RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	     CASE:  PD-2014-03370
BRANCH OF SERVICE:  Army                                                                  SEPARATION DATE:  20090110

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E5, Carpentry and Masonry Specialist, medically separated for “chronic right shoulder pain…” and “chronic right knee pain…” rated 10% and 10% respectively, with a combined disability rating of 20%. 

CI CONTENTION:  The CI requested consideration of all conditions.  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 based upon a 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 - 20081120	VARD - 20090616 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Shoulder Pain…	5099-5003	10%	Right Shoulder Subacromial Bursitis with Supraspinatus Tendonitis (Major)	5019	10%	20090224	
Chronic Right Knee Pain…	5099-5003	10%	Right Knee Medial Meniscus Degenerative Changes	5010-5260	10%	20090224	
Asthma	Not Unfitting	Asthma	6602	10%	20090224	
History of Depression with Post Operation Iraqi Freedom Stress Symptoms	Not Unfitting	Acquired Psychiatric Disorder to Include Post Traumatic Stress Disorder 	9411	30%	20090224	
Vitamin D Deficiency	Not Unfitting	Vitamin D Deficiency	7899-7805	NSC	20090224	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Chronic Right Shoulder Pain.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic right shoulder pain condition began after a series of injuries in March 2003 while throwing a softball, February 2006 lifting a duffel bag and March 2006 putting on a rucksack.  A post- arthrogram MRI study in March 2006 showed a very high-grade partial thickness tear of the undersurface of the supraspinatus tendon anteriorly.  A repeat MRI in September 2006 showed mild, stable supraspinatus tendinosis without a tear and stable subacromial bursitis (collection of fluid).  The CI was treated with physical therapy and steroid injections.  She subsequently underwent a lateral clavicle resection, subacromial decompression and biceps tenodesis of the right shoulder in July 2007 followed by physical therapy postoperatively.  She reinjured her shoulder after a fall in September 2007 and had pain thereafter, although her range of motion (ROM) and strength improved.  She was unable to wear body armor, rucksack, or perform her MOS duties.  Electrodiagnostic studies of the right upper extremity and neck were normal in April 2008.  An MRI in April 2008 revealed a mild component of tendinopathy involving the supraspinatus tendon, but no evidence of a tear.  Minimal fluid within the subacromial/subdeltoid bursa suggested bursitis.  Three rounded densities were noted in the area of the humeral head suggestive of debris or loose bodies.  A rheumatologic workup in March 2008 was negative.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “right shoulder pain with tendinopathy” for PEB adjudication.  

At the MEB examination (recorded on DD Form 2807 Report of Medical History and DD Form 2808 Report of Medical Examination) dated 8 September 2008, 4 months prior to separation, the CI reported “rotator cuff right shoulder.”  Physical examination revealed well healed portal scars about the right shoulder with flexion to 160 degrees and abduction to 160 degrees.  Orthopedic evaluation on 10 September 2008 showed a full active ROM of the right shoulder with negative Neer and Hawkins impingement tests, negative Speed (for biceps tendinitis), load and shift and apprehension tests (to assess the stability of the glenohumeral joint) and a mildly positive O’Brien test (to determine a tear of the labrum of the shoulder).  There was symmetric internal and external rotation and there was 4/5 strength in the right arm compared to the left.  X-rays of the right shoulder in September 2008 showed a widened acromioclavicular joint.  The NARSUM examination dated 12 September 2008, performed 4 months prior to separation, revealed active ROM of the right shoulder as seen in the chart below.  Strength was 5/5 of the upper extremities bilaterally.  Reflexes and sensation were intact.  There was an increase in pain, lack of endurance, fatigue and weakness with repetition, but no instability, incoordination, or decrease in the ROM. 

At the VA Compensation and Pension (C&P) examination on 24 February 2009, performed 1 month after separation, the CI reported intermittent right shoulder pain depending on activities and fatigability and lack of endurance when lifting overhead with weighted objects.  Physical examination revealed no shoulder atrophy, edema, effusion, instability, weakness, redness, heat, abnormal movement, or guarding.  Shoulder ROMs are noted in the chart below.  There was some discomfort over the supraspinatus muscle and its strength was 3-4/5.  There was pain on palpation of the subscapularis tendon/muscle and acromioclavicular area.  

The ROM examinations 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 ~4 Mo. Pre-Sep	VA C&P ~1 Mo. Post-Sep	
Flexion (180 Normal)	160, 155, 160	0-170	
Abduction (180)	160, 160, 160	0-170	
Comments	Pain at end ranges	No limitation of motion on repetition	
§4.71a Rating	PEB 10%	VA 10%	

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 loss of range of motion.  The VA also assigned a 10% rating using the 5019 code (bursitis) based on the VA C&P examination 1 month after separation, citing limited/painful motion.  The VASRD §4.71a threshold for rating for ROM impairment (code 5201, arm limitation of motion) is “at shoulder level” (approximately 90 degrees from the side), and the examinations in evidence demonstrated motion above this level.  Although there was insufficient limitation of motion to support a rating under the 5201 code, Board members agreed that a 10% rating was justified with application of VASRD §4.59 (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).  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 chronic right shoulder pain condition.  

Chronic Right Knee Pain.  According to STRs and the MEB NARSUM, the CI’s chronic right knee pain condition began in June 2006 after kicking a duffle bag during loading of equipment and gear.  An MRI of the right knee was consistent with a medial collateral ligament second-degree sprain.  Also noted were a mild grade 1 to 2 signal at the posterior horn and posterior body of the medial meniscus and mild central articular cartilage thinning of the medial and lateral compartments.  A repeat MRI in September 2007 was unchanged with an incidental finding of a distal small likely enchondroma (later called a femoral cyst).  The CI continued to have discomfort in the right knee and was unable to do any impact activities.  She underwent a diagnostic arthroscopy in October 2007 with debridement and excision of arthrofibrosis (joint thickening) and a medial suprapatellar plica (a fold of synovial membrane) removal.  She continued to have pain despite physical therapy with weight bearing, ruck marching, and any impact activities.  A bone scan in March 2008 revealed photopenic (decreased density) defects about both knee joints.  Orthopedic evaluations of the right knee in March 2008 and September 2008 showed no effusion, erythema, or ecchymosis.  There was full active ROM (0-142 degrees) of the right knee.  Quadriceps and hamstring strength was 5/5 with no tenderness to palpation over the medial or lateral joint lines.  There was no instability and the knee ligaments were stable.  There was a palpable medial plica, which was not symptomatic or painful.  X-rays of the bilateral knees in September 2008 were normal.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic anterior knee pain” for PEB adjudication.  

At the MEB examination (recorded on DD Form 2807 Report of Medical History and DD Form 2808 Report of Medical Examination) dated 8 September 2008, 4 months prior to separation, the CI reported arthritis in the right knee and used a “brace on the knee as it acts up.”  Physical examination of the right knee revealed a full active ROM (0-140 degrees three times without pain) with tenderness to palpation on the medial compartment.  There was no laxity or evidence of a meniscal tear.  The NARSUM examination dated 12 September 2008, 4 months prior to separation, revealed a full ROM of the right knee with tenderness to palpation over the medial compartment.  There was no instability, crepitus, or effusion.  The ROM was 0-140 degrees bilaterally three times without pain or decrease in the ROM.

At the VA C&P examination on 12 September 2008, performed 4 months before separation, the CI reported right knee pain as constant.  Physical examination revealed minimal leg length discrepancy with the left greater than the right.  ROM measurements of the knees bilaterally were 0 - 145 degrees with limitation of motion with repetition.  There was no laxity or evidence of a meniscal tear.  Strength was 5/5 with no pain and the CI was able to bear weight on the right leg and then the left leg.    

The ROM examinations 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 Knee ROM
(Degrees)	MEB ~4 Mo. Pre-Sep	VA C&P ~1 Mo. Post-Sep	
Flexion (140 Normal)	0-140 	0-145	
Extension (0 Normal)	0	0	
Comment	Increase in pain with repetition; no decease in ROM with repetition	Limitation of motion with repetition	
§4.71a Rating	PEB 10%	VA 10%	

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 painful motion.  The VA also assigned a 10% rating using a dual 5010-5260 code (traumatic arthritis and leg, limitation of flexion) based on the VA C&P examination 1 month after separation, citing limited/painful motion.  There was no limitation of motion which supported a 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 examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258).  The 5259 code (cartilage, semilunar, removal of, symptomatic) was applicable in this case but the maximum 10% rating under that code provided no benefit to the CI.  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).  Therefore, there was 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 chronic right knee pain condition.  
  
Contended PEB Conditions: Asthma, History of Depression with Post Operation Iraqi Freedom Stress Symptoms, and Vitamin D Deficiency.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the chronic right shoulder pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic right knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended asthma, history of depression with post operation Iraqi freedom stress symptoms, and vitamin D deficiency 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 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 20140626, 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

17 NOV 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160017180 (PD201403370)

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