RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00552
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070928

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E-5 (Food Services) medically separated for bilateral shoulder and right knee conditions.  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 U3/L3 profile and referred for an Medical Evaluation Board (MEB).  Left and right shoulder osteoarthropathy and right knee osteoarthritis and chondromalacia were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated bilateral shoulder pain and right knee osteoarthritis and chondromalacia as unfitting, rated 10% and 0%, respectfully, with cited application of the US Army Physical Disability Agency (USAPDA) pain policy to rate the bilateral shoulder pain.  The CI made no appeals and was medically separated.

CI CONTENTION:  His bilateral shoulder and right knee conditions were injured in service.  He was not evaluated for left knee, neck, low back and hip conditions.  His complete submission is at Exhibit A.

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 condition outside the Board’s defined scope of review (such as the additional left knee, neck, low back and hip conditions cited in the contention) 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 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 20070719	VA* - (~6 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Shoulder Pain	5099-5003	10%	Right Shoulder Injury…	5299-5201	20%	20080331	
			Left shoulder Condition…	5099-5003	10%	20080331	
Right Knee Osteoarthritis…	5003	0%	DJD, Right Knee…	5024	10%	20080331	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 1	
RATING:  10%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20080611 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:

Bilateral Shoulder Pain.  The earliest note in the service treatment record (STR) dated 28 September 1998 indicated the CI hurt his left shoulder and left trapezius when deployed.  Treatment consisted of Robaxin (Methocarbamol, a muscle relaxer) and Naprosyn (Naproxen, a nonsteroidal anti-inflammatory drug (NSAID)).  A line of duty (LOD) report dated 1 March 2000 indicated the CI injured his right shoulder while unloading baggage on 8 May 1999 raising the possibility of a rotator cuff injury.  Arthroscopic surgery of frayed tissue of the posterior labrum (fibrocartilaginous tissue) was debrided and a modified partial acromioplasty was carried out.  A note dated 1 October 2003 indicated left shoulder pain, present for 6 months, was treated with a steroid injection to the subacromial bursa.  Improvement was noted 1 week later and X-rays showed AC (acromioclavicular) spurring.  On 10 November 2003, the CI underwent arthroscopic subacromial decompression and a rotator cuff repair and was seen in follow-up on 15 January 2004 at which time he was doing well with minimal to no pain.  Active forward elevation (flexion) was to 175 degrees (normal 180) and strength was normal.  On 5 March 2007 the CI had right shoulder pain for 6 months and a history of arthroscopic surgery in 2000.  On examination there was tenderness to palpation of the anterior superior shoulder and crepitation in the subacromial space.  Active flexion was to 160 degrees and impingement signs were positive.  X-rays revealed a type II acromion (more curved and downward dipping), spurring and os acromiale (failure of fusion of the acromial process) as well as mild AC joint arthrosis and degenerative changes at the cuff insertion site.  The impression was os acromiale impingement syndrome and rotator cuff tear.  On 12 March 2007, the CI underwent an arthroscopic rotator cuff repair and subacromial decompression of the right shoulder.  By April 2007, the CI had an active flexion to 150 degrees.  In June 2007 the CI reported he fell in a hole and significantly jarred his shoulder, but the soreness was getting better.  Flexion was to 160 degrees.  In August 2007 the flexion was to 165 and the CI was able to return to work without restriction.

The commander’s statement dated 30 November 2006 indicated the CI had been limited to his duties due to shoulder problems.  At the MEB examination, (DD Form 2807-1, Report of Medical History) the CI reported he had surgery on his right shoulder twice and left shoulder once and was told he had arthritis in both shoulders and had a crack in his right shoulder bone.  The examiner noted on a DD Form 2808, Report for Medical Examination, a decreased range-of-motion ROM and decreased strength of the right shoulder and a healed arthroscopic scar of the left shoulder with strength 5/5.  A permanent U3 profile was issued in June 2007 for left and right shoulders, post traumatic osteoarthropathy, osteoarthritis with limitations of all military functional activities, all physical fitness training except sit-ups, and no lifting more than 20 pounds.

The MEB narrative summary (NARSUM) examination, dated 25 June 2007, 3 months before separation, indicated the CI injured his right shoulder in 1999 during an advanced training period when moving bags off a truck and as he caught one, it snatched his arm and shoulder back, which caused an acute injury, pain, and limitation of motion.  He underwent a rotator cuff repair in 2000.  Pain persisted; he had findings of bone spurs; and he eventually underwent a second surgery on the right shoulder in March 2007.  His left shoulder bothered him in 2001-2002 due to compensating for the right shoulder, which caused a rotator cuff injury and subsequent surgery in 2003.  Examination of the shoulders revealed old, healed scars over both shoulders with decreased strength.  There was tenderness to pressure anteriorly over the left and right shoulders.  No specific atrophy was noted.  ROM measurements of the shoulders were limited by pain and were as follows:  right and left flexion 150 degrees each shoulder, abduction 142 degrees right and 135 degrees left (normal 180).  The CI was limited in his normal functional capacities by chronic shoulder pain, which was 4/10 in severity (10 being the worst pain), but up to 8-9/10 with activity or [cold] weather changes.  The CI took constant diclofenac, (an NSAID) for the frequent pain.
At the VA Compensation and Pension (C&P) examination dated 31 March 2008, 6 months after separation, the CI reported constant pain in his right shoulder and intermittent pain in his left shoulder.  He described the pain as a sharp, stabbing pain that was worse with activity requiring him to raise his arms overhead or heavy lifting.  He took Vicodin (Hydrocodone/APAP (Acetaminophen), a narcotic and pain reliever combination) for severe shoulder pain and an NSAID for mild to moderate pain.  He noted flare-ups of pain that were incapacitating 3 times a month, which lasted for several days that required him to take off work.  On examination he had a well healed 8 cm scar on the left shoulder.  There was a moderate amount of crepitus and grinding of his right shoulder, which was guarded.  ROM measurements for the right shoulder were forward flexion 0-150 degrees and abduction 0-160 degrees.  All ROMs had moderate limitation due to pain.  He had increased grimacing, increased guarding and increased weakness of the right shoulder with repetitive motion, but no additional loss in the ROM.  ROM measurements for the left shoulder were forward flexion 0 to 170 degrees and abduction 0 to 170 degrees.  All ROMs had minimal limitation of motion due to pain.  He had no additional weakness, guarding, facial grimacing or additional loss in the ROM with repetition of the left shoulder.  

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

DOS 20070928
Shoulder ROM
(Degrees)	Ortho
~5 Mo. Pre-Sep
	MEB 
~3 Mo. Pre-Sep
	Ortho
~1 Mo. Pre-Sep
	VA C&P
~6 Mo. Post-Sep
	
	Right	Left	Right	Right	Left	Right	
Flexion (180 Normal)	150	150	150	165	170	150	
Abduction (180)	--	135	142	--	170	160	
Comments	1 month postoperative	Limited by Pain	5.5 months postoperative	Limitation due to pain-moderate right; minimal left	
§4.71a Rating	0%	PEB 10%	0%	10% (VA 20%)	VA 10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5099-5003 (Degenerative arthritis) for bilateral shoulder pain.  The VA continued an assigned 20% rating originally granted on 30 September 2000 for the right shoulder using code 5299-5201 (Arm, limitation of motion) for residuals of right shoulder injury, post-operative (major) based on abduction of 90 degrees and a 10% rating for the left shoulder using code 5099-5003 for left shoulder condition associated with residuals of right shoulder injury, post-operative (major).  The Board sought a route to a higher rating.

Board Approach to PEB Consolidated Rating.  The PEB combined the left shoulder and right shoulder conditions under a single service disability rating, coded analogously to 5003.  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  IAW DoDI 6040.44, if the PEB combined adjudication is not compliant with the 5003 combined rating criteria, each condition subsumed under the single service disability rating must be reasonably justified as separately unfitting in order to remain eligible for a service rating.  The Board’s initial charge in this case was directed at determining whether the PEB’s combined adjudication was justified in lieu of separate ratings.  The evidence for both conditions was presented above; however, if performance based fitness criteria demonstrates that each condition is reasonably justified as separately unfitting and is separately ratable; then IAW VASRD §4.7 (Higher of two evaluations), separate ratings are recommended.  IAW DoDI 6040.44 the combined rating for the conditions determined to be separately unfitting and ratable may not be lower than the single disability rating from the PEB.  In this case, both left shoulder and right shoulder conditions were profiled, considered to fail retention standards, and implicated in the commander’s statement. The Board noted that each shoulder having a noncompensable ROM, but with objective evidence of painful motion VASRD §4.59 (Painful motion) is eligible for a 10% rating using code 5099-5003.  The Board then sought a route for a higher rating, but in the absence of ankylosis, humerus impairment, clavicle or scapula impairment, or further limitation of motion (such as the VA found in 2000, which improved by 2007/2008) a higher rating could not be found.  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 right shoulder condition and a disability rating of 10% for the left shoulder condition.

Right Knee Osteoarthritis.  A note in the STR from 17 June 2004 indicated the CI reported a several year history of bilateral anterior knee pain.  He had swelling after running and felt the knee “pops” and “gives way,” but did not lock.  On examination he ambulated with a slight limp, but was able to heel and toe walk, had valgus knees bilaterally, and some patella apprehension.  An orthopedic evaluation in July 2004 noted a partially compliant medial collateral ligament and recommended a trial of an unloading brace since there was no surgical indication.  An MRI of the right knee dated 7 August 2006 showed a minimal joint effusion, very early findings of chondromalacia patella (degeneration of the cartilage of the kneecap), a small Baker’s cyst, and very early osteoarthritic changes.  In March 2007 X-rays showed a bony fragment off of the medial epicondylar region of the knee.  An MRI in March 2007 showed a mild degenerative change in the posterior horn of the lateral meniscus, mild patella tendinosis at the origin of the patella tendon, and a small right knee joint effusion.  Examination in March 2007 noted laxity with recurvatum (bending backward) of both knees.  The right knee had increased play compared to the left and laxity to the collateral ligaments on the right as compared to the left.  He used a brace when ambulating long distances.  Physical therapy was recommended.  A bone scan of the right lower leg was normal.  In April 2007 the pain seemed to be specifically in the medial compartment.  He had a positive McMurray test (to determine a meniscal tear) with excessive recurvatum and valgus deformity.  Treatment consisted of an off-loader brace, a therapeutic injection, and Voltaren (Diclofenac, an NSAID).  By May 2015 there was improvement of the pain with good ROM and no gross effusion.  In June 2009, more than 20 months post-separation, arthroscopy was performed for a complex lateral meniscus tear with a radial tear of medial meniscus with a grade 4 change of lateral tibial plateau, with grade 3 changes of medial femoral condyle and patellofemoral joint, with an extensive hypertrophic synovium (sac surrounding the joint), and a large medial plica band (fibrous tissue).  A synovectomy and chondroplasty (removal of the cartilage) were performed and the anterior cruciate ligament, which was partially torn, was repaired.  

The commander’s statement dated 30 November 2006 indicated the CI had limited his duties due to knee problems.  At the DD Form 2807-1 dated 16 March 2007 that he had arthritis in both knees and the examiner noted on DD Form 2808 retropatellar crepitus (grinding behind the kneecap).   A permanent L3 profile was issued in June 2015 for right knee chondromalacia and osteoarthritis with limitations of all functional military activities and physical fitness training except sit-ups.

At the MEB NARSUM) examination, dated 25 June 2007, 3 months before separation, the CI reported he was on airborne jump status from 1983-1992 with standard trauma to the knees and had discomfort and some crepitus in the knees over the years.  His right knee was injured on AT in 2004 with acute knee strain and subsequent evaluation revealed degenerative arthritis.  A knee brace and physical therapy were instituted along with medication.  A surgical debridement was suggested, but the CI was hesitant to proceed with surgery.  Flexion of the right knee was 133 degrees (normal 140) and extension was 0 degrees with some limitation from pain.  There was a 2+ Lachman (to determine laxity) on the right and there was retropatellar crepitus present as well as tenderness to palpation of the anterior knee.  The CI was limited in his normal functional capacity by chronic knee pain, which was 5/10 at baseline, increased to 6-7/10 with normal activity, and to 9-10/10 with more activity.  The CI wore a knee sleeve all the time and a knee brace with working or activities.

At the VA Compensation and Pension (C&P) examination dated 31 March 2008, 6 months after separation, the CI reported he was given a series of injections and took Aleve (Naproxen, an NSAID, which helped decrease the pain.  He had constant, throbbing pain and giving away or buckling of the right knee.  Prolonged standing, running, or any climbing up or down stairs caused increased pain and swelling of the right knee.  He wore a right knee brace, which helped with stability, but did not help the pain.  He had flare-ups of pain and swelling about twice a month that lasted 2 to 3 days in duration when he was unable to work.  On examination he ambulated with a steady but slow gait and the right leg was somewhat guarded.  He had a 10 degree valgus deformity of the right knee and a moderate amount of swelling, tenderness and palpable warmth of the right knee.  ROM measurements were flexion 0 to 120 degrees with moderate limitation due to pain and extension 0 degrees with moderate limitation due to pain.  There was CI also a moderate amount of mediolateral collateral ligament instability.  With repetition he had increased weakness, incoordination and pain.  However, he had no additional loss of motion as a result of repetition, but he had difficulty with squatting and shifted his weight to the left.

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

Right Knee ROM
(Degrees)	MEB ~3 Mo. Pre-Sep
	VA C&P ~6 Mo. Post-Sep
	
Flexion (140 Normal)	133	120	
Extension (0 Normal)	0	0	
Comment	 Some limitation from pain; Lachman 2+; retropatellar crepitus; tender to palpation prepatellar and anterior knee	Painful motion, valgus deformity, mediolateral collateral ligament instability	
§4.71a Rating	PEB 0%	VA 10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating using code 5003 (Degenerative arthritis).  The Board sought a route for a higher rating.  Although the ROM of the right knee was noncompensable at both the MEB and VA examinations, the motion was painful and he had instability of the right knee.  Therefore, application of a 10% rating using code 5003 or using code 5263 (Genu recurvatum) is not unreasonable.  The Board then discussed whether an additional rating for instability is appropriate.  Code 5257 (Knee, other impairment) offers a rating for recurrent subluxation or lateral instability.  The Board discussed the extent of instability and concluded it was consistent with a 10% rating for slight instability, but evidence did not support the disability to rise to a moderate level.  Multiple ratings for a knee disability do not amount to pyramiding under VASRD §4.14.  In the absence of ankylosis, dislocated semilunar cartilage or removal of cartilage, or impairment of the tibia and fibula, the Board was unable to find a route to a higher rating.  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 right knee 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, PEB reliance on the USAPDA pain policy for rating the bilateral shoulder condition was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the right shoulder pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the left shoulder pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the right knee osteoarthritis condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:

CONDITION	VASRD CODE	RATING	
Right Shoulder Pain	5099-5003	10%	
Left Shoulder Pain	5099-5003	10%	
Right Knee Osteoarthritis	5099-5003	10%	
RATING (w/ BLF)	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131223, 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, AR20160003086 (PD201400552)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with Reserve retirement.  

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:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with Reserve retirement.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with Reserve retirement.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for payment of permanent retired pay at 30% effective the date of the original medical separation for disability with Reserve retirement.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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:

			      
						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA