RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01899
BRANCH OF SERVICE:  marine corps 	SEPARATION DATE:  20080415

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Military Policeman, medically separated for the overall effect of “right shoulder pain” and “right knee pain,” with a disability rating of 0%.

CI CONTENTION:  His disability rating is incorrect but no specific condition was identified.  The 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 review of disability ratings assigned 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 or non-compensable.  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 determination 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(s) 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 - 20080114	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder Pain 	Overall Effect	0% 	No VA Exam in Evidence	
Right Knee Pain				
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Right Shoulder Pain and Right Knee Pain (Overall Effect).  The PEB combined the right shoulder and right knee conditions under a single disability rating for “overall effect” as permitted by DoDI 1332.38 (E3.P3.4.4).  The combination of multiple conditions as a single disability reflects the PEB’s determination that each condition was not separately unfit, but the functional impairment resulting from the conditions when considered together was unfitting.  The panel’s initial charge in this case was therefore directed at determining if the PEB’s single overall effect rating was justified in lieu of separate unfit determinations and ratings.  If the panel judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each “unbundled” condition was unfitting in and of itself as shown by a preponderance of evidence.  The panel’s recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the right shoulder and right knee conditions were presented separately above with separate fitness determinations and rating recommendations, if indicated, are below.

Right Shoulder Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right shoulder condition began in February 2007 without an inciting injury.  During the 6 September 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, the CI reported severe chronic pain in the right shoulder when performing certain movements.  Physical examination showed positive tenderness of the acromioclavicular (AC) joint and limited range of motion (ROM).  

At an orthopedic visit on 17 September 2007, the CI continued to have right shoulder pain despite physical therapy and use of a nonsteroidal anti-inflammatory drug and narcotic pain reliever.  He reported pain with a sensation of grinding and clicking during active elevation combined with rotation, but no pain at rest.  Examination revealed soft tissue crepitus (grinding sensation) of both shoulders with equal ROM bilaterally.  However, combined glenohumeral abduction with rotation at 90 degrees produced pain on the right side.  The examiner’s assessment was impingement syndrome of the right shoulder with tendonitis and bursitis.  Treatment consisted of a subdeltoid bursa injection of a steroid/anesthetic combination.  
  
The 25 October 2007 MEB NARSUM examination, 6 months prior to separation, noted CI complaints of right shoulder pain without an injury.  He occasionally experienced popping and pain when moving his arm in a throwing motion, but his abilities were not limited otherwise.  Physical examination showed 172 degrees of abduction (normal 180), 170 degrees of forward flexion (normal 180), and 48 degrees of extension (normal 60).  Internal rotation was to vertebral level T-7 compared to T-4 on the left side.  External rotation was 77 degrees (normal 90) on the right and 84 degrees on the left.  O’Brien’s testing (to determine a glenohumeral joint labral tear) was positive and Hawkin’s testing (to determine subacromial impingement of the shoulder) was negative.  There was no pain with palpation of the AC joint or with cross-arm testing.  There was no ligamentous laxity and the sulcus sign (to test for inferior instability of the shoulder) was negative.  The CI had mild pain when the right arm was placed in the late cocking phase and brought forward.   A small amount of crepitus was elicited.  Shoulder X-rays were normal.  There was no VA examination in evidence proximate to separation.

The panel first considered if the right shoulder condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Neither a profile nor limited duty was authorized for the condition.  Treatment beyond an injection at the orthopedic clinic was not documented in the STR, and except for pain in a certain position, the right shoulder condition did not impair the CI’s duty performance.  Therefore, the panel concluded that the preponderance of evidence showed the right shoulder condition would not have caused the CI to be referred into the DES or to be found unfit, and accordingly cannot recommend a separate rating for it.

Right Knee Pain.  According to the STR and the MEB NARSUM, the CI’s right knee pain began in 2000 after an automobile accident.  At a 20 March 2007 physical therapy visit, the CI reported he fell off of his bunk when his knee gave out.  He described medial knee pain that was dull and constant with weakness.  Physical examination showed full knee ROM bilaterally with normal movement, negative anterior and posterior drawer tests, and a negative Lachman’s test (to determine laxity).  There was an increase of laxity on the right lateral collateral ligament but Apley’s testing (compression and distraction) of the knees was negative.  The examiner noted tenderness at the medial joint line and posterior knee and McMurray’s testing (to determine a meniscal tear) was positive.  There was no tenderness at the lateral joint line or patellar tendon.  The CI’s posture was abnormal with his use of a crutch (which was discontinued), knee brace, and right knee slightly bent with standing.  X-rays were normal.  

On 27 June 2007, the CI underwent arthroscopy with a right medial plica excision, a small anterior horn medial meniscal tear debridement, and a medial femoral condyle osteochondritis dissecans (OSD) debridement.  He began physical therapy, and at an orthopedic clinic visit on 30 August 2007, he reported minimal pain when resting with his leg extended.  The pain increased to 5/10 with any movement and 8-9/10 with running.  On examination, wounds were well healed without signs of infection.  The CI had regained near full ROM and was neurovascularly and ligamentously intact.  He did not have joint line tenderness but did have pain over the patella.  Pain was additionally elicited with medial and lateral patellar motion and a patellar grind test.  

During the 6 September 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, the CI reported “painful swelling in the right knee usually associated with excessive use of joint or when joint isn’t moved,” “pain, locking, and occasional giving out in the right knee,” use of a knee brace, and arthroscopic surgery.  Physical examination of the right knee showed mild tenderness along the medial joint line without ROM.  An L3 profile for right knee pain was issued on 30 August 2007 with restrictions on running.

The 25 October 2007 MEB NARSUM examination, 6 months before separation, noted CI complaints of constant right knee pain.  Physical examination showed a non-antalgic gait and right knee ROM of 0-136 degrees (normal 140).  There was no varus or valgus laxity.  He had very mild medial, but no lateral, joint line tenderness.  External rotation was not increased at 30 or 90 degrees.  The examiner documented a 1A Lachman test with no gapping during varus or valgus stressing.  The CI had pain with patellar motion, especially on the medial side, but there was no popping with McMurray’s testing.  He was neurovascularly intact distally.  There was no VA examination in evidence proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence.  Members concluded the preponderance of evidence showed that the right knee condition, status post arthroscopy, meniscal debridement, plica excision, and OSD debridement, was separately unfitting for continued military service.  The panel next considered rating options.  There was no limitation of flexion or extension to support a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  Examinations proximate to separation did not show the presence of ligamentous instability or laxity (5257).  Although the CI reported locking and swelling (not confirmed objectively), there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions to support a rating under code 5258.   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).  Furthermore, there was no evidence of painful motion with functional loss to support a 10% rating (based on §4.59, §4.40 and §4.45), although the CI had pain with patellar motion on examination.  Members agreed the 5259 code (cartilage, semilunar, removal of, symptomatic) was most applicable in this case, and provided a definitive route to a 10% rating.   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 knee pain condition, coded 5259.  

BOARD FINDINGS:  In the matter of the right shoulder pain condition and IAW VASRD §4.71a, the panel unanimously recommends agrees that it cannot recommend a finding of unfit for additional disability rating. In the matter of the right knee pain condition, the panel unanimously recommends a disability rating of 10%, coded 5259 IAW VASRD §4.71a.  

There are no other conditions within the panel’s scope of review for consideration.  The panel recommends 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	NA	Not Separately Unfitting	
Right Knee Pain	5259	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150710, w/atchs
Exhibit B.  Service Treatment Record

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve Affairs)
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 28 Sep 17 ICO XXXXXXXXXXXXXXXXXX, former USN
	(c) PDBR ltr dtd 17 Oct 16 ICO XXXXXXXXXXXXXXXXXX, former USMC 
	(d) PDBR ltr dtd 20 Sep 17 ICO XXXXXXXXXXXXXXXXXX, former USMC
	(e) PDBR ltr dtd 28 Sep 17 ICO XXXXXXXXXXXXXXXXXX, former USN
	(f) PDBR ltr dtd 20 Sep 17 ICO XXXXXXXXXXXXXXXXXX, former USMC
	(g) PDBR ltr dtd 20 Sep 17 ICO XXXXXXXXXXXXXXXXXX, former USMC
	(h) PDBR ltr dtd 15 Jun 17 ICO XXXXXXXXXXXXXXXXXX., former USN
	(i) PDBR ltr dtd 20 Sep 17 ICO XXXXXXXXXXXXXXXXXX, former USN
	(j) PDBR ltr dtd 5 Sep 17 ICO XXXXXXXXXXXXXXXXXX, former USMC 

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (j) are approved.  The official records of the following individuals are to be corrected as follows:

     a. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge. 

     b. XXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     d. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 40 percent rating (increased from 20 percent) effective date of discharge.

     e. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge. 

     f. XXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.

     g. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS 

     h. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.

     i. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge. 
     
3.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.

	XXXXXXXXXXXXXXXXXX
	Acting