RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00978
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20020402

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Quartermaster and Chemical Equipment Repairer, medically separated for “chronic right shoulder and left knee pain,” with a disability rating of 10%.

CI CONTENTION:  He requests a review of all conditions.  His complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’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 panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’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 panel 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 panel 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 - 20020117	VARD - 20020326	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Shoulder and Left Knee Pain	5099-5003	10%	Supraspinatus Tendon Tear, Right Shoulder 	5304	10%	20010412	
			Early Arthritic Changes, Left Knee, Status Post Multiple Surgeries	5010	10%	20010412	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Right Shoulder Pain.  The PEB combined the right shoulder and left knee pain conditions as a single unfitting condition coded analogously to 5003 (arthritis, degenerative) and rated 10% with application of the US Army Physical Disability Agency (USAPDA) pain policy and AR 635-40 B24.f.  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The panel also noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The panel’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the right shoulder and left knee conditions is presented separately, with attendant recommendations regarding separate unfitness, and separate ratings if indicated.  

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-hand dominant CI injured his right shoulder in 1994 when he ran into a pole while playing softball.  The 26 September 2001 right shoulder magnetic resonance imaging (MRI) study revealed a supraspinatus tendon insertion tear and anterior labrum tear.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic right shoulder pain with small supraspinatus tendon tear” for PEB adjudication.  In this case, the right shoulder pain was considered to fail retention standards, was implicated in the NARSUM and in the commander’s statement, and was profiled.  

According to the MEB NARSUM evaluation on 26 November 2001, 4 months prior to separation, the CI complained of persistent pain mainly with overhead work.  Shoulder dislocations were not reported.  Physical examination of the right shoulder showed that there was full range of motion (ROM) with 180 degrees of active forward elevation, symmetric external rotation, and symmetric internal rotation.  The abduction measurement was not reported.  There were mildly positive impingement signs (equivalent of painful motion).  He had no pain with resisted internal/external rotation.  He was 5/5 in all muscle groups, except for 4/5 strength of the supraspinatus tendon with mild pain.  He also had pain with O'Brien supraspinatus maneuvers and pain with an apprehension maneuver, but no instability.  

At the 12 April 2001 VA Compensation and Pension (C&P) examination, 12 months before separation, the CI reported an intermittent dull pain localized in the lateral aspect of the shoulder.  He also described weakness, stiffness, instability, inflammation, fatigue, and lack of endurance.  His symptoms were intermittent with flare-ups described as excruciating.  The flare-ups occurred daily and lasted for several hours to 1 day per episode.  His symptoms were exacerbated with lifting or performing any work above shoulder level.  Right shoulder ROM following repetitive movement showed flexion of 180 degrees (normal 180 degrees) and abduction of 180 degrees (normal 180 degrees).  Shoulder ROM was not limited by fatigue, weakness, lack of endurance, or incoordination.  Complaint of discomfort was elicited with palpation of the biceps tendon region bilaterally (right greater than left).  

The panel directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the panel first considered whether the right shoulder condition remained separately unfitting, having been de-coupled from a combined PEB adjudication.  As noted above, the PEB bundled the right shoulder condition with left knee and applied a single 10% rating coded 5099-5003, citing the USAPDA pain policy.  The VA rated the right shoulder condition 10%, coded 5304 (Group IV. Function), citing moderate muscle injury.  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.  There was no evidence of scapulohumeral ankylosis (5200), recurrent dislocation, loss of humeral head, nonunion, fibrous union, or malunion of humerus (5202), or nonunion or malunion of clavicle or scapula (5203) for consideration under the respective codes.  The panel agreed a 10% rating was supported based on VASRD §4.40 (functional loss) and §4.59 (painful motion).  The panel concluded that the evidence did provide sufficient grounds for recommending a separate right shoulder disability ratings in this case.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the right shoulder condition, coded 5099-5003.  

Left Knee Pain.  According to STRs and the MEB NARSUM, the CI injured his left knee while playing flag football in 1997.  He underwent left knee surgery in February 1998 for anterior cruciate ligament (ACL) and medial meniscus tears.  Because of a fall and persistent effusion (fluid collection), the CI underwent diagnostic arthroscopy 8 weeks after the initial surgery.  The arthroscopy revealed an intact reconstructed ACL, an intact repaired medial meniscus, and diffuse synovitis (synovial membrane inflammation).  The 2 November 2000 left knee MRI revealed an intact and stable ACL repair and no meniscus tear.  Due to persistent pain, the CI opted for repeat surgery.  On 24 January 2001, the CI underwent left knee arthroscopy which revealed Grade II patellar chondromalacia (cartilage softening or degeneration), mild ACL graft impingement, and intact medial and lateral menisci.  The surgeon performed medial patellar facet chondroplasty (surgical cartilage repair) and revision notchplasty (intercondylar notch enlargement).  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic left knee pain with early osteoarthritic changes, s/p anterior cruciate ligament reconstruction and medial meniscus repair” for PEB adjudication.  In this case, the left knee pain was considered to fail retention standards, was implicated by the NARSUM and in the commander’s statement, and was profiled.  At the 21 February 2001 physical therapy (PT) appointment, 13 months prior to separation, the examiner recorded the gait was normal.  Left knee ROM following repetitive movement was flexion of 125 degrees (normal 140) and extension of 0 degrees (normal 0).  

The 26 November 2001 MEB NARSUM, 4 months before separation, noted that in the 10 months after surgery, the CI had mild improvement, but his knee was not completely pain free and it still prevented him from doing strenuous activities such as running, jumping, marching, or sporting activities.  The physical examination documented a normal gait.  The left knee examination revealed a well-healed surgical incision and medial joint line tenderness.  Examination tests for ligamentous instability and meniscus pathology were negative.  Left knee ROM following repetitive movement was flexion of 120 degrees and extension of 0 degrees.  

At the 12 April 2001 C&P evaluation the CI reported intermittent sharp pain with a constant achy discomfort localized to the medial and lateral aspects of the left knee.  He also described associated weakness, stiffness, instability, inflammation, lack of endurance, fatigue, locking, and intermittent swelling.  His symptoms were constant with intermittent flare-ups described as excruciating.  The flare-ups occurred daily and lasted for several days per episode.  His symptoms were exacerbated with sitting, walking, running, squatting, and kneeling.  The CI also reported difficulty performing his daily functions as he experienced difficulty sitting, walking, running, squatting, or kneeling for prolonged periods of time due to his left knee discomfort.  The physical examination documented a normal gait.  The left knee examination revealed no discomfort upon palpation.  Left knee ROM following repetitive movement was flexion of 140 degrees and extension of 0 degrees.  Knee ROM was not limited by fatigue, weakness, lack of endurance, or incoordination.  Examination tests for ligamentous instability and meniscus pathology were negative.  

The panel directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the panel first considered whether the left knee condition remained separately unfitting, having been de-coupled from a combined PEB adjudication.  As noted above, the PEB bundled the left knee condition with right shoulder and applied a single 10% rating coded 5099-5003 citing the USAPDA pain policy.  The VA rated the left knee condition 10%, coded 5010 (traumatic arthritis), citing painful and limited motion.  The ROM values in the proximate examinations did not support a minimum rating under the limitation of knee flexion (5260) and extension (5261) codes.  While the CI underwent a “medial meniscus repair,” there was no dislocated meniscus (5258) or symptomatic removed meniscus (5259) for consideration under the respective codes.  There was no knee ankylosis (5256), knee recurrent subluxation/lateral instability (5257), tibia and fibula nonunion/malunion (5262), or genu recurvatum (5263) for consideration under the respective codes.  However, the panel agreed a 10% rating was supported based on VASRD §4.40 (functional loss) and §4.59 (painful motion).  The panel concluded that the evidence did provide sufficient grounds for recommending a separate left knee disability rating in this case.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left knee condition, coded 5099-5003.  

BOARD FINDINGS:  In the matter of the right shoulder pain condition, the panel unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the left knee pain condition, the panel unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  There were no other conditions within the panel’s scope of review for consideration.  

The panel 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	
Right Shoulder Pain	5099-5003	10%	
Left Knee Pain	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150608, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170007358, XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction. 

	A copy of this decision has also been provided to the Department of Veterans.

Sincerely,	
Enclosure