RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02173
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20071109

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Motor Transport Operator, medically separated for “bilateral shoulder pain” and “posttraumatic arthritis, right knee,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  The CI received higher ratings from the VA for his conditions.  The CI’s 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 - 20071019	VARD – 20080620	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Shoulder Pain	5099-5003	10%	Right Shoulder Impingement	5201-5019	10%	20080114	
			Left Shoulder Impingement, S/P Arthroscopic Debridement, AC Decompression and Distal Clavicle Excision	5201-5203	10%		
Posttraumatic Arthritis, Right Knee	5010	0%	DJD Right Knee, S/P ACL Repair	5260-5010	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Right Shoulder Pain.  The PEB combined the right and left shoulder conditions under a single service disability rating, coded 5099-5003 (analogous to degenerative arthritis) rated 10%, with application of the USAPDA pain policy 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 Board also noted that “bundling,” the combining of 2 or more major joints, may be permissible under the VASRD 5003 rating requirements, and this approach does not compromise the VASRD §4.7 directive to choose the higher of 2 valid ratings.  The Board’s initial charge in this case was 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 right and left shoulder conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-hand dominant CI began experiencing right shoulder pain in 2004.  The CI denied any specific injury or trauma.  The February 2007 Magnetic resonance imaging (MRI) studies, showed a small antero superior labral tear, with an otherwise normal shoulder.  

At the 1 August 2007 orthopedic clinic appointment, 3 months prior to separation, the examiner recorded the shoulder exhibited no muscle atrophy or weakness.  The range of motion (ROM) measurements showed forward flexion limited to 90 degrees (normal 180) and abduction to 120 degrees (normal 180).  At the 15 August 2007 physical therapy examination, showed forward flexion, after 3 repetitions, of 167, 167 and 170 degrees and abduction of 141, 146 and 145.  Pain did not limit the CI’s ROM, but he did experience catching and tightness in the shoulder.  At the October 2007 the MEB examination (recorded on DD Forms 2807-1 and 2808), 1 month prior to separation, physical examination showed decreased ROM due to pain, no measurements given, tenderness to palpation and no instability.  At the 12 October 2007 MEB NARSUM evaluation, the CI conveyed experiencing constant pain with increased activity and sitting exacerbating the pain.  Examination showed the shoulder was non-tender to palpation, with mildly decreased ROM due to pain and normal motor strength.  At a 4 January 2008 primary care clinic appointment, 2 months after separation, the CI continued to experience shoulder pain.  Physical examination showed both forward flexion and abduction was limited to 90 degrees.  At the 14 January 2008 VA Compensation and Pension (C&P) examination, performed 2 months after separation, the CI reported pain rated 8/10 elicited by physical activity with weakness, stiffness, lack of endurance and fatigability.  On examination, the right shoulder could flex and abduct to 175 degrees (each) with painful motion present and no sign of weakness, tenderness or guarding of movement.  Pain had the major functional impact, additionally limiting the joint function by 8 degrees.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating, combined with the left shoulder, under an analogous 5003 code (degenerative arthritis), citing the US Army Physical Disability Agency (USAPDA) Pain Policy.  The VA assigned a 10% rating using a 5201-5019 code (arm limitation of motion - bursitis) for painful motion.  The Board first considered if the right shoulder condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The right shoulder was profiled and implicated in the commander’s statement.  The shoulder continued to affect the CI’s ability to perform tasks required of his occupational specially and required numerous medical evaluations and physical/occupational therapy.  Members agreed the right shoulder condition was reasonably justified as separately unfitting and it met VASRD §4.71a criteria for separate rating.  Accordingly, it should be afforded separate service disability rating.

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; however, panel members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion).  There was no mal-union or recurrent dislocation of the humerus and no dislocation or nonunion of the clavicle or scapula to justify a higher rating under the 5202 (humerus, other impairment of) or 5203 (clavicle or scapula, impairment of) codes.  Panel members also agreed the 15 August 2007 physical therapy and C&P evaluations were more thorough examinations than the VA primary care appointment on 4 January 2008, with the physical therapy and C&P identifying separate movement measurements and overall functional abilities.  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.  

Left Shoulder Pain.  The CI underwent left shoulder surgery in June 2007 for SLAP repair (superior labrum, anterior to posterior), subacromial decompression and distal clavicle excision.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded left shoulder pain after surgery for PEB adjudication.

At the 1 August 2007 orthopedic clinic appointment, 3 months prior to separation, the CI reported stiffness in the shoulder and motion was improving.  The examiner recorded the CI could flex the shoulder to 90 degrees and abduct to 120 degrees.  The shoulder showed no muscle atrophy, weakness or erythema.  A the 15 August 2007 physical therapy examination, showed flexion, after 3 repetitions, of 152, 152 and 149 degrees and abduction of 137, 152 and 164.  Pain did not limit the CI’s ROM, but he did experience catching and tightness in the shoulder.  At the 24 September 2007 orthopedic appointment, the CI reported ongoing pain rated 4/10.  On examination flexion and abduction ROM measurements equaled 90 degrees with no swelling, muscle atrophy or tenderness present.  At the October 2007 MEB examination (DD Forms 2807-1 and 2808), 1 month prior to separation, examination showed decreased ROM due to pain, no measurements given, but less pain than the right shoulder.  At the 12 October 2007 MEB NARSUM evaluation, the CI reported constant pain for one year that travelled to his left elbow.  He could function without medication and was not receiving any treatment.  Physical activity could elicit pain.  Physical exam showed the shoulder was non-tender to palpation, mildly decreased ROM due to pain and normal motor strength.  At the 14 January 2008 VA Compensation and Pension (C&P) examination, performed 2 months after separation, the CI reported pain rated 1/10 with 4/10 during exacerbations.  The pain was elicited by physical activity.  At the time of the examination, the CI was not receiving treatment for the condition.  On examination, the left shoulder could flex and abduct to 180 degrees with no sign of weakness, tenderness or guarding of movement.  Pain had the major functional impact, additionally limiting the joint function by 8 degrees.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for the left shoulder condition.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating, combined with the right shoulder, under an analogous 5003 code, citing the US Army Physical Disability Agency (USAPDA) Pain Policy.  The VA assigned a 10% rating using a 5201-5203 code (arm limitation of motion – impairment of the clavicle or scapula) for mal union or nonunion of the clavicle or scapula.  The panel first considered if the left shoulder condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The left shoulder was profiled, implicated in the commander’s statement and noted to fail retention standards.  The shoulder continued to affect the CI’s ability to perform tasks required of his occupational specially and required numerous medical evaluations and physical/occupational therapy.  Members agreed the left shoulder condition was reasonably justified as separately unfitting and it met VASRD §4.71a criteria for separate rating. Accordingly, it should be afforded separate service disability rating.

There was no limitation of motion of the shoulder to support a rating under diagnostic code 5201 (arm, limitation of motion of).  Both the MEB examination (DD Forms 2807-1 and 2808) dated October 2007, 1 month prior to separation and most proximal to separation, and the MEB NARSUM evaluation on the same day noted findings of painful motion to support a 10% rating IAW VASRD §4.59, §4.40 or §4.45.  The CI noted on the Report of Medical Assessment (Form 2697), the left shoulder was a condition which limited his ability to work in his primary specialty.  There was no mal union, deformity, or recurrent dislocation of the humerus to justify a rating under the 5202 code (humerus, other impairment of); and no nonunion or mal union of the clavicle or scapula to warrant any rating under the 5203 code (clavicle or scapula, impairment of).  Panel members also agreed the 15 August 2007 physical therapy and C&P evaluations were more thorough examinations than the orthopedic assessment on 24 September 2007, with the physical therapy and C&P identifying separate movement measurements and overall functional abilities.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for the left shoulder condition.  

The panel notes that unbundling the right and left shoulder would not advantage the CI and the total overall rating would remain 10% for the bilateral shoulder (10% for the right, 0% for the left shoulder).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left shoulder condition.  

Posttraumatic Arthritis, Right Knee.  The CI’s right knee condition began in 1990, while running track in high school.  After surgery to repair the anterior and lateral cruciate ligaments, he recovered well.   In 1991 while in ROTC he was processed through MEPS where the knee disqualified him for service.  The CI enlisted in the Army in 2001 without a waiver.  In 2004 he deployed to both Afghanistan and Iraq, the knee began to bother him again.  On 16 august Radiographic studies, showed anterior cruciate ligament (ACL) repair with no evidence of graft failure but degenerative changes of several areas of the knee with cartilage thinning and mild fissuring in the lateral compartment.  A small cystic structure suggestive of a small ganglion cyst and a small hypodense oval structure, possibly representative of a small loose body such as a fragment of bone or cartilage was also evident.  The examiner attributed the degenerative changes to intensive training over the past 5 years.  He observed that leaving the knee in one position very long, caused it to stiffen and ache, and requiring adjustment.  There was no further surgical intervention recommended.  The examiner opined the knee condition existed prior to service but was permanently aggravated by service.  The pain was constant and he tolerated the pain by avoiding activity.  American Medical Association (AMA) Pain Rating was slight and constant.  

At the 15 August 2007 physical therapy clinic appointment, the examiner recorded flexion ROM measurements of 128, 131 and 133 degrees (normal 140) and extension of 0 degrees (normal 0).  The measurements were performed without pain or mechanical limitation.  On 23 September 2007 follow-up orthopedic clinic assessment, showed no signs of effusion, swelling, crepitus, patellar instability, tenderness, ligament laxity or grinding.  The 12 October 2007 MEB examination (DD Form 2808) listed examiner comments of marked crepitus, audible popping sounds with extension and flexion and no instability.  At the 12 October 2017 MEB NARSUM, noted complaints of pain when wearing battle gear and running.  As an Army truck driver, driving also caused knee pain.  The examiner noted the knee was non-tender to palpation, with marked crepitus and popping.  The knee stiffened and ached after remaining in one position during the interview.  At the 14 January 2008 VA Compensation and Pension (C&P) evaluation, performed 2 months after separation, the CI reported weakness, stiffness, swelling, lack of endurance, fatigability and dislocation.  The pain rated 8/10 and was elicited by physical activity.  Physical examination showed no edema, effusion, weakness, tenderness, subluxation, guarding of movement, locking or crepitus.  The CI could flex his knee to 140 degrees and extend to 0 degrees without pain.  Test to identify any ligament or meniscus instability were negative.  He reported he could function without medication when the pain was present.  He took over the counter medication as needed for pain.  There was no painful motion, weakness or prosthesis.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 0%, coded 5010 (arthritis, due to trauma), citing non-compensable ROM.  The VA rated the right knee condition 10%, coded 5260-5010 (leg limitation of flexion - arthritis, due to trauma), citing the application of painful or limited motion to multiple joints if no limited or painful is present.  

There was no evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  There likewise was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and 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 mal union of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  No additional functional limitation was evidenced by the examinations.  Therefore the Board concluded there was not sufficient evidence to support a rating higher than the 0% adjudicated by the PEB.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right knee condition.  

BOARD FINDINGS:  
In the matter of the bilateral shoulder condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the post-traumatic arthritis, right knee condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150810, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170012122, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

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,