RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-03783
BRANCH OF SERVICE:  Army		SEPARATION DATE:  20051218

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E6, Light Wheeled Vehicle Mechanic, medically separated for “left knee osteoarthritis” rated at 0%.  Right shoulder pain existed prior to service (EPTS) and was not rated.

CI CONTENTION:  “Please consider 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 - 20050922	VARD - 20070613	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Osteoarthritis	5003	0%	Left Knee Osteoarthritis	5003	10%	20070409	
Right Shoulder Pain	5099-5003	---%	Right Shoulder Condition	5201	NSC		
Mechanical Low Back Pain (LBP)	Not Unfitting	Lumbosacral Strain	5237	10%		
Bilateral Neurosensory Hearing Loss		Bilateral Hearing Loss	6100	NSC		
Osteoarthritis of Left Great Toe		Left Foot Condition	5284	NSC		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:

Left Knee Osteoarthritis.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), this CI injured his left knee in April 2004 while moving sand bags during his deployment overseas.  He was treated conservatively with non-steroidal anti-inflammatory drugs, physical therapy (PT), and a knee brace; however, he continued to experience pain, locking and giving way.  At an orthopedic visit in March 2005, 9 months before separation, the examiner reported the CI had a previous medial meniscectomy (2002). Range of motion (ROM) findings were not cited.  The CI was advised a total knee replacement was the only remaining treatment alternative. During a second orthopedic examination in March 2005, the examination revealed mild genu varus deformity, and no cruciate ligament instability.  Flexion was 110 degrees (normal 140), and extension was 0 degrees (normal 0).  There was some anterolateral joint line tenderness, possible osteophyte over the medial joint line and mild patellofemoral crepitus.  The examiner recommended arthroscopy. The CI received a left knee arthroscopy which revealed torn anterior cruciate ligament (ACL), mild chondromalacia on medial patella, and other knee joint discrepancies. 

Despite treatment, the left knee condition did not improve adequately to meet the physical requirements of the CI’s military specialty, and he underwent an MEB.  The MEB forwarded osteoarthritis left knee for PEB adjudication.  The MEB NARSUM, dated June 2005, referenced an orthopedic examination conducted in May 2005, 8 months before separation.  That examination revealed an ACL deficient left knee with mild pain.  The examiner opined that the CI could return to light activities, but avoid all sudden and rapid direction changes with limited running on regular terrain and limit unassisted lifting to 50 pounds.  ROM findings were not cited.  At a PT examination in May 2005, the CI reported a painful knee.  Flexion was 119 degrees.  There was an antalgic gait and decreased stance time.

At a PT examination conducted in November 2005, 1 month before separation, the CI was still having left knee pain, but making gradual and consistent progress.  Flexion was 120 degrees and extension was 0 degrees.  During a case management visit in December 2005, 3 days before separation, the case manager documented the CI was on narcotics for pain control.  During the VA orthopedic visit in July 2006, 7 months after separation, the examiner noted the CI was given a valgus uploader brace which provided some stability and pain relief.  The examination showed positive Lachman and drawer testing.  Flexion was 110 degrees, and extension was 0 degrees, with patellofemoral crepitus during ROM.  Radiographic imaging showed degenerative joint disease (DJD) with varus deformity. 

At the VA Compensation and Pension (C&P) examination in April 2007, performed 16 months after separation, the CI reported he worked a trucking job but was currently laid off.  He complained of chronic knee pain, wore a knee brace and used a cane for support.  Occasionally the knee felt like giving way.  The examination revealed stable medial and lateral, anterior and posterior [ligament] testing.  Flexion was 110 degrees and extension was 0, with painful motion.  Repetitive use did increase pain, but no change was noted in the examination.  

The Board directed attention to its rating recommendation based on the evidence.  The PEB rated the left knee condition 0%, coded 5003 (arthritis, degenerative).  The VA rated the left knee condition 10%, coded 5003, based on the C&P examination 16 months after separation, citing 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).  

The STR examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity; however, the VA orthopedic examination 7 months after separation did show some evidence of ligamentous laxity.  After deliberation, the Board determined that there was insufficient evidence to support a 10% rating for instability, at the time of separation.  The Board acknowledged the CI’s history of meniscal surgery.  The 5259 code (cartilage, semilunar, removal of, symptomatic) was applicable in this case; however, the maximum 10% rating under that code is not greater than the 10% rating for painful motion with functional loss as cited above.  There is no benefit to the CI if the Board recommends code 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 no VASRD §4.71a route to a rating higher than 10%, and no grounds for additional rating based on joint instability.  After due deliberation, and considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left knee condition, coded 5299-5260.

Right Shoulder Condition.  According to the STR, this right-handed CI was struck in the right shoulder by a passing automobile’s mirror, while assisting another motorist in May 2002.  Magnetic resonance imaging (MRI) in August 2002 showed supraspinatus tendinopathy (shoulder impingement) and acromioclavicular hypertrophic change.  The CI had right shoulder surgery in October 2002.  After surgery, he continued to have intermittent pain.  In March 2003 a second MRI was done, and showed tendinitis, with status post torn and repaired rotator cuff.  In August 2004, the CI exacerbated his right shoulder condition while breaking down multiple truck tires and removing lug nuts.  The CI did not seek medical attention, because he was alone (only one available in his unit) and had an important job to do.

At the PT visit in April 2005, 8 months before separation, the CI reported a weak-painful shoulder.  ROM testing revealed forward flexion of 116 degrees (normal 180) and abduction was 74 degrees (normal 180), with painful motion.  During a subsequent PT visit 1 month later, ROM testing showed forward flexion of 135 degrees, and abduction of 120 degrees, with painful motion. According to the MEB NARSUM, the CI did not seek medical attention for his shoulder until he entered the MEB process, and was prompted to mention his problem after receiving [MEB] briefings.

At the April 2007 C&P examination, 16 months after separation, the CI reported chronic right shoulder pain.  ROM testing revealed forward flexion of 90 degrees, and abduction was 90 degrees, with painful motion.  The ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, are summarized in the chart below.

Right Shoulder ROM
(Degrees)	PT  ~7 Mo. Pre-Sep	PT (MEB) ~7 Mo. Pre-Sep	VA C&P ~16 Mo. Post-Sep	
Flexion (180 Normal)	135	116	90	
Abduction (180)	120	74	90	
Comments	Painful motion	Painful motion	Painful motion	

The Board directed attention to its rating recommendation based on the evidence.  The PEB found the right shoulder condition unfitting, coded 5099-5003 (analogous to degenerative arthritis).  They did not rate the condition, as they determined the condition was EPTS and there was no permanent service aggravation (PSA).  The VA found the right shoulder condition to be not service connected, citing the PEB proceedings.  The VA rater wrote: “It was not incurred or aggravated while entitled to basic pay, and not incurred or aggravated in the line of duty.”

The Board carefully reviewed all available evidence.  The right shoulder injury occurred in May 2002.  The CI entered active duty on 7 December 2003.  The Board searched for evidence of PSA. After due deliberation, and 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 of the right shoulder condition.

Contended PEB Conditions:  LBP, Bilateral Sensorineural hearing loss, and Osteoarthritis of Left Great Toe.  According to the STR, and the MEB NARSUM, the CI injured his back in August 2004 while breaking down multiple truck tires.  He did not seek medical attention because he was alone, with an important job to do.  In March 2005, MRI showed broad disc protrusion at L4-L5, with slight narrowing of the neural foramina, but no evidence of radicular compression. The CI had a series of lumbar epidural steroid injections.  In June 2005, the CI’s commander wrote: “His physical limitations did not seem to prevent him from performing any of his assigned duties.” 
The MEB NARSUM diagnosis for the back was: “Chronic low back pain, medically retainable.”  This low back pain (LBP) condition was adjudicated by the Army PEB as: “Not unfitting, not rated.” Two other conditions (Sensorineural hearing loss, and osteoarthritis of left great toe) were also adjudicated by the PEB as: “Not unfitting, not rated.”  The Board’s main charge with respect to these three conditions is to assess the appropriateness of the PEB adjudication.  The Board’s threshold for countering a fitness determination is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. These three conditions were thoroughly reviewed by the medical officer and considered by the Board.  The Board found insufficient evidence that any of these conditions significantly interfered with performance of military duties.  After due deliberation, and in consideration of the evidence, the Board found insufficient cause to recommend a change in the PEB adjudication of the.  

BOARD FINDINGS:  In the matter of the left knee condition, the Board unanimously recommends a disability rating of 10%, coded 5299-5260, IAW VASRD §4.59, §4.40, §4.45, and §4.71a.  In the matter of the right shoulder condition, the Board unanimously recommends no change in the PEB adjudication as EPTS, with no PSA.  In the matter of the LBP, sensorineural hearing loss, and osteoarthritis of left great toe; the Board unanimously recommends no change in the PEB adjudication as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  

The Board therefore recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Left Knee Osteoarthritis, with ACL deficiency	5299-5260 	10%	
Pain, Right Shoulder, status post repair rotator cuff	5099-5003	---%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140418, w/atchs
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 XXXXXXXXXXXXXXXXXX, AR20160016451 (PD201403783)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 10% without re-characterization of the individual’s separation.  This decision is final.  

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.   

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:

CF: 
DoD PDBR
DVA