RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01593
BRANCH OF SERVICE: Army 	SEPARATION DATE:  20090601

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, C41 Operator/Maintainer, medically separated “left knee pain” with a disability rating of 10%.    

CI CONTENTION:  The CI contends for his unfitting left knee, his not unfitting mental health (Depression) and right shoulder conditions, and a condition not identified by the MEB/PEB.  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 - 20090130	VARD - 20100823	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Pain	5099-5024	10%	Left Knee, Iliotibial Band Syndrome, S/P Surgical
Release of the Iliotibial Band	5299-5260	10%	20100405	
Depression	Not Unfitting	Major Depressive Disorder, Recurrent	9434	30%	20100405	
Right Shoulder Pain	Not Unfitting	S/P Surgical Repair of Torn Labrum, R Shoulder, with Moderate Degenerative Joint Disease at the R Shoulder	5201	10%	20100405	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

LEFT KNEE PAIN.  A radiology report dated 24 January 2007 indicated the CI had left knee pain off and on for 2 years without any history of trauma.  He had pain going up and down stairs and tenderness to palpation along the joint line, but he had no popping or locking.  X-rays of the knee were normal. Follow-up magnetic resonance imaging (MRI) demonstrated very mild thickening of the proximal aspect of the lateral collateral ligament.  There was no evidence of a meniscal tear or cruciate ligament injury.  In April 2007, the CI stated he had been involved in a motor vehicle accident and X-rays of the left knee showed a small joint effusion and intact bony structures.  A note in November 2007 indicated the CI had a history of a possible iliotibial (IT) band syndrome of the left knee, which was reinjured while running. Treatment consisted of naproxen (a nonsteroidal anti-inflammatory drug [NSAID]) and a referral to physical therapy.  At an orthopedic evaluation in April 2008, the CI could not hold his knee in a fully extended position since he was diagnosed with the IT band syndrome that was not improved by physical therapy.  On examination the CI had significant tenderness to palpation overlying the proximal fibular head what felt to be a thickened bursa over the insertion of the lateral collateral ligament onto the proximal fibula.  Range-of-motion (ROM) testing was 0 degrees extension when forced out straight and about 135 degrees flexion.  There was no laxity other than “a little bit of booking open of the knee joint with varus stress at 30 degrees” with a firm endpoint laterally.  The impression was a chronic lateral collateral ligament sprain and chronic biceps femoris insertion sprain.  Magnetic resonance imaging (MRI) in May 2009 demonstrated findings consistent with an osteochondral lesion in the femoral condyle and an abnormal fluid signal anterior to the patella (kneecap).  All ligaments were intact.  In July 2008 an open partial release of the IT band was planned.  Diagnostic arthroscopy, an open IT band debridement, and a bursectomy were performed on 10 August 2008.  By 29 August 2008 the CI was healing well and had a ROM from 0 to 90 degrees without obvious palpable clicking.  In November 2008 the CI reported his left leg felt very strong (could squat 400 pounds and run long distance); however, the CI still complained of pain with activities such as climbing stairs or running more than a mile.  On 26 November 2009 the CI requested a Medical Evaluation Board as did his unit since he stated his knee was not getting better despite a recent report of 60% improvement.  On examination he had no frank clicking as the leg was brought into flexion and extension.  He had an intact IT band and there were no signs of an effusion.  There was mild tenderness to palpation over the popliteus (a muscle behind the knee) tendon, but the knee was stable.  The orthopedic assessment was chronic IT band syndrome that failed operative intervention.  

At the MEB examination the CI reported on DD Form 2807-1, Report of Medical History, dated 24 November 2008, left knee buckling/IT syndrome and left knee iliopsoas release.  The examiner noted on DD Form 2808, Report of Medical Examination, dated 5 December 2008, and increased pain on the ROM of the left knee.  The commander’s statement dated 5 December 2008 indicated the profile hindered the CI’s performance.  A permanent L3 profile was issued on 16 December 2008 for the left knee IT band friction syndrome with limitations of the physical fitness testing of the 2-mile run and push-ups and all military functional activities except wearing a protective mask and all chemical defense equipment.  The MEB narrative summary (NARSUM) dated 12 December 2008 noted the CI complained of left medial and lateral knee pain with a severity of 6-7/10 and when he ambulated for a prolonged time the pain increased to 7-8/10.  Weight-bearing activities aggravated his pain as did prolonged standing, walking or running.  Examination of the left knee showed lateral medial joint tenderness coursing superiorly along the lateral aspect of the leg to the mid-shaft region.  Tests for laxity and a meniscal tear were negative; however, there appeared to be some instability during a heel-to-toe stand at which time the CI complained of tenderness to the posterior aspect of the epicondyle of the left knee.  There was no edema; and neurologic evaluation was unremarkable.  As a result the CI was unable to perform the requirements of his occupational specialty due to chronic pain.

At the VA Compensation and Pension (C&P) examination dated 5 April 2010, performed 10 months after separation, the CI reported pain, instability, swelling and stiffness.  On examination there was tenderness at various locations at the left knee including at the lateral femoral condyle as well as along the distal half of the left IT band.  On examination left knee flexion was 0-140 degrees and extension was 0 degrees.  There was pain with the last 10 degrees of extension, but there was no loss of motion with repetition.  Ober’s test was positive for a tight IT band on the left.  Knee X-rays in June 2009 were normal bilaterally.  As a result of the left IT band syndrome the CI had difficulty climbing ladders and stairs and was limited with running and riding a bike because of knee pain.  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.

Left Knee ROM
(Degrees)	PT ~8 Mo. Pre-Sep
	MEB ~6 Mo. Pre-Sep
	VA C&P ~10 Mo. Post-Sep
	
Flexion (140 Normal)	135	120	140	
Extension (0 Normal)	0	0	0	
Comment	Tenderness to palpation around lateral incision and distal 1/3 of IT band	Painful motion; pain began at 90; Lachman’s test +1; ROM limited by pain	Ober’s test positive	
§4.71a Rating	10%	10%	VA 10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5099-5024 (tenosynovitis) for left knee pain from the IT band syndrome.  The VA assigned a 10% rating using code 5299-5260 (leg, limitation of flexion) for left knee IT band syndrome, status post-surgical release of the IT band.  The Board sought a route to a higher rating; however, in the absence of ankylosis, knee impairment with recurrent subluxation or lateral instability, meniscal dislocation with frequent episodes of “locking,” pain and effusion into the joint, symptomatic meniscal removal, flexion limited to 30 degrees or less, extension limited to 15 degrees or more, or tibia and fibula 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 for the left knee pain condition.

Contended PEB Conditions.  

Depression.  The CI was referred by his commander in January 2006 for evaluation.  He indicated he had been depressed for years, but in the prior several months his depression had worsened and he had been unable to fulfill his mission as a recruiter.  The initial diagnosis was adjustment disorder with a depressed mood with a Global Assessment of Functioning (GAF) of 45 (serious symptoms).  The CI was admitted for treatment of a major depressive disorder versus double depression (episode of major depression in addition to dysthymia chronic, depressed mood accompanied by just one or two other symptoms of clinical depression that lasts at least 2 years) with a GAF of 30 (serious impairment in communication or judgment or inability to functioning almost all areas).  He had significant vegetative symptoms with significant weight loss.  On examination he had a flat affect with a sad mood.  He gave brief answers, had no hallucinations or delusions, and was not suicidal.  The CI responded well to hospitalization with an improved mood and treatment with Celexa (citalopram, an antidepressant medication) and trazadone (an antidepressant medication) for insomnia.  Outpatient therapy was carried out and the CI was advised to avoid alcohol.  He discontinued Celexa and was started on Wellbutrin (bupropion, an antidepressant) in July 2006.  In December 2008 the CI reported his biggest stressors were the pending MEB, which he did not want, and chronic left knee pain.  The CI met the mental health active duty retention standard at that time.  He agreed to a trial of Zoloft (sertraline, an antidepressant) and was recommended to continue his exercise routine and focus on sleep hygiene.  His affect was normal with some mild flattening and anhedonia.  His mood was euthymic and calm and his affect was congruent with his mood.  Thought processes were not impaired.  Insight was intact and there was no suicidal or homicidal ideation.  The impression was atypical depressive disorder.  In May 2009 the CI reported that he was depressed more than half the day.  He did not tolerate crowds very much and went out of his way to avoid things that reminded him of certain events. He was also startled easily and was on guard constantly.  At a social work outpatient visit the CI was oriented with an angry mood and a guarded affect.  His thought process was organized and goal-directed.  He had no hallucinations, phobias, or delusional thinking noted.  His Axis I diagnosis was depression and his GAF was 60-65 (moderate symptoms to some mild symptoms).  The MEB narrative summary (NARSUM) dated 12 December 2009 noted the CI had a history of depression, was hospitalized, but felt he was stable at time of the NARSUM and had no follow-up.  At the VA C&P Mental Disorders examination dated 5 April 2010, performed 10 months after separation, the CI reported he randomly felt really down, had weight gain and loss, and sleep impairment.  He was working full time and denied suicidal ideation and homicidal ideation.  On examination his speech was unremarkable; his affect was constricted; his mood was depressed; his orientation to person, time and place was intact; thought process and content were unremarkable; he had no delusions or hallucination; his judgment and insight demonstrated understanding; he had no panic attacks or suicidal or homicidal thoughts; and his immediate memory was mildly impaired, but remote and recent memory were normal.  His Axis I diagnosis was major depressive disorder, recurrent with a GAF of 60 (moderate symptoms).  He did not have deficiencies in judgment, thinking, family relations, work, mood or school; however, there was reduced reliability and productivity due to mental disorder symptoms.  Social isolation and irritability negatively impacted social functioning and his reported chronically depressed mood likely negatively impacted his quality of life.     The Board majority determined that there was not sufficient evidence of this depression affecting his ability to perform the duties of his MOS.  The depression condition was not profiled and not implicated in the commander’s letter.  Therefore the Board majority determined that the evidence in the record was insufficient to overturn the PEB’s fitness determination.

Right Shoulder Pain.  An MRI dated 11 December 2008 was ordered for chronic intermittent right shoulder pain that began in 2005.  It demonstrated a possible posterior labral detachment with possible posterior impingement, subchondral cystic change at the deltoid muscle insertion, which may have indicated long-standing inflammatory change and chondromalacia (inflammation and softening of the cartilage) and possible minimal biceps tendinosis.  At an orthopedic evaluation on 22 December 2008 the CI had positive apprehension and relocation tests (to determine laxity) and his right sub-acromial pain was treated with a steroid injection, which provided pain relief; and he was referred for physical therapy.  At an emergency room visit on 20 March 2009, the CI had pain and muscle spasms in the right shoulder following same day surgery on his shoulder.  Treatment consisted of Valium (diazepam, a muscle relaxer), which diminished the pain.  A note dated 9 June 2009, 1 week after separation, indicated the CI’s right shoulder had a diminished ROM that required further physical therapy.  In October 2009 an orthopedic surgeon noted the CI, who complained of severe right shoulder pain, had a history of multiple injuries to the shoulder and had developed the ability to voluntarily subluxate or dislocate his shoulder posteriorly prior to having a posterior labral repair 3 months before separation.  On examination the CI had a forward flexion of 150 degrees, abduction of 100 degrees, external rotation of 45 degrees, and internal rotation to T-12.  Tests were positive for shoulder impingement, a possible labral tear, and bicipital tendinitis.  Nonoperative and operative options were offered including a diagnostic arthroscopy of the right shoulder with labral and biceps treatment as indicated with possible subpectoral biceps tenodesis with probable subacromial decompression and distal clavicle resection.  In November 2009 arthroscopy and extensive debridement including a synovectomy (joint membrane removal) of the glenohumeral joint, chondral (cartilage) debridement including resection of a large articular cartilage cyst and extensive labral debridement along with loose body and loose suture removal were carried out.  At the VA C&P examination dated 5 April 2010 the CI reported injuring his right shoulder during log roll physical training and reinjured it during a basketball game in 2008.  He noted he underwent surgery in which bone was shaved down and the labrum was repaired followed by postoperative physical therapy.  Shoulder pain was not as severe post the second surgery.  The ROM measurements were forward flexion 0-180 degrees, right abduction 0-150 degrees with repetition, right external rotation 0-70 degrees, and right internal rotation 0-60 degrees.  

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.

Right Shoulder ROM
(Degrees)	MEB ~# Mo. Pre-Sep
	VA C&P ~10 Mo. Post-Sep
	
Flexion (180 Normal)	-	180	
Abduction (180)	-	150	
Comments	Increased pain and weakness; LROM; pre-shoulder surgery	Post shoulder surgery two times; abduction decreased from 180 to 150 with repetition	
§4.71a Rating	(PEB-Not Unfit) 	VA 10%	

The aforementioned was reviewed and considered by the Board.   There was no performance based evidence from the record that the depression and right shoulder pain conditions significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board majority concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the depression and right shoulder pain contended conditions; and, so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the left knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended depression and right shoulder conditions, the Board majority recommends no change from the PEB determinations as not unfitting.  The single voter for dissent submitted the appended minority opinion.  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 20140401, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

		

Minority Opinion

Depression.

The CI should be found unfit for depression, which had been present for years in the form of dysthymia.  Furthermore, it was exacerbated by his inability to perform as a recruiter, other life challenges, and knee pain.  As a result he was removed from recruiter duty and then performed other support duties.  The commander’s statement on which Board members use as a guideline in determination of fitness/unfitness was prepared on a form which had yes or no answers.  The two boxes checked no clearly and unequivocally defined the CI’s inability to do any job.  He could not perform his assigned MOS duties in the unit and did not perform alternate duty well.  However, the shortfall of the commander’s statement was evident.  The CI had a mental health condition, but the questions in Section III INDUSTRIAL CAPACITY STATEMENT, which is specifically for those individuals with a psychiatric disorder, a traumatic brain injury, and/or other neurological conditions was labeled N/A with a line was drawn down the list of critical questions for the determination of fitness such as whether the CI worked an 8 hour day, was going to appointments, had memory issues, was able to complete tasks, or sustain an ordinary routine without extra support.  Furthermore, the sole, brief statement “Profile hinders job performance” in Section V missed the opportunity to address other medical issues that the CI had—namely mental health and right shoulder pain (discussed below).  That silence on critical questions failed to provide guidance for the psychiatric evaluation, which noted that the CI had depression that persisted and was marked by decreased sleep, energy and concentration as well as the stressors related his chronic left knee pain, but did not mention the CI’s right shoulder pain.  While the CI was determined to meet mental health active duty Army retention standards, the caveat “at this time” was most evident.  However, the psychiatrist did not address the industrial factors that limited the CI’s ability to remain fully functional on active duty—his removal from recruiting duty and his inability to perform his MOS or to perform alternate duty well.  Furthermore, the diagnosis of an atypical depressive disorder was made and sertraline was prescribed, but there was no GAF score and there is no evidence as to whether the CI was seen at a follow-up psychiatry appointment that was scheduled for 12 January 2009.  However, the CI was seen by a Licensed Certified Social Worker in May 2009, who recorded a GAF score of 60-65 (moderate symptoms).  Since the CI was not performing his MOS and had long term depressive symptomatology, his fitness for duty at best was dubious and he was certainly not fit for full duty without limitations, whether those be for medication or follow-up mental health treatment and/or evaluation.  Therefore, it is recommended the Board determine the CI was not fit for full duty because of depression and he be assigned a 10% rating (occupational and social impairment due to mild or transient symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress, or, symptoms controlled by continuous medication) using code 9434 IAW §4.130 criteria.

Right Shoulder Pain.  The CI’s right shoulder pain began in 2005 and he underwent surgery in 2009 based upon MRI findings of a possible posterior labral detachment with possible posterior impingement, subchondral cystic change at the deltoid muscle insertion, which may have indicated long-standing inflammatory change and chondromalacia (inflammation and softening of the cartilage) and possible minimal biceps tendinosis.  Postoperatively he had muscle spasms and pain.  Post-separation the CI had a forward flexion of 150 degrees, abduction of 100 degrees, external rotation of 45 degrees, and internal rotation to T-12.  Tests were positive for shoulder impingement, a possible labral tear, and bicipital tendinitis.  In November 2009 arthroscopy and extensive debridement including a synovectomy (joint membrane removal) of the glenohumeral joint, chondral (cartilage) debridement including resection of a large articular cartilage cyst and extensive labral debridement along with loose body and loose suture removal were carried out.  
Clearly with pathology so significant, the CI would be unable to do has job and was, in fact, unable to do his job.  While the focus of orthopedic intervention was directed to the CI’s knee condition, nevertheless the right shoulder pain also warranted intervention that was deferred or delayed until shortly before separation and ultimately required at least two surgical interventions proximate to separation.  Furthermore, it should be noted that increased shoulder pain and instability occurred after the profile and commander’s statement were prepared thereby precluding the shoulder condition to be addressed in those documents.  Therefore, it is recommended the Board determine the CI was not fit for full duty based on the preponderance of evidence with regard to the functional impairment of the right shoulder pain contended condition and he be assigned a 10% rating using code 5099-5003 (degenerative arthritis) IAW  VASRD §4.71a criteria. 

For the aforementioned reasons, the Board minority 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	
Left Knee Pain	5099-5024	10%	
Depression	9434	10%	
Right Shoulder Pain	5099-5003	10%	
RATING	30%	

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 XXXXXXXXXXXXXXXXXXXXXXX AR20160007302 (PD201401593)

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