly showed DJD of the left shoulder and there was painful motion.  The CI was entered into the MEB process for generalized osteoarthritis rather than for a specific joint.  The Board determined that the left shoulder could not be reasonably justified as separately unfitting.  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 left shoulder condition.  

Right Hip.  X-rays of the right hip dated 20 January 2004 were normal.  The CI passed the run on the final fitness test on 13 May 2005.  A bone scan done for bilateral hip pain on 3 August 2005 noted mild increased uptake in the large and small joints without specifying particular joints.  At the MEB examination, the CI reported arthritis in multiple joints treated with medications.  The examination noted crepitus (an audible or sensible grating sensation on movement) in both knees with reduced range of motion (ROM).  The MEB NARSUM showed motion limited to 110 degrees of flexion, internal rotation to 10 to 20 degrees, and external rotation of 50 degrees, and abduction of 45 degrees.  Adduction (legs in) and extension were not recorded.  There was groin pain with motion.  Impingement signs were present.  Strength was normal.  It was noted that bilateral hip X-rays were consistent with DJD.  As noted above, the commander’s comments were general.  The profile was for both hips, shoulders, and knees.  At VA C&P evaluation, the gait was normal but not brisk.  The examination showed flexion of 115 degrees, extension of 10 degrees, abduction of 35 degrees, internal rotation of 35 degrees, and external rotation of 45 degrees.  Adduction was not documented.  All motion was painful.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right hip in conjunction with the other joints at 10%, coded 5003.  The VA rated the right hip condition at 10%, coded 5003, noting painful and limited motion on the VA C&P examination.  The Board considered if the right hip was separately unfitting.  The CI was on a profile for no running, but still was able to pass the physical fitness test and passed the run portion of the fitness test.  X-rays possibly showed DJD of the right hip and there was painful motion.  The CI was entered into the MEB process for generalized osteoarthritis rather than for a specific joint.  The Board determined that the right hip could not be reasonably justified as separately unfitting.  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 hip condition.  

Left Hip.  X-rays of the left hip dated 20 January 2004 were normal.  The CI passed the run on the final fitness test on 13 May 2005.  A bone scan done for bilateral hip pain on 3 August 2005 noted mild increased uptake in the large and small joints without specifying particular joints.  At the MEB examination, the CI reported arthritis in multiple joints treated with medications.  No pathology was documented on the examination.  The MEB NARSUM showed motion limited to 110 degrees of flexion and 45 degrees abduction (legs out).  Adduction (legs in) and extension were not recorded.  The hip was stable and without signs of impingement.  Strength was normal.  It was noted that bilateral hip X-rays were consistent with DJD.  As noted above, the commander’s comments were general.  The profile was for both hips, shoulders, and knees.  At VA C&P evaluation, the gait was normal but not brisk.  The examination showed painful flexion of 115 degrees, extension of 10 degrees, and abduction of 35 degrees.  Internal rotation was 35 degrees, and external rotation was 45 degrees.  Adduction was not documented.  All motion was painful.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left hip in conjunction with the other joints at 10%, coded 5003.  The VA rated the left hip condition at 10%, coded 5003, noting painful and limited motion on the VA C&P examination.  The Board considered if the left hip was separately unfitting.  The CI was on a profile for no running, but still was able to pass the physical fitness test and passed the run portion of the fitness test.  X-rays possibly showed DJD of the left hip and there was painful motion.  The CI was entered into the MEB process for generalized osteoarthritis rather than for a specific joint.  The Board determined that the left hip could not be reasonably justified as separately unfitting. 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 left hip condition.  

BOARD FINDINGS:  In the matter of the left knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the bundled bilateral shoulders, bilateral hips, and right knee conditions 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.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140521, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXX AR20160016220 (PD201400440)

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