RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03734
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080623

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E4, Tactical Automated Fire Control Systems, medically separated for “chronic right (dominant) shoulder pain” and “patellofemoral pain syndrome left knee,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI contends he was rated 20% for his right shoulder, 10% for his left knee, by the VA and that “obstructive sleep apnea (OSA), low back strain, and bilateral foot pain were not addressed 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 based on 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 – 20080307	VARD - 20081114	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right (Dominant) Shoulder Pain	5099-5003	10%	Residuals, Status Post Arthroscopic Repair, SLAP Tear Right Shoulder	5201	10%	20080807	
Patellofemoral Pain Syndrome Left Knee	5099-5003	10%	Degenerative Joint Disease, Patellofemoral Syndrome Left Knee 	5010-5260	0%		
Obstructive Sleep Apnea	Not Unfitting 	Obstructive Sleep Apnea	6847	50%		
Bilateral Foot Pain		Plantar Fasciitis, Bilateral	5299-5276	10%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Right (Dominant) Shoulder Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), this right-handed CI underwent right shoulder surgery in July 2007 to repair torn cartilage.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic right shoulder pain status-post SLAP [superior labral anterior-posterior] repair” for PEB adjudication.

At the time of the physical therapy (PT) appointment on 10 January 2008, the CI reported constant pain.  He was able to do vertical push-outs from a wall, but unable to perform a standard push-up from the floor.  On examination, arm strength of the right shoulder was slightly decreased.  Range of motion (ROM) was recorded as flexion of 165 degrees (180 normal) and abduction of 170 degrees (180 normal).  At the MEB NARSUM examination on 22 January 2008 (5 months prior to separation) the CI complained of right shoulder pain.  He was able to work briefly with his arm at a horizontal position, but working higher than shoulder level was not possible.  Shoulder dislocations were not reported.  The CI was not taking any pain medication.  Physical examination showed no signs of impingement, or tear of the rotator cuff (the muscles & tendons supporting the shoulder).  ROM was recorded as flexion of 165 degrees and abduction of 160 degrees.  

At the 7 August 2008 VA Compensation and Pension (C&P) evaluation, performed 6 weeks after separation, the CI reported mild shoulder pain that was made worse with shoulder activity.  He was taking no pain medication, and he denied shoulder dislocation.  His civilian job involved reaching and lifting, which aggravated the shoulder pain.  Physical examination showed good strength, tone, and bulk of the right arm, with intact sensation.  ROM was recorded as flexion of 165 degrees and abduction of 155 degrees.  Radiologic (X-rays) studies of the right shoulder were normal.  
 
The Board directed attention to its rating recommendation based on the evidence.  The PEB assigned a 10% rating under an analogous 5003 code (analogous to degenerative arthritis), citing painful motion.  The VA also assigned a 10% rating using 5201 code (arm, limitation of motion), citing “limited, painful range of motion.”  The VASRD §4.71a threshold for rating for ROM impairment (code 5201, arm limitation of motion) is “at shoulder level” (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 5201 code, Board members agreed that a 10% rating was justified with the 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 clavicle to warrant the next higher 20% rating under the 5203 code (clavicle or scapula, impairment of).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board found insufficient cause to recommend a change in the PEB adjudication for the chronic right shoulder pain.  

Patellofemoral Pain Syndrome, Left Knee.  According to STR and the MEB NARSUM, the CI’s left knee condition began in October 2005 after running.  Magnetic resonance imaging showed evidence of joint inflammation.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty. The MEB forwarded “chronic left knee pain due to patellofemoral syndrome” for PEB adjudication.  

The MEB NARSUM examination on 22 January 2008 (5 months prior to separation) noted complaints of left knee pain that was increased by exercise or changes in weather.  The CI reported an inability to do “any significant running.”  On physical examination, there was “no particular pain on patellar grind” (the presence of pain, a positive test, is indicative of possible damage to the cartilage under the kneecap).  There was no swelling and ligament and meniscal signs were negative (indicating there were no signs of damage to ligaments, or meniscal cartilage).  ROM was noted to be limited by bulky muscles, and not limited by pain, with flexion of 112 degrees (140 normal) and normal extension of 0 degrees.  At the time of the PT appointment on 20 March 2008, the CI reported mild knee pain (1/10) after walking 2 miles.  He had no pain with stairs.  Physical examination revealed no swelling, good mobility of the joint, strength was normal, he was able to do 10 squats without pain, and ROM was normal.  

At the 7 August 2008 VA C&P examination (6 weeks after separation), the CI reported mild pain with climbing stairs or prolonged standing.  He denied swelling, redness, or locking, but reported occasional mild instability.  He denied use of medication or braces.  Knee dislocations were denied.  The knee pain did not interfere with work or activities of daily living.  On physical examination the CI had a normal gait and ROM testing showed left knee flexion to 130 degrees.  Knee ROM was limited by the size of his muscles.  All tests for ligamentous laxity were negative.  

The Board directed attention to its rating recommendation based on the above evidence.   The PEB rated the left knee condition 10%, coded 5099-5003 (analogous to degenerative arthritis), citing pain on motion.  The VA rated the left knee condition 0%, coded 5010-6260 (arthritis due to trauma and limitation of leg flexion), citing a non-compensable evaluation.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260 and 5261). The knee examinations proximate to separation did not show the presence of ligamentous instability or laxity (5257).  There was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258).  There was no history of surgery to remove a meniscus (5259).  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 was 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, and 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.

Contended PEB Conditions:  Obstructive Sleep Apnea (OSA) and Chronic Bilateral Foot Pain.  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, 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.  In the matter of the OSA and the bilateral foot pain, 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 20140707, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

MEMORANDUM FOR Commander

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXX, AR20160011764 (PD201403734)

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