RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02466
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20091008

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Infantryman, medically separated for “right knee pain” and “left shoulder pain,” rated 10% and 10%, respectively, with a combined disability rating of 20%.  

CI CONTENTION:  “Please consider all conditions.”  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 - 20090624	VARD - 20091123	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain	5099-5003	10%	Right Knee Chondromalacia Patella	5260	0%	20090804	
Left Shoulder Pain	5099-5003	10%	Left Front Shoulder Tendinitis/Left Pectoralis Tendon Sprain	5201	0%	20090804	
			Left Elbow Bicipital Tendinitis/Left Distal Biceps Tendinitis	5206	0%	20090804	
Folliculitis	Meet Medical Retention Standards	No VA Placement	
Anxiety Disorder		Major Depressive Disorder	9434	30%	20091001	
Dysthymic Disorder						
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Right Knee Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right knee condition began in August 2005 while in basic training with a twisting injury.  His pain resolved and did not bother him again until June 2007, when he developed pain while running during a deployment to Iraq.  Evaluation by Orthopedics diagnosed right knee patellofemoral dysfunction and chondromalacia of the patella. Operative intervention and immobilization were not recommended.  Despite treatment, the right knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for a MEB.  The MEB forwarded “chondromalacia patella right knee” for PEB adjudication.  During the MEB examination (recorded on DD Forms 2807 and 2808) dated 16 July 2008, 15 months prior to separation, the CI reported “my right knee hurts if I don’t take medications…pain increases with amount of activity.”  Physical examination showed full range of motion (ROM), no laxity or tenderness, and a negative McMurray test.  The examiner noted that the CI pointed to the infrapatellar region as the source of pain.  At the time of the Physical Therapy (PT) clinic appointment on 26 August 2008 (CPF 840) for MEB ROM measurements, physical examination showed right knee flexion of 125 degrees (normal 140) and a normal extension of 0 degrees.  Limitation of motion was secondary to pain and there was no change in ROM measurements after three repetitions.  There was no swelling, no spasm, no atrophy, no deformity, and no scarring.  Pain did not cause interference with standing, sitting, or weight bearing of the right knee.  At the MEB NARSUM, 14 January 2009, the CI reported constant tension in the knee with intermittent pain under the knee cap. The pain was described as sharp at times and rated 8/10 at its worst.  The MEB physical examination noted no deformity, erythema, edema, or warmth.  There was no point tenderness or laxity with varus and valgus stress.  ROM measurements with a goniometer were unchanged compared with the ROM measurement taken by PT on 26 August 2008 referenced above.  At the time of the Physical Therapy (PT) clinic appointment on 21 April 2008, for MEB ROM measurements, physical examination showed right knee flexion of 138 degrees (normal 140) and 7 degrees hyperextension (normal 0).  Limitation of motion was secondary to pain and there was no change in ROM measurements after three repetitions.  There was no swelling, no spasm, no atrophy, no deformity, and no scarring.  Pain did not cause interference with standing, sitting, or weight bearing of the right knee.  At the 4 August 2009 Compensation and Pension (C&P) evaluation, performed 2 months before separation, the CI reported constant right knee pain, 1/10 at best, which flares to 8-9/10, 4 to 5 times a week.  Triggers were jumping, running, standing, up/down stairs, kneeling, and squatting.  The CI reported that he could walk for 30 minutes before needing to sit and stand for more than 5 minutes before having to shift his weight.  The CI occasionally used a patellar tendon brace for weight-bearing for any length of time.  Physical examination showed a normal gait, muscle strength, and deep tendon reflex.  There was no joint swelling, effusion, tenderness, or laxity.   There was crepitus and grinding. ROM measurements showed normal flexion of 140 degrees and a normal extension of 0 degrees.  There was no evidence of pain during ROM measurements, and no additional limitations after repetitive ROM measurements.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 10%, analogously coded 5003 (arthritis, degenerative), citing functional loss due to pain.  The VA rated the right knee condition 0%, coded 5260 (leg, limitation of flexion), citing full ROM without any painful motion.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261). However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB. 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 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 therefore no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code, and no grounds for additional rating based on the presence of instability.  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.  

Left Shoulder Pain.  According to STR and the MEB NARSUM, the right-hand dominant CI injured his left shoulder in December 2006 associated with weight lifting.  Magnetic resonance imaging (MRI) studies on 26 November 2008 showed mild tendonitis of the supraspinatus and minimal bursitis of the subacromial and sub deltoid bursae.  An Orthopedics evaluation in January 2009 reported that there was no indication for surgery.  Despite treatment, the left shoulder condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for a MEB.  The MEB forwarded “left shoulder supraspinatus tendonitis” and “left bicipital tendonitis” for PEB adjudication.  During the MEB examination (recorded on DD Forms 2807 and 2808) dated 16 July 2008, 15 months prior to separation, the CI reported “my left shoulder starts to bother me if I use it a lot.  Mainly, it hurts when I try to work it out with moderate weights.”  Physical examination showed no tenderness to palpation or scapular winging. There was full ROM.  Shoulder tests for instability and impingement were negative (Apprehension test, open can, drop arm) except for positive Neers impingement sign.  At the time of PT clinic appointment on 11 September 2008, 13 months prior to separation, the CI reported left shoulder and bicep pain mainly during weight lifting.  On examination there was full ROM and normal strength and sensation.  Shoulder tests for instability and impingement were negative.  There was tenderness to palpation at the bicipital insertion and long head of the biceps and discomfort with bicep stretch.  At the time of the Orthopedics clinic appointment on 22 October 2008, 12 months prior to separation, the CI reported left shoulder and left elbow pain.  Examination of the left shoulder showed no tenderness to palpation.  Shoulder tests for instability and impingement were negative.  Examination of the elbow showed full active and passive ROM.  There was tenderness to palpation and normal muscle strength.  The examiner noted that radiographic images (X-rays) were negative for the elbow and shoulder.  According to the MEB NARSUM evaluation on 14 January 2009 (9 months prior to separation) the CI complained of left shoulder and biceps pain that prevented him from doing pushups and limited his ability to swim; however, he stated that it did not significantly limit other activities.  The CI was able to lift 40 pounds without problems.   Physical examination of the upper extremities showed full ROM without impingement signs. There was mild tenderness below the coracoid process and over the distal biceps.  There was normal grip, and rotator cuff muscle strength.  ROM measurements of the shoulders and elbows performed in PT on 13 January 2009, showed full ROM of the left elbow and left shoulder.  The examiner stated “In my mind this continues to meet retention standards.”  At the 4 August 2009 VA Compensation and Pension (C&P) examination, performed 2 months before separation, the CI reported shoulder pain with episodes where he was pain-free, but more often than not, even at rest, he had 1/10 pain that flared to 7-8/10 burning pain.  The CI also noted a slight improvement in his biceps pain (pain was not constant, also noted the he had not been lifting weights).  Physical examination showed normal motor strength.  There was no joint swelling, effusion, tenderness, or laxity.  Deep tendon reflexes showed the biceps at 1+.  The left shoulder showed painful pectoralis muscle/tendon with internal rotation and the elbow showed tenderness to palpation at the distal biceps tendon near the olecranon fossa.  There was full ROM of both the shoulder and the elbow.  There was no evidence of pain with ROM measurements, no evidence of pain following repetitive motion nor additional limitations.  X-ray evidence showed the shoulder and elbow within normal limits.  MRI studies showed mild tendinitis distal fibers of the supraspinatus tendon without a tear.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB combined the “left shoulder supraspinatus tendonitis” and the “left bicipital tendonitis” and assigned a 10% rating under analogously coded 5003 (arthritis, degenerative), citing functional loss due to pain. The VA assigned two separate conditions and rated each condition at 0%.  The “left front shoulder tendonitis and left pectoralis tendon sprain” condition, coded 5201 (arm, limitation of motion), and “left elbow bicipital tendinitis and left distal biceps tendinitis” condition, coded 5206 (forearm, limitation of flexion), citing full range of motion of the left shoulder and left elbow without painful motion.  The Board considered whether the bundling of the left shoulder and left elbow (bicipital tendonitis) was appropriate.  The Board noted that the MEB and NARSUM documented the left shoulder and elbow conditions as meeting retention standards; however, the conditions were profiled and implicated in the commander’s statement.  Board members agreed that each condition could be reasonably justified as separately unfitting.  The Board directed its attention to its rating recommendation.  The left shoulder demonstrated painful motion for a 10% rating IAW VASRD 4.49 (painful motion).  The left elbow examinations demonstrated tenderness to palpation, but there was no evidence of painful motion, pain with repetitive motion, or examiner observed painful motion with flare-ups for a 10% rating for painful motion or elbow limitation of 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 left shoulder condition, coded 5299-5201 and 0% rating for the left elbow condition , coded 5299-5206.  The Board noted that the rating recommendation would not result in a rating higher than the overall rating assigned by the PEB; therefore, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left shoulder and bicep tendonitis conditions.  

Contended PEB Conditions:  Folliculitis, Anxiety Disorder, and Dysthymic Disorder.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the right knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left shoulder and bicep tendon pain conditions and IAW VASRD §4.71a, the Board unanimously no change in the PEB adjudication.  There were 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 20150812, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170004629, XXXXXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	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.

A copy of this decision has been provided to the counsel you listed on your application, XXXXXXXXXXXXXXXXXXXXX.

Sincerely,					      
						      					
Enclosure