RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03857
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070614

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Watercraft Operator, medically separated for bilateral shoulder pain and bilateral knee pain with a disability rating of 0%.  

CI CONTENTION:  The CI requests that all medical conditions be reviewed.  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 – 20070509	VARD - 20080225	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Shoulder Pain, without specific injury; 
and Bilateral Knee Pain, slight and occasional	5099-5003	0%	Left Shoulder Impingement Syndrome (Non-dominant)	5201	0%	STR	
			Right Shoulder Impingement Syndrome (Dominant)	5201	0%		
			Left Knee Patella Femoral Pain Syndrome	5014	0%		
			Right Knee Patella Femoral Pain Syndrome	5014	0%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Bilateral Shoulder Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), this right-handed CI began having shoulder pain in 2005, with no history of specific injury or trauma.  There was no surgical indication and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “bilateral shoulder impingement” for PEB adjudication.  The shoulder range-of-motion (ROM) evaluations in evidence which the Board weighed in arriving at its recommendation, are summarized below.  

 Shoulder ROM
(Degrees)	NARSUM ~ 3 Mos. Pre-Sep
(20070316)	PT ~2 Mos. Pre-Sep
(20070411)	
	Left	Right	Left	Right	
Flexion (180 Normal)	170	170	90	115	
Abduction (180)	160	160	90	100	
Comments	Painful Motion	Painful Motion	Painful Motion	Painful Motion	

On 3 March 2007, 3 months prior to separation, the CI was seen by family practice.  He reported shoulder pain that increased by raising his arms above shoulder height.  He denied swelling, stiffness, numbness and tingling, and said that “the shoulder does not feel like it will slip out of place.”  On physical examination (PE), the shoulders were tender and pain was elicited by motion.  The shoulders “showed a normal appearance,” and “motion of the shoulders was normal.”  Testing for rotator cuff injury was negative and no instability was noted.  Strength and reflexes were normal.

At the MEB NARSUM examination on 16 March 2007, 3 months prior to separation, the CI reported shoulder pain that occurred when he raised his arm to the side (abduction).  He was taking ibuprofen and said that it was effective in treating the pain.  PE showed both shoulders to be tender.  There was no swelling, redness, atrophy, or warmth on either shoulder.  X-rays showed some thickening of bone in the prominent area at the top of the upper arm where muscles attach (the greater tuberosity) for the right shoulder, while the left shoulder indicated no abnormalities.  The ROM for each shoulder was reported at 170 degrees of forward flexion (180 normal) and 160 degrees of abduction (180 normal).  At the MEB examination (recorded on DD Form 2807 Report of Medical History and DD Form 2808 Report of Medical Examination) dated April 2002, 2 months prior to separation, the CI indicated a pain level of 0 (pain free).  With regard to musculoskeletal symptoms, there were no arthralgias (painful joints) and no swelling.  The PE showed a normal musculoskeletal system, with normal motor function and normal reflexes. 

The CI medically separated from service in June 2007.  The VA did not perform a Compensation and Pension (C&P) examination of the shoulders.  The Board directed attention to its rating recommendation based on the evidence.  The Army PEB combined the right and left shoulder pain with bilateral knee pain, under a single service disability rating.  They used VASRD code 5099-5003 (analogous to degenerative arthritis), and assigned a 0% disability rating.  The Board evaluated whether or not it was appropriate for all four joints to be “bundled” together.  The Board must determine if the PEB’s approach of combining the joints under a single rating was reasonably justified in lieu of separate ratings.  The Board must apply separate ratings in its recommendation if separate compensable ratings are achieved IAW the VASRD.  If the Board judges that two or more separate ratings are warranted; however, it must satisfy the requirement that each ‘unbundled’ condition was separately unfitting.  After due deliberation, the Board agreed that the evidence supports a conclusion that the shoulder problem and the knee problem, separately, would have rendered the CI unable to perform his required military duties.  Therefore, the Board recommends a separate rating for the shoulders, and a separate rating for the knees.  The Board determined that it was not appropriate for the bilateral shoulder pain to be bundled with the bilateral knee pain, and treated as a single unfitting condition.  

The Board also evaluated whether or not it was appropriate for the two shoulders to be “bundled” together.  The Board must determine if the PEB’s approach of combining the shoulders under a single rating was reasonably justified in lieu of separate ratings.  The Board must apply separate ratings in its recommendation if compensable ratings are achieved IAW the VASRD.  If the Board judges that two or more separate ratings are warranted; however, it must satisfy the requirement that each ‘unbundled’ condition was separately unfitting.  After due deliberation, the Board agreed that the evidence does not support a conclusion that each of the shoulder problems, separately, would have rendered the CI unable to perform his required military duties.  Therefore, the Board does not recommend a separate rating for each of the shoulders.  The Board determined that it was appropriate for the right shoulder pain to be bundled with the left shoulder pain, and treated as a single unfitting condition.  

The Board carefully reviewed the data from the examinations described above, and noted the disparity between the ROM measurements.  At the March 2007 NARSUM examination, forward flexion was 170 degrees (bilaterally), and abduction was 160 degrees (bilaterally).  Four weeks later, on 11 April 2007, shoulder ROM was significantly decreased.  There was no indication in the record of a re-injury, or other explanation for this ROM reduction.  

The Board questioned the validity and probative value of the April 2007 ROM values.  It is possible that the examiner recorded the point at which the CI had pain, instead of recording the true ROM.  The Board determined that, based on the totality of the evidence, the April 2007 ROM measurements had diminished validity and probative value.  

The Board determined that, IAW VASRD §4.10 (Functional impairment), §4.40 (Functional loss), §4.45 (The joints), and §4.59 (Painful motion), when part of the musculoskeletal system becomes painful on use, it must be regarded as seriously disabled.  A 10% rating is warranted when there is satisfactory evidence of functional loss and disability due to pain.  

There was no path to a higher rating for the shoulders, since there was insufficient evidence of a seriously disabling bone or joint abnormality which would justify a higher rating.  After due deliberation, the Board determined that a disability rating of 10% for the shoulders was appropriate.  Considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a 10% disability rating for the bilateral shoulder pain.  

Bilateral Knee Pain.  In 1996, this CI started having knee pain, with no specific history of trauma or injury.  Left knee surgery was done in September 1998.  After surgery, the CI was treated with medication, physical therapy (PT), and other therapeutic measures.  Despite all treatment efforts, the bilateral knee pain did not improve adequately to meet the physical requirements of his military specialty.  In April 2007, the MEB forwarded “bilateral patellofemoral syndrome” for PEB adjudication.  The ROM evidence which the Board weighed in arriving at its recommendation, is summarized in the chart below.

Knee ROM
(Degrees)	MEB ~2 Mos. Pre-Sep
(20070411)	
	Left	Right	
Flexion (140 Normal)	115	125	
Extension (0 Normal)	0	0	
Comment	Normal Gait, Painful Motion 	Normal Gait, 
Painful Motion	

At the family practice visit on 3 March 2007, 3 months prior to separation, the CI reported pain in both knees that got worse with weight bearing and activities.  He had occasional knee swelling and stiffness.  While he denied knee locking, he did on occasion experience knee buckling and heard knee popping.  On examination, there was no swelling or fluid build-up and there was a negative McMurray’s test (a test for cartilage damage).  Neither knee weakness nor limping was observed.  The examiner wrote that the left knee “flexion was not decreased” and “extension was not decreased.”

At the MEB NARSUM examination on 16 March 2007, 3 months prior to separation, the CI noted complaints of knee pain, swelling, and giving way, but not knee locking.  The physical examination showed lateral tracking on both kneecaps (the kneecaps shifted slightly, as the knees were bent).  Tenderness and crepitus (popping or grinding sensation) was noted in each knee.  Testing indicated possible patellofemoral pain syndrome.  Knee X-rays showed some narrowing in the cartilage of the left knee between the upper and lower leg bones, an indicator of the degenerative process associated with arthritis.  During the MEB examination (recorded on DD Form 2807 Report of Medical History and DD Form 2808 Report of Medical Examination) dated 3 April 2007, 2 months prior to separation, the CI reported being free of pain (pain rated 0), with no arthralgias (joint pain) and no soft tissue swelling.  Physical examination reported gait and stance as normal, and the musculoskeletal system was reported as normal.  

At the PT appointment on 11 April 2007 ROM was measured for the MEB and the examiner reported posture, gait and stance as normal.  Flexion for the left knee was 115 degrees (140 normal) and the right knee was 125 degrees.  Motion for each knee was limited by pain.  

As noted above, the CI was medically separated from service in June 2007.  The VA did not perform a C&P examination of the knees.  The Board directed attention to its rating recommendation based on the evidence.  The Army PEB combined the right and left knee pain under a single service disability rating.  They used VASRD code 5099-5003 (analogous to degenerative arthritis), and assigned a 0% disability rating.  The Board evaluated whether or not it was appropriate for the two knees to be “bundled” together using the same criteria as the bundling discussion above for the shoulders.  The Board must determine if the PEB’s approach of combining the knees under a single rating was reasonably justified in lieu of separate ratings.  After due deliberation, the Board agreed that the evidence does not support a conclusion that each of the knee problems, separately, would have rendered the CI unable to perform his required military duties.  Therefore, the Board does not recommend a separate rating for each of the knees.  The Board determined that it was appropriate for the right knee pain to be bundled with the left knee pain, and treated as a single unfitting condition. 

The Board determined that, IAW VASRD §4.10 (Functional impairment), §4.40 (Functional loss), §4.45 (The joints), and §4.59 (Painful motion), when part of the musculoskeletal system becomes painful on use, it must be regarded as seriously disabled.  A 10% rating is warranted when there is satisfactory evidence of functional loss and disability due to pain.  

There was no path to a higher rating for the knees, since there was insufficient evidence of a seriously disabling bone or joint abnormality which would justify a higher rating.  After due deliberation, the Board determined that a disability rating of 10% for the knees was appropriate.  Considering all of the evidence and mindful of VASRD §4.3 (Reasonable doubt), the Board recommends a 10% disability rating for the bilateral knee pain.

BOARD FINDINGS:  In the matter of the bilateral shoulder pain, the Board unanimously recommends a disability rating of 10%, coded 5299-5203, IAW VASRD §4.10, §4.40, §4.45, and §4.59.  In the matter of the bilateral knee pain, the Board unanimously recommends a disability rating of 10%, coded 5299-5260, IAW VASRD §4.10, §4.40, §4.45, and §4.59.  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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Bilateral Shoulder Pain	5299-5203	10%	
Bilateral Knee Pain	5299-5260	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140820, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 (PD201403857)

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 20% 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