RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01258
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041211

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E5, Canon Crewmember, medically separated for “chronic right shoulder impingement” with a disability rating of 0%.  “Chronic bilateral knee pain,” was determined to have existed prior to service (EPTS) with no permanent service aggravation and was not rated.  

CI CONTENTION:  The CI contended for his unfitting conditions as well as his lower back.  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 - 20041119	VARD - 20060612	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Shoulder…	5099-5003	0%	Right Shoulder Sprain	5201	NSC	20050829	
Chronic Bilateral Knee Pain	5099-5003	---(EPTS)	Right Knee Strain	5260			
			Left Knee Strain with Baker’s Cyst				
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:  

Chronic Right Shoulder Impingement Syndrome.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic right (dominant) shoulder condition began in September 2002 after throwing a football.  Magnetic resonance imagery (MRI) showed a partial thickness tear of the rotator cuff.  He was referred to orthopedics and was found to have no surgical indication.  After an adequate period of therapy and a steroid injection the condition could not be adequately rehabilitated to allow for unrestricted activity.  The MEB forwarded “chronic right shoulder impingement syndrome” for PEB adjudication.  An MRI of the right shoulder 14 June 2003, 17 months prior to separation, showed evidence of a partial thickness tear of the supraspinatus tendon and moderate degenerative changes in the acromioclavicular joint.  No other abnormality was noted on the MRI.  The Statement of Medical Examination and Duty Status, DA form 2173, dated 11 December 2003 found that the right shoulder injury was incurred in the line of duty.  The MEB NARSUM examination on 30 September 2004, 2 months prior to separation, noted complaints of pain that was unchanged from the time of the initial injury.  Physical examination showed decreased internal rotation (though the examiner did not quantify the limitation) otherwise full range of motion (ROM).  The examiner noted pain over the supraspinatus muscle with ROM and palpation.  

At the 29 August 2005 VA Compensation and Pension (C&P) evaluation, performed 9 months after separation, the CI reported he avoided lifting heavy objects due to right shoulder pain.  He also reported occasional stiffness.  He denies taking medications and said that he did not have episodes of dislocation.  Physical examination showed forward flexion to 180 degrees (normal 180), abduction to 180 degrees (normal 180) with painful motion after 170 degrees.  The examiner noted no instability, muscle atrophy, spasm or limitation of motion due to pain.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic right shoulder condition 0%, coded 5099-5003 (arthritis, degenerative), citing full range of motion and normal radiographs.  The VA did not service connect the chronic right shoulder condition, based on the VA C&P examination 9 months  after separation, citing no medical evidence was submitted as part of the CI’s claim which showed the condition was incurred in or caused by service.  There was no limitation of motion of the shoulder to support a rating under diagnostic code 5200 (scapulohumeral articulation, ankyloses of) or 5201 (arm, limitation of motion of).  There was no malunion, deformity, or recurrent dislocation of the humerus to justify a rating under the 5202 code (humerus, other impairment of); and no nonunion or malunion of the clavicle or scapula to warrant any rating under the 5203 code (clavicle or scapula, impairment of).  The Board agreed that the VA C&P examination 9 months after separation did note a finding of painful motion beyond 170 degrees to support a minimum compensable rating of 10% using analogous code 5299-5201 IAW VASRD §4.59 (painful motion).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the chronic right shoulder impingement syndrome condition, analogously coded 5299-5201.  

Contended Chronic Bilateral Knee Pain.  The PEB determined the left and right knee conditions EPTS and were not permanently aggravated by service based on its statement of "no evidence of permanent service aggravation."  Therefore, the Board considered whether or not there was evidence of service aggravation.  A presumption of service aggravation may only be overcome by a preponderance of competent medical evidence and accepted medical principles that the natural progression of a pre-existing condition was clearly unaltered by any consequence of military service.  The PEB clearly did not provide a preponderance of evidence to overcome the presumption of service aggravation.  There was a statement of medical examination that indicated the CI, while on active duty for more than 30 days, was injured on or about 20 September 2002 while loading equipment into the back of a truck.  The MEB indicated that the bilateral knee conditions were permanently service aggravated.  In addition, the PEB combined the bilateral knee pain conditions as a single unfitting condition analogously coded 5099-5003 (arthritis, degenerative).  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 Board’s second 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 Board 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 Board 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 left and right knee pain conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  According to the STR and the MEB NARSUM, the CI’s chronic left knee pain was of unknown origin, with symptoms occurring prior to the CI’s mobilization in 2002; however, he noted that the left knee pain greatly increased after a twisting injury while loading a truck in September 2003.  The MEB forwarded “chronic bilateral knee pain, EPTS” for PEB adjudication.  

The Statement of Medical Examination and Duty Status, DA form 2173, dated 11 December 2003 found that the bilateral knee pain was incurred in the line of duty.  An MRI of the left knee performed 07 January 2004, 23 months prior to separation, demonstrated a small Baker’s cyst otherwise a normal evaluation of the left knee, the lateral and medial menisci were intact as were all of the stability producing ligaments.  

The MEB NARSUM on 30 September 2004, 2 months prior to separation, noted complaints of bilateral knee pain but that the CI was not required to do unit physical training (PT), running and did very little walking each day perhaps ¼ to ½ mile per day.  The CI did no other aerobic exercise at that time.  The examiner did note that a Baker’s cyst was seen on an MRI of the knee but that the CI had no symptoms from the cyst.  Physical examination showed tenderness over the anterior and medial aspects of both knees with no signs of instability or laxity.  ROM was not documented.  

At the 29 August 2005 VA C&P evaluation, performed 9 months after separation, the CI reported that he injured his left knee in 2002 while loading a truck.  He described pain in the medial aspect of the left knee.  However, no swelling, no locking, he was not taking any medications at that time.  He was able to walk for 30 minutes without difficulty but walking beyond 30 minutes caused left knee pain.  Squatting and heavy lifting caused increased pain in the left knee.  Physical examination showed left knee ROM extension to 0 degrees (normal 0), flexion 140 degrees (normal 0-140), there was pain at the extreme of flexion that did not limit ROM.  There was no instability.  Repetitive use showed no fatigue, incoordination, lack of endurance and no additional loss of motion by pain.  

The Board directed attention to its rating recommendation based on the above evidence.  The Board noted that the circumstances leading to the CI’s bilateral knee pain was investigated prior to the MEB and his commander concluded that the injuries were incurred while in the line of duty.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  There was evidence of pain at the extremes of motion; however, without loss of ROM or functional loss.  There was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), to support a rating under the respective codes.  The 5259 code (cartilage, semilunar, removal of, symptomatic) was not applicable in this case.  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).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 0% for the chronic left knee pain condition, analogously coded 5299-5260.  

According to the STR, the MEB NARSUM and the MEB Orthopedics consultation, the CI’s chronic right knee pain was of unknown origin; however, pain in the right knee was reported to be present prior to activation while the CI was performing duties at his civilian job.  There is no provided history of right knee injury in the line of duty.  At the 29 August 2005 VA C&P evaluation, performed 9 months after separation, the CI reported he had injured his right knee in 1995 when he slipped and fell.  He described pain at the medial aspect of the right knee with no locking or give out.  The CI complained of increased right knee pain with walking more than 30 minutes but that compared to the left knee pain it was “not so bad”.  Squatting and heavy lifting also aggravated the right knee.  The physical examination showed extension to 0 degrees (normal 0), flexion to 140 (normal 140) with “some pain at 140 degrees”.  There was no instability of the right knee, repetitive use showed no fatigue, incoordination, and lack of endurance and no additional loss of motion by pain.  The Board noted that all of the references to knee injury while entitled to pay were to the left knee.  The details of the incident listed on the DA form 2173, Statement of Medical Examination and Duty Status (line of duty determination), while investigating bilateral knee pain, only list the injury to the left knee.  All imaging studies (X-ray and MRI) were of the left knee.  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 right knee pain condition.  

BOARD FINDINGS:  In the matter of the chronic right shoulder impingement condition, the Board unanimously recommends a disability rating of 10%, analogously coded 5299-5201 IAW VASRD §4.71a.  In the matter of the chronic left knee pain condition, the Board majority recommends a disability rating of 0%, analogously coded 5099-5003 IAW VASRD §4.71a.  The single voter for dissent recommended a 10% rating analogously coded 5299-5260 and did not elect to submit a minority opinion.  In the matter of the chronic right knee pain condition, the Board uannamously recommended no change in PEB adjudication analogously coded 5099-5003.  There were no other conditions within the Board’s scope of review for consideration.  

The Board 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	
Chronic Right Shoulder Impingement Syndrome	5299-5201	10%	
Chronic Left Knee Pain	5099-5003	0%	
Chronic Right Knee Pain	5099-5003	EPTS	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150614, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170005976, 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 Affairs.

Sincerely,	
Enclosure