RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01629
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060921

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Shower/Laundry and Clothing Repair Specialist, medically separated for “chronic left knee pain status post ACL repair” and “chronic left shoulder pain secondary to IED blast,” rated 0% and 0%, respectively; with a combined disability rating of 0%.

CI CONTENTION:  The applicant makes no specific contention in his application.  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 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 - 20060718	VARD - 20080918	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain…	5099-5003	0%	Residuals, Status Post Left Knee ACL Repair	5299-5257	10%	20080728	
Chronic Left Shoulder Pain…	5099-5003	0%	Status Post Left Distal Clavicle Resection with DJD of the Left AC Joint (Non-Dominant)	5010-5203	10%	20080728	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:

Chronic Left Knee Pain.  According to service treatment records and the Medical Evaluation Board (MEB) orthopedic addendum to the narrative summary (NARSUM), the CI underwent left knee surgery in 2000 for a torn anterior cruciate ligament (ACL) with a revision ACL surgery in June 2003 following a twisting injury.  He left knee was reinjured proximate to an improvised explosive device (IED) explosion in September 2004.  Magnetic resonance imaging (MRI) studies April 2005 showed the ACL graft and posterior cruciate ligament (PCL) intact.  The medial collateral ligament (MCL) and lateral collateral ligament (LCL) complexes were also intact.  There was no evidence of acute meniscal tear.  There were no areas of cartilage loss or abnormality.  There were stable post-traumatic changes involving the lower pole of the patella (degenerative arthritis).

At the time of the orthopedic clinic appointment on 8 July 2005, 15 months before separation, the physical examination showed knee pain elicited by motion and tenderness to palpitation.  Testing indicated no instability.  No meniscal integrity tests were performed.  The range of motion (ROM) was 0-100 degrees (normal 0-140).

Despite treatment, the CI’s knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and was referred for MEB.

The MEB orthopedic addendum to the NARSUM on 26 March 2006, performed 7 months before separation, noted the CI had knee pain at rest and difficulty negotiating stairs and with twisting motions.  He complained of frequent swelling and used a custom knee brace.  The physical examination showed a mildly antalgic gait on the left side and mild medial joint line tenderness.  Testing for lateral and medial collateral ligament instability was negative.  A Lachman test was 2A for ACL integrity (abnormal; 6-10mm loose movement with a good endpoint).  There was no rotary instability and minimal signs of degenerative arthritis.  The ROM was limited as charted above.

At the VA Compensation and Pension (C&P) examination on 28 July 2008, performed 23 months after separation, the CI reported 8/10 left knee pain with weakness, stiffness, swelling, instability, locking, fatigability and lack of endurance.  The physical examination showed a normal gait.  The medial and lateral collateral ligaments were intact.  The ACL, PCL, MCL and LCL were intact.  Medial and meniscus test were negative.  The ROM was painful and limited.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 0%, coded analogous to 5003 (arthritis, degenerative), citing “no gross instability (Lachman 2A) is reported as limited to 72 degrees by pain alone, no evidence of mechanical block.”  This was likely application of AR 635-40 in effect at the time (although the 72 degrees limit [versus 104 degree knee limit] was likely shoulder flexion reported on the MEB orthopedic addendum).

The VA rated the left knee condition 10% coded analogous to 5257 (knee, other impairment of; instability), citing painful or limited motion of one major joint, based on the post-separation C&P examination 23 months after separation.
The Board noted the disparity between the MEB and VA examinations and carefully reviewed the evidence proximate to separation to determine the probative value of each examination.  The Board adjudged that the MEB examination had the highest probative value for rating at separation due to being substantially closer to the date of separation.

There was no limitation of flexion or extension that supported a minimum rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  The examinations proximate to separation did not show evidence of frequent locking with effusions or any indication of dislocated meniscus or loose body (5258), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  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).

The Board next considered whether dual rating of the knee for instability under code (5257) was supported by the evidence.  The MEB orthopedist examination documented a “2A” Lachman test (for ACL deficiency) which indicated abnormal laxity of 6-10mm of movement; with the “A” being interpreted as a firm endpoint.  “2A” is categorized from mild to moderate instability following ACL repair, depending on the medical reference used.  The Board adjudged the instability was slight (10%).

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 chronic left knee pain condition, coded 5099-5003, plus a disability rating of 10%, coded 5257.

Chronic Left Shoulder Pain.  According to service treatment records and the MEB orthopedic addendum to the NARSUM, the right hand dominant CI injured his left shoulder in 2004.  Magnetic resonance imaging (MRI) studies in April 2005 were normal.  Ongoing pain led to surgery in December 2005 (subacromial decompression and Mumford procedure), approximately 9 months prior to separation.  Surgery failed to adequately improve the condition.  Following surgery, further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “left shoulder acromioclavicular joint arthrosis” for PEB adjudication.

According to the MEB orthopedic addendum to the NARSUM evaluation on 2 March 2006 (7 months prior to separation) the CI complained of shoulder pain with any overhead activity which caused him to be unable to lift his arm over his head, reach for his wallet or carry heavy objects.  Shoulder dislocations were not reported.  Physical examination showed a negative apprehension relocation test for instability.  There was a positive Hawkins test for impingement and a positive O’Brien’s test indicating potential labral or acromioclavicular (AC) lesions as a cause of shoulder pain.  There was tenderness to palpitation over the AC joint.  There was a positive cross arm test suggestive of AC joint arthritis or painful motion.  Plane radiographs revealed resection of the distal clavicle.  Left shoulder additional examination findings
.
At the VA C&P examination the CI reported pain on motion.  Physical examination showed tenderness and facial grimacing on ROM testing.  There was no guarding of movement, effusion, instability or weakness.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under an analogous 5099-5003 code (degenerative arthritis), citing limitation of flexion due to pain (likely application of AR 635-40).  The VA assigned a 10% rating using a 5010-5203 code (arthritis due to trauma - clavicle or scapula, impairment of) for painful or limited motion of a major joint or group of minor joints, based on the VA examination.

The Board noted the disparity between MEB and VA examinations and carefully reviewed the evidence proximate to separation to determine the probative value of each examination.  The Board adjudged that the MEB examination had the highest probative value for rating at separation due to being substantially closer to the date of separation.

The evidence supported a rating higher than the PEB’s rating with application of VASRD-only criteria.  The VASRD §4.71a (code 5201, arm limitation of motion) threshold for a rating for ROM impairment is “at shoulder level” (90 degrees from the side).  The 20% rating for the non-dominant arm (minor) requires motion limited to “at shoulder level” and the MEB orthopedic examination, most proximate to the date of separation, reflected this degree of limitation, with functional limitation of inability to work overhead.  There was no evidence that the non-dominant shoulder was limited to 25 degrees from the side for any 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 20% for the left shoulder condition.

BOARD FINDINGS:  In the matter of the chronic left knee pain, the Board unanimously recommends a disability rating of 10%, coded 5099-5003, plus a disability rating of 10%, coded 5257, both IAW VASRD §4.71a.  In the matter of the left shoulder pain, the Board unanimously recommends a disability rating of 20%, coded 5201 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  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 prior to medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Left Knee Pain	5299-5003	10%	
	5257	10%	
Chronic Left Shoulder Pain	5201	20%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140410, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

28 JUL 2016

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, AR20160006815 (PD201401629)

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 recharacterize the individual's separation as a permanent disability retirement with the combined disability rating of 40% 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 40% 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
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