RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01478
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20071113

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E5, Infantryman, medically separated for “chronic left knee pain,” “chronic right shoulder pain,” and “chronic neck pain,” rated 0% each, with a combined disability rating of 0%.  

CI CONTENTION:  All injuries occurred on active duty and most have worsened over time.  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 FPEB - 20070709	VARD - 20080520	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain	5099-5003	0%	Status Post (S/P) Left Knee Surgery	5010-5260	10%	20080314	
Chronic Right Shoulder Pain	5099-5003	0%	S/P Right Shoulder Surgery…	5201-5010	10%	20080314	
Chronic Neck Pain	5242	0%	Cervical Spine…	5242	10%	20080314	
Left Ankle Pain	Not Unfitting	Left Ankle…	5013-5271	0%	20080314	
Right Ear Mild Hearing Loss	Not Unfitting	Hearing Loss	6100	10%	20080228	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Chronic Left Knee Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s left knee condition began in 1995 and required an anterior cruciate ligament repair.  He was pain-free until 2000, when he experienced increased pain with running or climbing stairs.  On 12 April 2005, the CI was evaluated in orthopedics for his left knee, left ankle, and right shoulder, all of which he reported injuring during pre-deployment maneuvers (available deployment records were silent for musculoskeletal complaints).  On examination, he had clinical findings consistent with a medial meniscus tear.  This was confirmed on MRI and the CI underwent surgical repair on 11 July 2005.  He remained symptomatic and had revision surgery on 3 August 2006.  This also failed to resolve his knee pain and additional surgery (at least the 4th operation of the left knee) was performed on 24 October 2006.  He initially did well, but post-operative adhesions required an arthroscopy in January 2007.  

At the 28 March 2007 MEB NARSUM orthopedic examination, 8 months prior to separation, the CI reported left knee pain which precluded running and carrying out his military specialty.  On examination, the knee was stable with a mild effusion.  Range of motion (ROM) was 0-135 degrees (normal 0-140).  The 17 April 2007 MEB NARSUM general examination, 7 months before separation, noted CI complaints of constant, sharp knee pain aggravated by activity, but could walk at his own pace and distance over even ground.  Physical examination noted normal ROM and appeared to mirror the April 2005 orthopedic consultation.  On 6 August 2007, an orthopedist noted a stable left knee with a 5-degree flexion contracture and painful motion.  

At the 14 March 2008 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported ongoing knee pain.  Physical examination showed a normal gait with no assistive device, and the ability to rise from a seat and transfer positions without difficulties.  Left knee flexion to 130 degrees with pain, and extension to 0 degrees, without fatigue, weakness, lack of endurance or incoordination.  After repetition, motion was limited by an additional 10 degrees with guarding, but no instability or signs of meniscal irritation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic left knee pain condition 0%, analogously coded 5099-5003 (arthritis, degenerative), citing full ROM without instability post-surgery.  The VA rated the “s/p left knee surgery with osteoarthritis and scars” condition 10%, coded 5010-5260 (arthritis-leg, limitation of flexion), based on the C&P evaluation, citing left knee ROM limited by pain.  Members agreed that while there was no limitation of motion which supported a rating under diagnostic codes 5260 or 5261, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  Additionally, the CI had meniscal surgery which supported a 10% rating under code 5259.  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), 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).  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 chronic left knee pain condition, coded 5259.  

Chronic Right Shoulder Pain.  According to the STR and MEB NARSUM, on 28 March 2005, the right-hand dominant CI reported a 3-month history of right shoulder pain which began without trauma.  An MRI showed evidence of a SLAP tear (part of the shoulder lining), and during an orthopedic visit, he related injuring his shoulder a year earlier when he fell during a training exercise.  He was referred for physical therapy (PT), but treatment did not take place for reasons unclear from the record.  A repeat MRI on 30 August 2005 confirmed the presence of a large SLAP lesion which, along with the shoulder capsule, was surgically repaired on 31 October 2005.  Following surgery, the CI healed well, but had persistent difficulty with overhead activity.  

At the 26 March 2007 PT evaluation, 8 months prior to separation, right shoulder flexion was 165 degrees (normal 180) and abduction 140 degrees (normal 180), with both motions limited by pain.  The 28 March 2007 MEB NARSUM orthopedic examination recorded ROM from 0-180 degrees for both flexion and abduction, with mild impingement signs; painful motion was not recorded.  No tenderness was noted and neurovascular findings were intact.  The 27 April 24 MEB NARSUM examination, 7 months before separation, noted complaints of constant aching, and occasionally sharp shooting pain. The physical examination referenced previous evaluations.

At the 14 March 2008 C&P evaluation, 4 months after separation, the CI reported that he injured himself when he fell from a flight of stairs in June 2004.  Physical examination showed guarding, but was otherwise unremarkable.  Flexion was to 160 degrees and abduction to 150 degrees, both with pain.  All ROMs were decreased 10 degrees after repetition due to pain.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic right shoulder pain condition 0%, analogously coded 5099-5003 (arthritis, degenerative), citing an inability to complete overhead position with minor loss of ROM due to pain.  The VA rated the “s/p right shoulder surgery with osteoarthritis” condition 10%, coded 5201-5010 (arm, limitation of motion–arthritis, due to trauma), based on the C&P evaluation, citing ROM limited by pain.  The VASRD §4.71a threshold for rating ROM impairment is “at shoulder level” (approximately 90 degrees from the side), and the examinations in evidence demonstrated motion above this level.  Although there was insufficient limitation of motion to support a rating under code 5201, members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion).  There was no malunion or recurrent dislocation of the humerus to justify a rating under code 5202 (humerus, other impairment of); and no nonunion with loose movement of the clavicle to warrant the next higher 20% rating under code 5203 (clavicle or scapula, impairment of).   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 chronic right shoulder pain condition, coded 5099-5003.  

Chronic Neck Pain.  According to the STR and MEB NARSUM, the CI was evaluated for neck pain in 2000 after he was rear-ended while driving.  Tenderness was present and X-rays showed an acute C7 injury.  On 28 March 2005, the CI reported a 3-month history of neck pain radiating to the right shoulder.  Radiographic imaging showed evidence of the old fracture at C7 as well as moderate degenerative disc disease (DDD) at C5-6.  An MRI on 27 May 2005 showed DDD, primarily at C5-C6, and multi-level degenerative joint disease.  A nerve root injection did not provide pain relief and electrodiagnostic testing was negative for radicular disease.  In PT on 23 June 2006, 17 months prior to separation, flexion was 40 degrees (normal 45) and combined ROM was 305 degrees (normal 340) with painful motion.  There were no additional STR entries for the neck until the CI was in the MEB process.  

The 17 April 2007 MEB NARSUM examination, 7 months prior to separation, did not address the neck pain other than noting it met Army retention standards.  While found to be not unfitting by the informal PEB, the neck pain was determined to be unfitting by the formal PEB following the CI’s appeal in which he stated he was unable to wear his helmet due to the condition.  The neck pain was determined to be secondary to degenerative arthritis without radiculopathy, tenderness, spasm, or deformity.  

At the 14 March 2008 VA C&P evaluation, 4 months after separation, the CI reported his neck condition began in 2003 and did not cause any incapacitation.  Measured ROM showed flexion to 40 degrees with pain and a decrease of 5 degrees with repetition.  The combined ROM was 335 degrees, decreasing to 325 degrees after repetition.  No fatigue, weakness, lack of endurance or incoordination was noted.  The neck showed normal curvature with symmetry in appearance and spinal motion.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the chronic neck pain condition 0%, coded 5242 (degenerative arthritis of the spine), citing ROM limited by pain.  The VA rated the “cervical spine discogenic disease, C3-6” condition 10%, coded 5242 (degenerative arthritis of the spine) based on the C&P evaluation, citing ROM limited by pain.  Members agreed that the ROM measurements recorded at the VA examination, most proximate to separation, supported a 10% rating but no higher.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  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 chronic neck pain condition, coded 5242.  

Contended PEB Conditions:  Left Ankle Pain and Right Ear Mild Hearing Loss.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  Only the hearing loss was profiled, however, neither of the contended conditions was 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 panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for either of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the chronic left knee pain condition, the panel recommends a disability rating of 10%, coded 5259 IAW VASRD §4.71a.  In the matter of the chronic right shoulder pain condition, the panel recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the chronic neck pain condition, the panel recommends a disability rating of 10%, coded 5242 IAW VASRD §4.71a.  In the matter of the contended left ankle pain and right ear, the panel recommends no change from the PEB determinations as not unfitting.  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; and, the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Left Knee Pain	5259	10%	
Chronic Right Shoulder Pain	5099-5003	10%	
Chronic Neck Pain	5242	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170307, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180004889, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

	A copy of this decision has also been provided to the Department of Veterans Affairs. 

Sincerely,					      
Enclosure