RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01902
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040419

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5, Infantryman, medically separated for “osteoarthritis, knees, shoulders and back,” with a disability rating of 20%.   

CI CONTENTION:   His conditions continue to worsen.  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 - 20040224	VARD - 20040520	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Osteoarthritis, Knees, Shoulders and Back	5003	20%	Early Osteoarthritis, Right Knee	5003	10%	20040127	
			Rotator Cuff Tendonitis, Left Shoulder	5024	10%		
			Rotator Cuff Tendonitis, Right Shoulder	5024	10%		
			Degenerative Disc Disease, Lumbar Spine	5299-5242	10%		
			Osteoarthritis, Left Knee	5003	NSC		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40% 	

ANALYSIS SUMMARY:  

Osteoarthritis, Right Knee.  The PEB combined bilateral knee pain, bilateral shoulder pain and low back pain as a single unfitting condition coded 5003 (Arthritis, degenerative (hypertrophic or osteoarthritis)) and rated 20% 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 2 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 2 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 knee pain, left knee pain, bilateral shoulder pain and low back pain are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee pain condition began in the spring of 2001 with complaints of right more than left anterior knee pain and swelling after running.  He was placed on a series of temporary profiles and frequently treated with anti-inflammatory medications.  The CI had several plain film X-Rays of the right knee from June 2001 to January 2004 which were all read as normal.  An MRI of the right knee 15 February 2002 showed likely fibrocystic changes of the distal medial femoral metaphysis posteriorly and a nuclear medicine bone scan was recommended.  The bone scan performed on 11 March 2002 and was normal.  At an orthopedic surgery evaluation on 29 May 2002 the surgeon reviewed all of these reports and after examining the CI determined that these were incidental findings and not the cause of the CI’s symptoms.  The surgeon diagnosed retropatellar pain syndrome.  There was no surgical indication and after additional physical therapy and activity modification, the CI’s condition could not be rehabilitated to allow for unrestricted activity and he was referred for MEB.  The MEB forwarded “osteoarthritis (knees, shoulders, back)” for PEB adjudication.  

The 6 January 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of continued knee pain that bothered him with running and physical training.  Physical examination showed stiffness and mild crepitus with good strength.  

At the 27 January 2004 VA Compensation and Pension (C&P) evaluation, 3 months before separation, the CI reported knee pain that caused swelling and stiffness but that it was not incapacitating.  Knee pain caused difficulty with marching, running and walking on uneven surfaces.  Physical examination showed a normal gait, flexion to 140 degrees (normal 140) and extension to 0 degrees (normal 0).  There was anterior tenderness noted about the right knee.  Joint ROM was not additionally limited by pain, fatigue or weakness.  A physical therapy evaluation 18 February 2004, 2 months prior to separation, for the purpose of range of motion (ROM) measurements for the MEB found flexion of 130 degrees extension of 0 degrees with no mention of painful motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the osteoarthritis condition 20%, coded 5003 (arthritis, degenerative), citing AR-635-40, paragraph B-24(f).  The VA rated early osteoarthritis, right knee condition 10% under code 5003 based on the STR and the C&P examination 3 months before separation, citing evidence of degenerative changes of the knee joint resulting in painful and limited joint motion.  

The panel first considered if the right knee pain, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The panel noted that the CI had been almost continuously profiled since May 2001 for the right knee condition and that due to the limitations, the CI had initially been referred for an MEB as early as April 2002.  The permanent profile authorized the CI to perform the alternate 2.5 mile walk to satisfy the APFT 2 mile run requirement and march up to 4 miles.  However, evidence indicates the right knee pain was the primary condition that resulted in the CI being referred to the MEB.  Panel members agreed that the evidence reasonably justified that the functional limitations associated with the right knee pain contributed to the CI’s inability to perform his military duties.  Accordingly, a separate disability rating is recommended.  

There was no limitation of motion which attained a minimum rating under the disability codes for limitation of flexion or extension (5260, 5261).  There was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  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 evidence of painful motion with functional loss supporting a minimal rating (based on §4.59, §4.40 and §4.45).  No additional functional limitation was evidenced by the examinations.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel would have recommended a disability rating of 0% for the right knee pain condition, coded 5003.  However, the panel noted that this would constitute a rating disadvantage to the CI and therefore the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right knee pain condition.  

Osteoarthritis, Left Knee.  According to the STR and the MEB NARSUM, the CI’s left knee pain condition began in the spring of 2001 with complaints of right more than left anterior knee pain (there was no report of left knee swelling).  He was placed on a series of temporary profiles and frequently treated with anti-inflammatory medications.  The CI had several plain film X-Rays of the left knee from June 2001 to January 2004 which were all read as normal.  At an orthopedic surgery evaluation 29 May 2002 the surgeon reviewed the X-Rays and after examining the CI diagnosed retropatellar pain syndrome.  There was no surgical indication and after additional physical therapy and activity modification, the CI’s condition could not be rehabilitated to allow for unrestricted activity and he was referred for an MEB.  The MEB forwarded “osteoarthritis (knees, shoulders, back)” for PEB adjudication.  

The MEB NARSUM examination noted complaints of continued knee pain that bothered him with running and physical training.  Physical examination showed stiffness and mild crepitus with good strength.  At the C&P evaluation the CI reported knee pain that caused swelling and stiffness but that it was not incapacitating.  Knee pain caused difficulty with marching, running and walking on uneven surfaces.  Physical examination showed a normal gait, flexion to 140 degrees and extension to 0 degrees.  Joint ROM was not additionally limited by pain, fatigue or weakness.  The physical therapy evaluation for the purpose of ROM measurements for the MEB found flexion of 130 degrees and extension of 0 with no mention of painful motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the osteoarthritis condition 20%, coded 5003 (arthritis, degenerative), citing AR-635-40, paragraph B-24(f).  The VA did not service-connect the osteoarthritis, left knee condition, citing it was not confirmed by X-Ray and there was no objective evidence on the VA examination of any chronic left knee disease or injury.  The panel first considered if the left knee pain, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The panel noted that the CI had been almost continuously profiled since May 2001 for the bilateral knee condition and that due to the limitations, the CI had initially been referred for an MEB as early as April 2002.  Although the right knee seemed to be a more prominent problem than the left knee, it is impossible to determine the level of disability caused by the left knee alone with the information available in evidence.  The permanent profile authorized the CI to perform the alternate 2.5 mile walk to satisfy the APFT 2-mile run requirement and march up to 4 miles.  Panel members agreed that the evidence reasonably justified that the functional limitations associated with the left knee pain contributed to the CI’s inability to perform his military duties.  Accordingly, a separate disability rating is recommended.  

There was no limitation of motion which attained a minimum rating under the disability codes for limitation of flexion or extension (5260, 5261).  There was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  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 evidence of painful motion with functional loss supporting a minimal rating (based on §4.59, §4.40 and §4.45).  No additional functional limitation was evidenced by the examinations.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel would have recommended a disability rating of 0% for the left knee pain condition, coded 5003.  However, the panel noted that this would constitute a rating disadvantage to the CI and therefore, the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right knee pain condition.  

Low Back Pain.  According to the STR and the MEB NARSUM, the CI’s low back pain condition first came to light in May 2002 when the CI was referred to orthopedics in preparation for the MEB.  Lumbar spine X-Rays showed degenerative changes at the L4 disc level with pseudolisthesis of L4 over L5 retrolisthesis due to congenitally short pedicles at L5.  The orthopedic surgeon disagreed with the findings of degenerative changes at the L4 disc space and diagnosed low back pain without radicular component.  He noted the CI did not have a surgical indication and prescribed exercises and weight loss.  Conservative treatment did not provide relief from the CI’s back pain condition to allow for unrestricted activity and he was referred for an MEB.  The MEB forwarded “osteoarthritis (knees, shoulders, back)” for PEB adjudication.  

During the December 2003 MEB examination (recorded on DD Forms 2807-1 and 2808) 4 months prior to separation, the CI reported the back pain history as above; however, there were no current complaints recorded.  Physical examination showed forward flexion to 90 degrees (normal), extension 30 degrees (normal), right and left lateral flexion 30 degrees each (normal).  Straight leg raising (test for lumbar radiculopathy) was normal.  The 6 January 2004 MEB NARSUM examination, 3 months prior to separation, the CI reported the back pain history as above; again, there were no current complaints recorded.  Physical examination showed forward flexion to 90 degrees (normal), extension 30 degrees (normal), right and left lateral flexion 30 degrees each (normal).  Straight leg raising was normal.  

At the C&P evaluation the CI reported low back pain that occurs 2 times per week and lasted 4-5 hours each time.  The pain was elicited by physical activity and relieved by rest and anti-inflammatory medications.  The CI reported that the condition did not cause incapacitation and he had not missed any work due to low back pain.  Physical examination showed normal gait and posture.  ROM measurement revealed flexion to 90 degrees (normal), extension 30 degrees (normal), right and left lateral bending 30 degrees each (normal), right and left rotation 30 degrees each (normal) and combined ROM of 240 degrees (normal).  Straight leg raising was negative and there was no muscle spasms.  There was tenderness with palpation of the lumbar paraspinous muscles.  

The panel first considered if the low back pain, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The panel noted that there were very few treatment notes concerning low back pain in the submitted STR and that there were no incidents of quarters being issued for this problem.  Although the permanent profile listed “osteoarthritis of the low back” there were no limitations associated with the low back.  The CI was able to perform sit-ups and he, in fact, passed his final APFT including the sit-up portion.  The panel agreed that the preponderance of evidence did not support the low back pain condition being separately unfitting and thus it could not recommend a separate disability rating.  

Bilateral Shoulder Pain.  According to the STR and the MEB NARSUM, the CI’s bilateral shoulder pain was first evaluated as part of his MEB physical in October 2007.  There is no record of treatment for pain in either shoulder.  As part of the MEB package the MEB forwarded “osteoarthritis (knees, shoulders, back)” for PEB adjudication.  During the December 2003 MEB examination (recorded on DD Forms 2807-1 and 2808) 4 months prior to separation, the CI reported bilateral shoulder pain began in October 2003.  Physical examination showed bilateral shoulder tenderness, right greater than left.  The 6 January 2004 MEB NARSUM examination, 3 months prior to separation, only records that “his shoulders also began causing discomfort and pain with physical activity.”  Physical examination showed tenderness to palpation over both anterior shoulders, right more than left with crepitus noted in the right shoulder and “strength ok.”  

At the 27 January 2004 VA C&P evaluation, 3 months before separation, recorded that the CI had complained of bilateral shoulder pain for 6 months.  The pain did not cause incapacitation.  The CI reported that he was unable to lift heavy objects and that he had lost one week of work due to shoulder pain (this was not found in the STR).  Physical examination of the shoulders showed the right shoulder flexion to be 150 degrees (normal 180) with pain at 140 degrees, abduction to 150 degrees (normal 180) with pain at 140 degrees.  Right shoulder motion was limited by pain.  Left shoulder ROM was flexion to 150 degrees (normal 180) with pain at 140 degrees and abduction of 150 degrees (normal 180) with painful motion at 140 degrees.  Left shoulder ROM was limited by pain.  

The panel first considered if the bilateral shoulder pain, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The panel noted that there were no treatment notes concerning either shoulder pain in the submitted STR and that there were no incidents of quarters being issued for this problem.  Although the permanent profile listed “osteoarthritis of bilateral shoulders” there were no limitations associated with the shoulders.  The CI was able to carry and fire his assigned rifle, perform push-ups and he, in fact, passed his final APFT including the push-up portion.  The panel agreed that the preponderance of evidence did not support the bilateral shoulder pain condition being separately unfitting and thus it could not recommend a separate disability rating  

BOARD FINDINGS:  In the matter of the osteoarthritis, knees, shoulders and back condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 6 June 2015, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170009274, XXXXXXXXXXXXXXXXXX 

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Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.

Sincerely,					       
						      					
Enclosure