RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00989
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20051122

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

CI CONTENTION:  No specific contention made.  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20051108	VARD - 20060526	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Shoulder and Right Knee Pain	5099-5003	10%	Left Shoulder Impingement	5201-5014	10%	20060228	
			Right Knee Strain	5260-5014	10%	20060228	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20% 	

ANALYSIS SUMMARY:  The PEB combined the left shoulder and right knee conditions under a single disability rating, coded 5099-5003 and rated 10% with application of the US Army Physical Disability Agency (USAPDA) pain policy and AR 635-40 B24.f.  This 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’s initial charge in this case was therefore directed at determining if 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 adjudicated by the PEB.  The evidence for the right shoulder and left knee conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

Chronic Left Shoulder Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s left (dominant) shoulder condition began in September 2004 after colliding with an opposing player during a unit-sponsored football game.  

At the physical therapy (PT) appointment on 3 March 2004, the CI reported anterior and lateral shoulder pain aggravated by throwing, overhead activities, and wearing gear; he was unable to sleep on his left side.  Range of motion (ROM) was within normal limits with pain at the end of flexion.  Muscle strength was noted as 5/5 throughout, with both anterior and lateral tenderness to palpation (TTP), and he was diagnosed with left shoulder impingement.  At the 10 March 2004 PT visit, ROM showed flexion of 130 degrees (normal 180) and abduction of 90 degrees (normal 180) with painful motion.  

At the PT appointment on 17 March 2004, the CI reported a moderate increase in ROM, but still had pain.  Examination showed flexion of 165 degrees and abduction of 115 degrees with painful motion.  During the 8 July 2004 primary care clinic (PCC) visit, the examiner noted full ROM with no deformities, crepitus, or tenderness.  On 19 May 2005, an MRI revealed findings consistent with supraspinatus tendinopathy, with focal partial thickness tear at the distal attachment of the supraspinatus tendon, but no full thickness tears noted.  

The 26 September 2005 MEB NARSUM examination, 2 months prior to separation, noted CI complaints of constant left shoulder pain, rated at 7/10, and aggravated by overhead movements, and lifting, pulling or pushing greater than 20 pounds.  Pain was localized over the anterior posterior glenohumeral joint, and did not radiate distally.  The CI denied numbness or weakness and reported the pain was most intense at night and worsened while sleeping on the injured side.  Physical examination showed mild deltoid atrophy compared to the right, but no abnormal markings, changes in color or swelling.  Flexion and abduction were both 180 degrees with painful motion.  The examiner noted the CI had “a limited capacity…and was unable to perform common soldier duties of grade and PMOS.  He was also unable to pass the standard or alternate APFT.”  

At the 28 February 2006 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI had chronic pain around the left shoulder blade with flare-ups after heavy lifting, raising the arm overhead, or laying on his left side.  Pain was relieved somewhat with light stretching and a non-steroidal anti-inflammatory drug (NSAID).  The CI reported no surgeries, episodes of dislocation or history of inflammatory arthritis.  Physical examination revealed tenderness but no effusion, atrophy, muscle spasm or instability.  Flexion was to 180 degrees and abduction to 170 degrees with painful motion.  Repetitive motion showed no fatigue, incoordination, lack of endurance, no additional loss of motion by pain.  On 28 February 2006, X-ray studies revealed a “circular ring “like calcium beneath the skin superior to the distal third of the clavicle,” but were otherwise unremarkable.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB combined the left shoulder and right knee conditions and rated them together at 10%, coded 5099-5003 (arthritis, degenerative), citing the USAPDA pain policy and slight, frequent pain.  The VA rated the left shoulder condition 10%, coded 5201-5014 (arm, limitation of motion of), based on the C&P evaluation, citing pain and limitation of forward flexion.  Members first considered whether the left shoulder, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The left shoulder was specifically profiled as “U3” with restrictions on pullups, sit-ups and pushups, and wearing load bearing equipment.  Members agreed the evidence reasonably justified that the CI’s condition functionally limited his ability to perform his military duties, and accordingly a separate disability rating is recommended.  The VASRD §4.71a threshold for rating for ROM impairment under code 5201 is “at shoulder level” (approximately 90 degrees from the side), and the examinations proximate to separation demonstrated motion above this level.  There was no malunion 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.  However, members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion).  After due deliberation, considering all of the evidence, the panel recommends a separately unfitting determination with a disability rating of 10% for the left shoulder pain condition, coded 5099-5003.  

Chronic Right Knee Pain.  According to the STR and MEB NARSUM, the CI’s right knee condition began in January 2003 after entering military service.  Permanent duty limitations, profiled on 28 September 2005, included no running, sit-ups or pushup with limitations on walking, running, biking or swimming at his own pace and no lifting anything over 25 pounds.  

During the 24 September 2003 PCC visit, the examiner noted normal ambulation and gait with muscle strength of 5/5 and full right knee ROM.  At the 14 March 2005 PCC appointment, physical examination showed retro patellar TTP and patellar grind (pain with compression), but no swelling, erythema or edema.  The examiner diagnosed retro patellar syndrome.  

The 26 September 2005 MEB NARSUM examination, 2 months prior to separation, noted complaints of right knee pain.  On examination, there was no edema, deformity or joint line tenderness.  Walking was performed unaided and without difficulty or pain.  There was tenderness with patellar compression and a positive grind test.  Sensation to light touch was intact with no pain noted during active or passive movement.  Right knee ROM was flexion of 130 degrees (normal 140) and extension of 0 degrees (normal).  The examiner noted the CI’s right knee pain was refractory to all treatment and surgical intervention was not indicated.  

At the 28 February 2006 C&P evaluation, 3 months after separation, the CI reported right knee pain along the medial aspect but no locking or giving way.  Flare-ups occurred while squatting or running, and pain relief was achieved through rest, light stretching and NSAID use.  There was no history of surgery, episodes of dislocation or inflammatory arthritis.  Physical examination showed a normal gait and posture without the use of an assistive device.  There was mild tenderness but no effusion, erythematous change, muscle atrophy, instability or crepitation. Right knee ROM was flexion 140 of degrees and extension 0 of degrees with painful motion.  Repetitive use showed no fatigue, incoordination, lack of endurance, or additional loss of motion.  Right knee X-rays were unremarkable and the examiner noted the CI was able to bear weight on both legs with no functional limitation on regular walking or standing.  

The panel directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB bundled the left shoulder pain with right knee pain and applied a single 10% rating, coded 5099-5003, citing the USAPDA policy, and slight, frequent pain.  The VA rated the right knee condition 10%, coded 5260-5014 (leg, limitation of flexion of), based on the C&P evaluation, citing painful motion.  Members first considered if the right knee, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above, and concluded there was not a preponderance of evidence in the service records which overcame the panel’s presumption that the bundled right knee condition was reasonably considered separately unfitting.  The panel then considered its rating recommendation for the unfitting right knee condition at the time of separation.  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  There was no history or evidence 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 those codes.  There was no fracture, nonunion or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) for the right knee pain condition.  After due deliberation, considering all of the evidence, the panel recommends a disability rating of 10% for the right knee condition, coded 5099-5003.  

BOARD FINDINGS:  In the matter of the bundled left shoulder and right knee pain condition, the panel recommends that each joint be separately rated at 10%, coded 5099-5003 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	
Chronic Left Shoulder Pain	5099-5003	10%	
Chronic Right Knee Pain	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140214, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180006630, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

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