RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01402
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080507

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E3, Motor Transport Operator, medically separated for “left shoulder injury” and “left knee pain,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI made no specific contention in his application.  The CI’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 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 - 20080226	VARD - 20090226	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Injury to the Left Shoulder	5099-5003	10%	Residuals, Left Shoulder Injury…	5201-5010	10%	20080911	
Chronic Left Knee Pain	5099-5003	10%	Left Knee Strain…	5260-5024	10%	20080911	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Left Shoulder Condition.  According to service treatment records and the MEB narrative summary (NARSUM), the right-hand dominant CI injured his left shoulder in August 2006 from pulling heavy equipment.  Magnetic resonance imaging (MRI) on 14 August 2006 showed a partial rotator cuff tear.  The CI was deployed and re-injured the shoulder and ongoing pain led to a distal clavicle resection in June 2007.  At an orthopedic follow-up visit on 16 July 2007, the CI reported continued shoulder pain and numbness and tingling from the surgical incision to the upper arm.  The examination noted decreased ROM and atrophy of the rotator cuff muscles, with painful motion, without objective sensory loss, and physical therapy was recommended.  In August 2007 the CI was involved in a motor vehicle accident which aggravated the shoulder pain.   

At the time of the orthopedic follow-up appointment on 23 August 2007, 2 months after surgery, the examiner recorded that the CI was not doing physical therapy as directed.  The CI reported that he continued to have left shoulder pain that was worse with movement.  On examination he had painful motion and was tender to palpation.  There were no sensory abnormalities and he had no swelling.  Shoulder X-rays indicated appropriate healing of the surgical site.  The CI’s left shoulder condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and was referred for a Medical Evaluation Board (MEB).

At the MEB examination (recorded on DD Forms 2807 and 2808) dated 17 December 2007, 5 months before separation, the CI reported that he was unable to perform certain motions due to his left shoulder condition.  Physical exam showed decreased ROM and pain with movement.  At the time of the physical therapy MEB ROM visit on 28 December 2007, 5 months before separation, the examiner recorded that the CI’s ROM, as indicated in the chart above, was limited by pain.  According to the MEB NARSUM evaluation on 10 January 2008 (4 months prior to separation) the CI complained of shoulder pain.  The CI also reported that he had “numbness, tingling or weakness in the left shoulder.”  Shoulder dislocations were not reported.  There was no swelling or redness and tests for rotator cuff pathology were negative.  He was neurovascularly intact, his reflexes were normal, and he had no atrophy in his left shoulder.  He had a well-healed surgical scar that was tender to palpation with “deep pressure.”  Left shoulder X-rays showed some bone formation at the end of the clavicle resection.

At the VA Compensation and Pension (C&P) examination on 11 September 2008, 4 months after separation, the CI reported symptoms of pain, weakness, stiffness, intermittent swelling, intermittent heat, redness, instability, locking, fatigability, and lack of endurance.  He had flare-ups twice a week that were precipitated by lifting, pulling or pushing movements such as changing a tire or doing the dishes and typing caused pain to radiate up his arm.  Physical examination showed tenderness, but no atrophy due to disuse and no swelling or redness.  Left upper extremity strength and reflexes were normal.  ROM was limited as indicated in the chart above.  Shoulder X-rays showed degenerative bony changes of the distal clavicle status post-surgery.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5003 code (degenerative arthritis), citing “slight limitation in full abduction.”  The VA also assigned a 10% rating using the 5201-5010 code (arm limitation of motion due to traumatic arthritis), citing “painful or limited motion of a major joint.”  The VASRD §4.71a (code 5201, arm limitation of motion) threshold for a minimum rating for ROM impairment is “at shoulder level” (90 degrees from the side), and the ROM in evidence demonstrated motion above this level.  Although the limitation of motion did not support a minimum rating (5201), Board members agreed that a 10% rating was justified coded as 5099-5003 for limited motion of a single major joint with imaging evidence of degenerative changes or with application of VASRD §4.59 (painful motion) for painful motion.  There was no malunion or recurrent dislocation of the humerus to justify a rating under the 5202 code (humerus, other impairment of); and no nonunion with loose movement of the clavicle to warrant the next higher 20% rating under the 5203 code (clavicle or scapula, impairment of).  Although the VA rated “nerve damage, left shoulder to hand, status post left rotator cuff surgery” under diagnostic code 8516-8519 at 0%, citing numbness of the left hand and shoulder, Board members agreed that the objective evidence contained in the examinations proximate to separation did not reflect significant disability due to the left upper extremity sensory disturbances, and any disability from this condition was subsumed in the PEB’s rating of the CI’s left shoulder.  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.

Left Knee Condition.  According to service treatment records and the MEB narrative summary (NARSUM), the CI reported left knee pain after the motor vehicle accident noted above.  Left knee X-rays were normal.  At the time of the orthopedic clinic appointment on 27 September 2007, 7 months before separation, the examiner noted the CI was in the MEB process for his left shoulder condition. The CI reported pain on the inside of the knee, aggravated by walking, kneeling and squatting.  He denied locking or other mechanical symptoms.  The examination showed crepitus and diffuse knee tenderness.  The CI had no swelling, edema, redness, or warmth on the knee.  He had full active ROM (reported as extension of 0 degrees and flexion of 130 degrees), without eliciting pain.  Tests for ligamentous instability and meniscal pathology were all negative.  The examiner indicated that the diagnosis was consistent with anterior knee pain, no surgery was indicated, and the CI was determined to meet retention standards for the left knee condition.  However, at a PC visit 11 December 2007, the examiner indicated that a medical board had been requested by the orthopedic specialist.   

At the MEB examination (recorded on DD Forms 2807 and 2808) dated 17 December 2007, 5 months before separation, the physical examination showed pain with movement, left greater than right.  At the MEB NARSUM examination on 10 January 2008, 4 months prior to separation, the CI reported that his knee pain was worse “with movement, walking, kneeling, or squatting.”  On examination he was noted to have patella crepitus and tenderness.  He had a negative McMurray’s test (meniscal injury) and there was no effusion, and the knee was stable to varus, valgus, and anterior/posterior drawer testing.  His ROM was described as full and is listed in the chart above.  A left knee MRI performed on 1 February 2008 at a non-military facility showed a medial meniscus tear with low grade chondromalacia and an osteochondroma (benign tumor- incidental finding not related to his symptoms).  

At the time of the physical therapy clinic appointment for MEB ROM on 6 February 2008, 3 months prior to separation, the examination showed that he had painful motion and a no evidence of instability.  His ROM was limited as indicated in the chart above. 
 
At the VA Compensation and Pension (C&P) examination on 11 September 2008, performed 4 months after separation, the CI told the examiner that he had pain, weakness, stiffness, swelling, redness, instability, locking, fatigability and lack of endurance in his left knee.  He denied flare-ups or episodes of dislocation or subluxation.  The CI reported that he didn’t walk much because of left knee pain.  The physical exam showed a normal gait without use of a cane or a crutch.  There was no evidence of tenderness, painful motion, effusion, or weakness.  Testing for ligamentous instability and meniscal pathology was negative.  Left knee motion was decreased as indicated in the chart above.  There was no additional loss of ROM, pain, weakness, fatigue, or lack of endurance with repetition of ROM.  Left knee X-rays on 14 July 2008 were noted to be negative (other than the benign tumor previously noted).

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5099-5003 code (degenerative arthritis), citing slight loss of ROM due to pain.  The VA also assigned a 10% rating using an analogous 5260-5024 code (limitation of flexion due to tenosynovitis) based on the VA C&P examination 4 months after separation, citing painful or limited motion of a major joint.  There was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 5261). However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB.  The knee MRI in February 2008 (following the MEB NARSUM exam) showed a tear of the left knee medial meniscus, thereby providing support for a 10% rating coded as 5299-5259, however, this provides no rating benefit to the CI and an additional rating cannot be provided because 5259 includes consideration of the same disability due to painful motion and is subsumed in the 5099-5003 rating.  The examinations proximate to separation did not demonstrate the presence of frequent locking with effusions or any indication of dislocated meniscus or loose body (5258) to support a higher rating with this code.  There was no evidence of instability for consideration of primary or additional rating under 5257.  There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  There is therefore no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code, and no grounds for additional rating based on the presence of instability.  

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.

BOARD FINDINGS:  In the matter of the left shoulder condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left knee condition 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 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 20140316, 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, AR20160006057 (PD201401402)

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