RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00934
BRANCH OF SERVICE:  Coast guard 	SEPARATION DATE:  20081121

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve, E5, Storekeeper, medically separated for right (dominant) shoulder injury and right knee injury; with a combined disability rating of 20%.  

CI CONTENTION:  He was given a higher rating for his condition(s) by the VA.  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 confined to review of medical records and all available evidence for application of Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical conditions 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 - 20071213	VARD - 20090324	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder, Group IV Function: ...	5304	10%	Osteoarthritis of the Right Shoulder (Dominant)	5010	10%	20080722	
Arthritis, Degenerative, Right Knee 	5099-5003	10%	Degenerative Arthritis of the Right Knee	5010	10%	20080722	
Bilateral Carpal Tunnel Syndrome (CTS)	Not Unfitting	Right CTS	8599-8515	0%	20080722	
		Left CTS	8599-8515	0%	20080722	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Right Shoulder Condition.  The narrative summary (NARSUM), supplemented by the outpatient service treatment record (STR), documents an onset of right (dominant) shoulder pain during combatives training in February 2006.  The pain persisted in spite of conservative measures, magnetic resonance imaging (MRI) was inconclusive for surgical pathology, but an MRI arthrogram suggested a partial thickness rotator cuff tear and labral (the labrum is the attachment for the joint capsule) injury.  The CI underwent surgery (arthroscopic repair, debridement, decompression) in January 2008 (10 months pre-separation).  An orthopedic follow-up note in June 2008 noted a “well-maintained” range-of-motion (ROM) without joint instability or impingement, and progression of activities (“playing some racquetball”).  There were no STR entries indicating significant ROM limitation, instability, ratable functional deficits, or incapacitation.

The NARSUM and a subsequent addendum are in evidence, but the dates are not documented on the available copies; however, it is clear that they preceded the shoulder surgery.  These documented persistent “shoulder pain with daily activities, especially with overhead activities.”  The NARSUM physical examination recorded tenderness and some signs of impingement (positive Neer’s and Hawkins signs), but no apprehension or indication of instability.  The NARSUM measured ROM was forward flexion to 180 degrees (normal), with other planes grossly normal, and specifying painful motion.  

A VA orthopedic Compensation and Pension (C&P) examination was conducted 22 July 2008 (6 months after surgery, 4 months pre-separation) and was supplemented by a general C&P examination of 3 July 2008.  These documented “intermittent” but “daily” pain rated 4-7/10 exacerbated by “raising the arms overhead.”  The VA physical examination recorded tenderness and guarding, making no note of instability or impingement.  The VA measured ROM was forward flexion and abduction to 180 degrees (normal, minimum compensable 90), specifying painful motion.  There was an X-ray finding of “mild osteoarthritis” by the VA.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 10% rating under 5304 (Group IV muscle code, applicable to rotator cuff muscles) was consistent with the VASRD §4.71a criterion of “moderate” muscle disability.  The VA’s 10% rating under 5010 (traumatic arthritis) invoked painful motion in support of the minimum compensable rating.  There was no compensable ROM impairment and members agreed that there was no functional evidence which would support a rating higher than 10% under the PEB’s muscle code.  There was no ankylosis or fracture (nonunion/malunion) of the shoulder girdle that would support a higher rating under any other joint code; and, there was no history of dislocations or findings of instability that would support a higher rating (even analogously) under code 5202 (humerus, other impairment).  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 of the right shoulder condition. 

Right Knee Condition.   There are conflicting histories in the STR and NARSUM regarding the exact onset or nature of injury for the right knee condition.  The most repeated history is a twisting injury during training dating to the same period as the shoulder injury, and there is documentation of pre-existing injury and two prior surgeries.  There was MRI evidence of an ACL tear and the CI underwent an arthroscopic ACL reconstruction in January 2007 (nearly 2 years pre-separation).  There was no indication of meniscal injury by imaging, the operative report documented the absence of significant meniscal tear or intervention, and there was no subsequent indication of meniscal injury (in the outpatient STR or NARSUM); so, it is unclear how the MEB diagnosis of meniscal tear was arrived at.  An orthopedic follow-up entry from November 2007 (12 months pre-separation) noted good surgical results and documented that the CI states “the knee feels stable ... little pain ... does wear a brace because he feels more comfortable ... not because the knee feels unstable.”  The physical examination at that time recorded the absence of effusion, stability to stress testing in all planes, and measured flexion to 130 degrees (normal 140, minimum compensable 45).  A repeat X-ray for the MEB demonstrated “very mild degenerative changes.”  There was no STR evidence for more significant ROM limitation, persistent effusions, locking, instability, or periods of incapacitation after surgical recovery.  There were numerous STR entries documenting a normal gait, with one entry near separation noting the presence of a limp.  

The NARSUM duplicated the history and findings as detailed above in the orthopedic evaluation of November 2007; and, independently recorded a normal gait, “full” ROM, and the absence of instability.  The pre-separation VA C&P examiners documented knee pain rated 4/10 interfering with prolonged sitting or standing, subjective instability, and the use of a brace.  The VA physical examinations recorded a “hesitant” gait, “snapping sensation” with repetitive motion, absence of effusion, “negative ligamentous instability,” and negative signs of impingement.  The VA measured ROM was flexion to “120/140” degrees “without pain.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 10% rating analogous to 5003 (degenerative arthritis) cited the above X-ray finding and was consistent with VASRD §4.71a criteria for the Service ROM evidence (conceding painful motion) and other ratable findings.  The VA’s 10% rating under 5010 (as for the shoulder) was “assigned based on objective evidence of limited motion....”  The evidence does not support the presence of locking with frequent effusions or other criteria to achieve a rating higher than 10% under any alternate code, or of joint instability for additional rating.  After due deliberation, considering all evidence and with deference to reasonable doubt, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication of the right knee condition.  

Contended Bilateral Carpal Tunnel Syndrome.  In April 2007 (20 months pre-separation) the CI was referred to a civilian neurologist for right hand pain and numbness, with subsequent complaints of bilateral symptoms.  Electrodiagnostic studies demonstrated “mild, right greater than left” carpal tunnel syndrome (CTS).  The CI was treated with splints, improved per the neurologist’s progress notes, and surgery was not required.  The condition was mentioned collaterally in subsequent STR entries addressing other complaints, but was not clinically acute or problematic.  A very detailed neurological examination of the right hand was found in an orthopedic entry from November 2007 (12 months pre-separation), and documented the absence of atrophy, 5/5 strength with all hand functions, and intact sensation over all dermatomes.  The NARSUM identified the condition and noted the use of hand splints, did not elaborate severity or specify functional limitations, but recommended continued use of the splints.  The NARSUM physical examination detailed normal strength of hand functions and sensation intact to light touch.  The commander’s performance statement did not specify different conditions or associated limitations, although did elaborate administrative duties which would logically require constant use of a keyboard.  The general post-separation VA examiner documented pain in both hands with a 2 year history of CTS.  The orthopedic C&P examiner noted subjective complaints of bilateral hand numbness and weakness, but objectively by examination detailed normal bilateral hand strength (without atrophy) and sensation.  These findings were the basis of the 0% ratings from the VA.  No use of hand splints or specific functional limitations was documented by either VA examiner.  

The Board’s main charge is to assess the fairness of the PEB’s determination that the bilateral CTS condition was not unfitting.  The Board’s threshold for countering fitness determinations 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.  The STR indicates that the condition was not clinically active at the time of separation.  Although the NARSUM documented that the use of hand splints was indicated and this could logically interfere with the duty requirements documented by the commander, there is no evidence over nearly a 2-year period that the CI was precluded from his duties purely on the basis of the CTS limitations.  Furthermore, the condition was subject to DoDI 1332.38 (E3.P3.3.3 - Adequate Performance Until Referral); which stipulates, “If the evidence establishes that the Service member adequately performed his or her duties until the time the Service member was referred for physical evaluation, the member may be considered fit for duty even though medical evidence indicates questionable physical ability to continue to perform duty.”  All members thus agreed that there was insufficient performance based evidence suggesting that the condition significantly interfered with duty performance.  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 contended bilateral CTS condition; thus, no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the right shoulder condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the right knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended bilateral carpal tunnel syndrome, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  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 20140225, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

Commandant
United States Coast Guard	Mail Stop 7907
2703 Martin Luther King Jr. Ave SE
Washington, DC 20593-7907
Staff Symbol: CG-1
Phone: (202) 475-5000

								   1850

Dear XXXXXXXXXX,
I am the Designated Decision Authority for the Coast Guard on applications submitted to the Department of Defense Physical Disability Board of Review (PDBR).  Under the authority of Title 10, United States Code, section 1554a, I accept the PDBR’s recommendation in your case (Case Number PD-2014-00934) and decline to modify your findings. 

Enclosed for your information are a copy of the PDBR’s recommendation and a copy of the record of proceedings. 

A copy of this decision has also been provided to Coast Guard Enlisted Personnel Management Branch, the PDBR, and the Department of Veterans Affairs. 

If you have any further questions, please contact the Coast Guard Personnel Service Center at (202)795-6645. 
	Sincerely,

2 Enclosures		
	
Copy:	CG Personnel Service Center (EPM-1)
DoD Physical Disability Board of Review
Department of Veterans Affairs