RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE: PD-2014-00832 
BRANCH OF SERVICE:  Army	SEPARATION DATE: 20090227 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E-3, Military Police, medically separated for “right arm limitation of motion due to right subacromial bursitis,” with a disability rating of 20%. 

CI CONTENTION:  His conditions continue to worsen and negatively impact his daily activities.  The applicants 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 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 PEB -  20090127	VARD -  20090608	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Arm Limitation of Motion	5019-5201	20%	Bilateral Shoulder Strain	5201	0%	20090123	
Cervical Spondylosis	Not Unfitting	Cervical Spondylosis with Disc Bulging at Cs-6	5242	10%		
Patellofemoral Syndrome, Bilateral		Chondromalacia and Patellar Femoral Syndrome, Right
Knee	5010	10%		
		Chondromalacia and Patellar Femoral Syndrome, Left
Knee	5010	10%		
Hip Pain, Bilateral		Right Hip Disability	5255	NSC		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Right Arm Limitation of Motion Due to Subacromial Bursitis.  The service treatment record (STR) indicated an X-ray series dated 28 January 2008, ordered for right shoulder pain, decreased range-of-motion (ROM), and limited strength following a fall, was normal.  Magnetic resonance imaging arthrogram of the right upper extremity dated 2 July 2008 was reported as negative.  An orthopedic evaluation on 9 July 2009 noted the CI complained of pain with activity and overhead use with crepitation.  Naprosyn (naproxen, a nonsteroidal anti-inflammatory drug [NSAID]) did not provide relief.  On examination there was diffuse tenderness to palpation.  The range-of-motion (ROMs) measurements were flexion 180 degrees and abduction 90 degrees with pain throughout.  Tests were positive for shoulder impingement and long head biceps tendinitis and a superior labral versus acromioclavicular abnormality.  The diagnosis of subacromial bursitis was made and treatment consisted of an injection in the subacromial space, Mobic (meloxicam, an NSAID), and tramadol/APAP (an opioid-like medication and pain reliever combination) and a physical therapy consult.  By 31 July 2008 the tests for shoulder impingement and a labral versus acromioclavicular abnormality were negative.  After a month of physical therapy the CI felt his shoulder pain was about the same.  An X-ray series of the shoulders was normal on 25 August 2008.  An orthopedic surgeon commented that the CI had neck pain since June 2008 that radiated in posterolateral upper extremities bilaterally and the test for a labral versus acromioclavicular abnormality was again positive.  ROM measurements by a physical therapist of the right shoulder were flexion 140 degrees, abduction 75 degrees, internal rotation 51 degrees, and external rotation 51 degrees.  

The commander’s statement dated 17 November 2008 indicated the CI was not capable of performing his duties due to profile restrictions.  At the Medical Evaluation Board (MEB) examination dated 21 November 2008, the CI reported pain in both shoulders on the DD Form 2807-1.  The MEB physical examiner noted tender subacromial areas of both shoulders and mild tenderness across the trapezius muscles.  The MEB narrative summary (NARSUM) dated 14 January 2009 noted that the right handed CI complained of right greater than left shoulder pain to a lesser degree than that of his neck, knees, and hips, which are discussed below.  A permanent U3 profile for shoulder pain as well as cervical spondylosis was issued on 15 January 2009, although the NARSUM noted the orthopedic surgeon issued a U3L3 profile on 2 December 2008.  Therefore, the limitations of all military functional activities and the physical fitness testing are not specific to the right shoulder per se.  

At the VA Compensation and Pension (C&P) examination dated 23 January 2009, performed a month before separation, the CI reported constant low-grade pain to the right shoulder with flare-up a couple of times a week; all ROMs of the right shoulder decreased to 30 degrees during flare-ups.  ROM measurements of the right shoulder were flexion to 160 degrees, abduction to 170 degrees, internal rotation to 90 degrees, and external rotation to 90 degrees.  There was painful motion in the final 30 degrees of abduction and the final 20 degrees of flexion, external rotation and internal rotation; and there was no loss of motion with repetition. 

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating using code 5019-5201 (Bursitis-Arm limitation of motion) for right subacromial bursitis.  The VA assigned a 0% rating using code 5201 for bilateral shoulder strain.  The Board sought a route to a higher rating and discussed a 30% rating for the CI’s dominant upper extremity.  However, abduction of 75 degrees is closer to a shoulder level rating than midway between the side and shoulder level.  Furthermore, a month prior to separation, the VA examination revealed an abduction of 170 degrees.  In the absence of ankylosis, humerus impairment or clavicle or scapula impairment, the Board was unable to find a route to a higher rating.  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 arm limitation of motion-subacromial bursitis condition.  

Contended PEB Conditions-Cervical Spondylosis, Bilateral Patellofemoral Syndrome, and Bilateral Hip Pain.  The cervical spondylosis and the bilateral hip pain were profiled (U3L3) as was the retropatellar pain syndrome presumably representing bilateral patellofemoral syndrome.  The conditions were not directly implicated in the commander’s statement, which noted the CI was not capable of performing his MOS due to profile limitations; and, the conditions were determined to be medically unacceptable and failed retention standards.  

Cervical Spondylosis.  A cervical spine X-ray series ordered for neck pain with radicular symptoms on 25 August 2008 was normal.  However, an MRI dated 28 August 2008 demonstrated mild broad based posterior disc bulging at C5-C6 minimally indenting the anterior margin of the thecal sac (that surrounds the spinal cord), mild right neural foraminal (where nerves pass through the vertebrae) narrowing at C4-C5, and no evidence of focal disc protrusion or significant cord impingement at an[y] level.  Electrodiagnostic studies of the upper extremities were normal.  An orthopedic evaluation dated 22 September indicated the CI had 5/10 neck pain that radiated into the posterolateral upper extremities since June 2008.  Cervical spine pain was elicited by motion, extension more than flexion, but motion was normal and there was no tenderness on palpation.  The diagnosis of cervicalgia was made and the CI was referred for physical therapy, which was carried out for six sessions.  The ROM as the last visit on 17 October 2008 was full with pain at the end ranges.  Orthopedic evaluation noted the CI still complained of 5/10 neck pain, which was a random occurrence and was better with rest.   Physical therapist ROM measurements were flexion 45 degrees, extension 42 degrees, left lateral flexion 30 degrees, right lateral flexion 30 degrees, left lateral rotation 52 degrees, and right lateral rotation 55 degrees.  Everything was an aggravating factor.  The NARSUM noted pain was tolerable with medication unless exacerbated by activity.  At the VA examination the CI reported mild-moderate pain to the neck, which was further aggravated with prolonged standing, lifting activities, wearing heavy items, and turning the neck.  On examination there was guarding, bilateral paraspinal muscle spasm and tenderness.  Straight leg raise testing (to determine nerve root irritation) was negative.  The ROMs of flexion, extension, and right and left lateral flexion were to 45 degrees each and right and left rotation ROMs were to 80 degrees each.  There was pain with right and left lateral flexion between 30-45 degrees and pain with right and left rotations between 60-80 degrees.  There was no loss of motion with repetition. 

Bilateral Patellofemoral Syndrome.  According to the NARSUM, prior to entry into the service, the CI spent 10 months in a Homeland Security training program where he experienced left knee pain.  Evaluation by X-rays and an MRI were negative and the CI indicated the pain resolved.  During basic military training in July 2007 he developed right knee pain and was diagnosed with right patellofemoral syndrome.  However, physical therapy did not improve the knee pain.  An MRI of the right knee in July 2008 showed no evidence of a meniscal or ligament tear, but there was an area of bursitis abutting the patella (kneecap) tendon, while an MRI of the left knee was negative for meniscal or ligament tears, but there was a soft tissue mass, possibly a lymph node posterior to the distal femoral shaft.  At a physical therapy evaluation, the CI indicated he had bilateral knee pain with a full ROM and significant pain at the end of flexion in August 2008.  The ROM measurements in December 2008 were right knee 140 degrees flexion and 0 degrees extension and left knee 139 degrees flexion and 0 degrees extension.  Aggravating factors included walking, running, and prolonged standing; pain severity was 8/10 pain (10/10 being the worst pain) with the aggravating factors.  At the VA C&P examination the CI reported he developed pain and swelling of the right knee, was placed on crutches for 4+ weeks, and then experienced a flare-up of left knee pain.  He was off and on profiles for persistent bilateral knee pain.  On examination there was bilateral painful patellar crepitation (grinding sensation), but no effusion or swelling and the ROM of flexion was to 140 degrees and extension was to 0 degrees without painful motion and no limitation of motion with repetition.  

Bilateral Hip Pain.  The NARSUM indicated at the MEB termination examination on 2 December 2008 the CI complained of bilateral hip pain, the right greater than the left.  However, the CI did not report any problem with his hips on DD Form 2807-1 nor did the examiner record any physical findings related to the hips, but did list left hip bursitis as a defect/diagnosis.  In a note dated 17 December 2008 the CI complained of 5-8/10 non-radiating hip pain, which was worse with prolonged sitting, activity, and exertion, but improved with rest.  The CI was unable to bear a combat load.  On examination there was tenderness to palpation of the hips at the origins of the hip flexors.  Ober’s test (to determine tightness of the iliotibial band) of the hips was negative.  Hip motion was normal with pain on resisted flexion.  There was no weakness, muscle spasms, tenderness, or instability. X-rays of the hips showed no evidence of acute osseous (bony) injury with minimal enthesopathy (inflammation where a tendon or ligament inserts on a bone) affecting the lesser trochanter on the left.  An MRI dated 23 December 2008 performed for bilateral hip flexor tendonitis marked by pain in both hips with a cracking and popping sensation since July 2008 was grossly normal with a symmetric appearance of both hips.  At the VA C&P examination the CI reported bilateral hip pain in about July 2008, which worsened in November 2008.  On examination there was tenderness with palpation over the left greater trochanter and pain in the left hip with a full squat.  The ROM measurements of the right and left hips were flexion to 125 degrees (Normal 125), extension to 30 degrees (Normal 20), abduction to 45 degrees (Normal 45), adduction to 25 degrees (Normal 45), internal rotation to 40 degrees (Normal approximately 40), and external rotation to 60 degrees (Normal 45).  There were no painful motions and no loss of motion with repetition and the CI was able to cross both legs.  

All were reviewed and considered by the Board.  After due deliberation, the Board agreed that the preponderance of the evidence with regard to the functional impairment of cervical spondylosis condition favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 5242 and meets the VASRD §4.71a criteria for a 10% rating.  

Board members then discussed the fitness of bilateral patellofemoral syndrome and bilateral hip pain conditions.  There was no performance based evidence from the record that bilateral patellofemoral syndrome and bilateral hip pain conditions significantly interfered with satisfactory duty performance.  However, a permanent profile addressed the conditions and the conditions were deemed medically unacceptable.  Nevertheless the Board members agreed neither the bilateral patellofemoral syndrome conditions nor the bilateral hip pain conditions were unfitting.  Members then discussed whether the “overall effect” of the conditions was unfitting IAW DoDI 1332.38 E3.P3.4.4 and AR 635-40 3-1.b. The majority of members felt the conditions taken together were not unfitting at the time of separation.  Therefore, 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 bilateral patellofemoral syndrome and bilateral hip pain contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the right shoulder subacromial bursitis condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended cervical spondylosis condition, the Board unanimously agrees that it was unfitting and unanimously recommends a disability rating of 10%, coded 5242 IAW VASRD §4.71a.  In the matter of the contended bilateral patellofemoral syndrome and bilateral hip pain 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.  The Board, therefore, 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 Arm Subacromial Bursitis	5019-5201	20%	
Cervical Spondylosis	5242	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140219, with attachments
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 XXXXXXXXXXXXXXXXXX, AR20160005592 (PD201400832)

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 severance pay.  

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 severance pay.

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

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

	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