RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX		CASE: PD-2017-03872 BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20071228

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Aircraft Maintenance Technician, medically separated for “bilateral patellofemoral instability, left shoulder rotator cuff tendinopathy, left ankle degenerative disease, and bilateral knee pain” with an overall effect disability rating of 0%.

CI CONTENTION:  Review all conditions.  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 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 - 20070924	VARD - 20080310	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Patellofemoral Instability	

Overall Effect	

0%	Right Patellofemoral Instability	5257	10%	

20071016	
			Left Patellofemoral Instability	5257	10%		
Bilateral Knee Pain			Right Knee Degenerative Arthritis	5014	10%		
			Left Knee Degenerative Arthritis	5014	10%		
Left Shoulder Tendinopathy			Chronic Left Shoulder Tendinitis	5099-5201	20%		
Left Ankle Degenerative ...			Left Ankle Degenerative Changes	5010	10%		
Lumbosacral Degenerative Disc Disease	Not Unfitting*	Low Back Strain [Subsuming Disc Disease and Radiculopathies]	5243	20%		
Other Chronic Pain		Fibromyalgia	5025	40%		
COMBINED RATING: 0%	COMBINED RATING OF ALL VA CONDITIONS: 90%	
* De facto not unfitting. Forwarded by MEB but not included in PEB overall effect rating or otherwise categorized.

ANALYSIS SUMMARY:

Consolidated Rating of Bilateral Knee, Left Shoulder, and Left Ankle Conditions. The PEB combined two bilateral knee conditions (designating separate diagnoses of patellar instability and pain), a left shoulder condition, and a left ankle condition under a single rating. This was based on a determination that these conditions were collectively unfitting due to their overall (OE) IAW DoDI 1332.38 E3.P3.4.4, meaning that the PEB determined no condition was separately unfitting, but rather it was the overall effect of the conditions considered together that rendered

the CI unfit. The panel’s initial charge in this case was therefore directed at determining if combining conditions under OE was justified in lieu of separate ratings. The panel evaluates each condition separately for fitness, but does not recommend a rating unless a preponderance of evidence demonstrates that a specific condition was separately unfitting at separation. Each incorporated condition is addressed separately below, with attendant fitness determinations and rating recommendations if indicated.

Bilateral Patellofemoral Instability and Bilateral Knee Pain. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI had experienced patellofemoral problems (loose attachment of kneecaps) since her teens, and suffered recurrent hyperextension injuries of both knees in the service starting in 2000, as well a left patellar subluxation in 2005 (basketball). She developed complaints of persistent left knee pain and patellar instability, and subsequently similar, but less severe, complaints with the right knee. Imaging (MRI) demonstrated significant patellofemoral degenerative changes bilaterally, but no meniscal or ligamental injuries. Surgery was considered, but ultimately judged to be not indicated based on the chronicity of symptoms and the orthopedist’s judgement that there was a significant psychological overlay (elaborated more fully below with the chronic pain condition).

Provider entries in the STR documented bilateral patellar laxity with a positive apprehension sign and patellar crepitus on the left, but not the right. There were ample bilateral findings of grossly normal gait and range of motion (ROM), with no joint instability, persistent effusion, or signs of impingement (locking). There was no record of contrary evidence, any indication of significant ROM limitation, or additional VASRD-ratable findings. With regards to functional capabilities, a provider entry on 11 June 2006 documented that the CI was “much improved ... but still unable to run at this time.” However, a later treatment note on 22 March 2007, stated that she was “involved in numerous sporting activities.” There was no other functional evidence from STR clinical entries directed specifically at knee limitations.

The only limited duty board (LIMDU) was dated 30 April 2007 and listed left knee pain, back pain, and left shoulder pain. The listed limitations (encompassing all conditions) prohibited running, lifting more than 10 pounds, prolonged standing, squatting, sit-ups, push-ups, and impact sports. The commander’s non-medical assessment (NMA) did not elaborate specific conditions or limitations, but noted overall significant work loss, shortened work hours, and side effects of pain medications.

The 30 July 2007 MEB NARSUM examination, 5 months prior to separation, was supplemented by an orthopedic addendum dated the same day. The NARSUM addressed multiple complaints, including some outside the panel’s scope of review, without specifically addressing the severity of symptoms or limitations for the knees. The orthopedic addendum noted bilateral diffuse knee pain (no differentiation of left versus right severity), rated at 5/10 “with standing and walking,” subjective locking of the left knee only, and no subjective joint instability. The physical examination (all findings bilateral) recorded patellar laxity (“translates 100% of its width”), stability to stress testing in all planes, no signs of impingement, and no note of tenderness or effusion. Measured bilateral ROM (bilateral) showed flexion to 145 degrees (normal 140) and “full” extension (normal 0 degrees), with “pain free” motion. The NARSUM examiner noted an antalgic gait (in conflict with contemporary STR entries) but attributed it to back pain.

The 16 October 2007 VA Compensation and Pension (C&P) joint examination, 2 months before separation, documented nonspecific left and right knee pain (no differentiation of severity) that was aggravated by squatting, negotiating stairs, and prolonged walking or sitting. There was no note of subjective locking or instability, and no mention of a brace in use. The examiner stated that the CI refrained from running or competitive sports, and opined that there was occupational impairment imposed by the inability to tolerate prolonged sitting. The physical examination (all findings bilateral) recorded a normal gait, “very mobile” patellae that were nevertheless  stable

and could not be dislocated, no effusion, and no joint instability to stress testing. Measured bilateral ROM revealed flexion to 145 degrees and extension to 0 degrees, with “slight ... discomfort [but no] significant functional impairment” on repetitive testing.

The panel directed attention to its recommendation based on the above evidence. The VA conferred separate ratings for each knee, in addition to dual rating for instability for each knee, as charted above. These were based on the C&P examination and consisted of ratings of 10% each for degenerative arthritis, coded 5014 (osteomalacia), citing painful motion (presumably conceding the slight discomfort with repetition during examination); and, separate ratings of 10% each for patellofemoral instability, coded 5257 (knee, other impairment), citing the applicable criterion of “slight recurrent subluxation or lateral instability of the knee.” It should be noted that code 5257 is for knee joint instability, a significantly more disabling condition than patellar instability.

The panel first deliberated whether the bilateral knee condition could be justified as separately unfitting by the above preponderance of evidence standard (begging the issue of whether each joint was in turn separately unfitting). It was noted that the left knee was included on the LIMDU, although the limitations (apart from those for the shoulder) were shared with the lumbar condition at the time they were imposed. As noted, the knee condition was not specifically addressed in the commander’s NMA. The panel conceded that the knees, especially the left one, contributed to unfitting limitations of running and other general military physical requirements. It was also acknowledged that the squatting limitation could be attributed more directly (but not necessarily exclusively) to the knees, and that squatting may have been an implicit requirement for the CI’s rate (avionics technician), although these conclusions entailed a degree of speculation. There were no other limitations, to include the prolonged sitting referenced as an occupational limitation by the C&P examiner, that were not enmeshed with the functional impairment from other conditions. There was also a lack of objective impairment, e.g., ROM limitation, distinctly painful motion, joint instability or impingement, or other limitation except for chronic (preceding enlistment) patellar hypermobility and subjective pain with a possible psychological overlay (see below). Thus, panel member consensus was that too much speculation would be required to conclude, based on a preponderance of evidence, that there were knee-specific performance limitations (separately or bilaterally) rendering the CI unfit independently of OE considerations. After due deliberation, panel concluded that there was insufficient cause to recommend a change in the PEB adjudication of the bilateral knee condition.

Left Shoulder Rotator Cuff Tendinopathy. The NARSUM noted an onset of left shoulder pain from a work injury (struck by heavy equipment) in 2001, although there was conflicting STR evidence for an earlier onset from a strain injury. An MRI demonstrated a tendinopathy (supraspinatus, no tear) but was otherwise normal. There were infrequent clinical entries specific to this condition, although various providers noted shoulder pain in the context of multiple other complaints. An orthopedic consult of 12 April 2007 documented that her “left shoulder cracks and pops when she is swimming ... otherwise she really does not have any pain in this shoulder of significance.” The physical examination recorded tenderness confined to the scapular edge with negative signs of instability or impingement. Measured ROM showed forward flexion to 160 degrees and abduction to 95 degrees (normal 180 for both). The consultant stated that there was “no evidence of significant shoulder pathology” and opined that the shoulder pain was intermingled with left upper extremity (LUE) radicular-type symptoms associated with an out-of- scope cervical condition (non-surgical degenerative disc disease). There was no evidence contrary to the above findings in any other STR provider entries. As previously noted, the left shoulder condition was listed on the LIMDU and was logically implicated by the lifting and push- up limitations; and, as previously noted, it was not specifically addressed in the NMA.

The NARSUM, although acknowledging the above 2001 contusion injury, also linked the left shoulder  pain  with  cervical  disease  and  radiating  LUE  pain.   The  NARSUM  did  not address

symptom severity or functional limitations related to the shoulder condition, and the examiner noted normal upper extremity neurological findings without a shoulder joint examination. The orthopedic addendum recorded nonspecific shoulder pain radiating from the scapula that was “worse with lifting her arm over her head,” and did not indicate any other functional limitations. The physical examination noted scapular tenderness, no signs of instability or impingement, forward flexion to 130 degrees, and abduction to 90 degrees.

The VA pre-separation C&P joint examination (same as above for knee condition) documented nonspecific bilateral shoulder pain (right shoulder pain was not corroborated by the STR evidence) that was aggravated by “vigorous rotary type of movements, pushing, pulling, lifting, or work overhead,” and that “such activities are limited by the pain and associated weakness, fatigability, and lack of endurance.” The physical examination recorded no evidence of structural abnormality, instability, tenderness or signs of impingement. Measured ROM revealed forward flexion to 120 degrees and abduction to 100 degrees, with painful motion but no “significant additional functional limitation” with repetition. The VA examiner opined that the CI was “unable to perform her normal occupational activities, which required a considerable amount of overhead type of work as well as climbing on various pieces of equipment.”

The panel directed attention to its recommendation based on the above evidence. The VA rated the left shoulder condition 20%, coded 5099-5201 (analogously for limitation of motion), referencing the C&P ROM measurements. Although a 20% rating under code 5201 requires limitation of forward flexion and/or abduction to 90 degrees (“shoulder level”), the decision stated that the measured ROM limitations were “coupled with functional impairment” citing the above quote from the C&P examination.

The panel first deliberated whether the left shoulder condition could be justified as separately unfitting applying the OE standard as elaborated above. There were significant, and arguably unfitting, upper extremity limitations in evidence; and, there were no other conditions within the panel’s scope of review that would have made any substantial contribution to those limitations. It was also noted that the left shoulder condition was implicated in the LIMDU board. The out- of-scope cervical condition and LUE radicular-type pain and symptoms, however, shared all functional limitations with the shoulder condition; thus, separating the left shoulder contribution from the overall upper extremity limitations was fraught with the same speculation as that discussed for the knee condition versus the other in-scope conditions.

The panel carefully considered the evidence for interference with overhead work as noted in the orthopedic addendum and the C&P examination. As discussed with the squatting limitation for the knees, this was arguably attributable primarily to the shoulder condition and possibly an unacceptable limitation for the CI’s rate and duties. It was a key element of the VA examiner’s directed opinion regarding occupational limitations of the shoulder condition. There was, however, an unexplained disparity between the explicit evidence for fairly mild severity and limitations at the time of the orthopedic consult, and those documented by the C&P examiner. There was no injury or other exacerbation in the 5-month interval between those examinations that would account for worsening severity, and no corroboration of the recent bilateral shoulder pain resulting in the limitations reported to the VA examiner. Given the timing of the service injury and chronicity of symptoms, member consensus was that the evidence captured in the orthopedic consult was a better reflection of the baseline severity and limitations. Pain with overhead work that could not be tolerated for extended periods, as reported in the orthopedic addendum, was reasonably consistent with the symptoms reported to the orthopedic consultant and was conceded. There was significant doubt, however, that this limitation alone would have resulted in medical separation. Panel member consensus, therefore, was that too much speculation would be required to conclude, based on a preponderance of evidence, that there were  shoulder-specific  performance  limitations  rendering  the  CI  unfit  independently  of OE

considerations. After due deliberation, panel concluded that that there was insufficient cause to recommend a change in the PEB adjudication of the left shoulder condition.

Left Ankle Degenerative Disease. The CI attributed persistent left ankle pain to an injury when medical personnel removed her shoe while treating the dislocated patella in 2005. There were no STR provider entries in evidence that were specifically directed at evaluation or treatment of the left ankle, and while it was mentioned in a few notes in the context of multiple other complaints, there was no documentation of ankle ROM of functional limitations. An X-ray in June 2007 demonstrated degenerative changes, with no note of other positive findings.

The ankle condition was not included in the LIMDU or implicated in the NMA, the NARSUM did not address the ankle, and the orthopedic addendum documented nonspecific pain without elaborating any functional limitations attributed to the ankle. There were no ankle ROM measurements by the service.

The pre-separation VA C&P joint examination noted “repetitive activities will be associated with slight increased [left ankle] discomfort without evidence of significant functional impairment.” The physical examination recorded no joint deformity, swelling, or tenderness. Measured ROM showed painless dorsiflexion to 15 degrees (normal 20) and plantar flexion to 70 degrees (normal
45)	with “posterior” pain, but no additional symptoms or functional impairment with repetition.

The panel directed attention to its recommendation based on the above evidence. The VA rated the left ankle condition 10%, code 5010 (arthritis due to trauma), based on the C&P examination and citing painful motion with plantar flexion. The panel deliberated whether the left ankle condition could be justified as separately unfitting applying the OE standard as elaborated above. Although it should be conceded that some ankle impairment overlapped with the lower extremity functional limitation elaborated in the knee evidence, there was no service or VA evidence for any significant functional limitation attributed to the ankle. Panel members thus agreed that too much speculation would be required to conclude, based on a preponderance of evidence, that there were ankle-specific performance limitations rendering the CI unfit independently of OE considerations. After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication of the left ankle condition.

Contended PEB Condition: Lumbar Degenerative Disc Disease. The NARSUM noted an onset of low back pain after driving over rough terrain in August 2006, although there was STR evidence for back pain from a vehicular accident in July 2005. An MRI demonstrated disc disease (L4/5, possible left nerve root impingement). Multiple neurological examinations were normal; it was opined that surgery was not indicated; and, the pain (with intermittent reports of bilateral leg radiation) did not respond to conservative treatment. Provider entries in the STR documented non-specific ROM limitation, with one entry estimating a 30% reduction, but none that indicated more severe limitation. There were numerous treatment notes that documented a normal gait and none that ascribed any definite functional limitations to back pain. Neurosurgery opined that the lumbar (and cervical) symptoms were due primarily to an overall pain disorder with only a “minor role” attributable to disc disease.

The NARSUM documented “lower back pain that tends to wax and wane, but is always there to some degree.” Specific functional limitations attributed to back condition were not elaborated, and back pain was included in the LIMDU and contributed to those limitations. The physical examination recorded an antalgic gait (walked slowly because of “visible back pain),” tenderness, and spasm, but a normal spinal contour and neurological findings (5/5 strength, symmetric reflexes, intact sensory). The examiner noted that flexion was limited to 45 degrees (normal 90) with pain starting at 30 degrees, but ROM in all other planes was normal. The orthopedic addendum did not address the lumbar condition. Of note, there were multiple STR entries in close proximity to the NARSUM, before and after, that documented a normal gait.

The pre-separation VA C&P examination documented “daily” nonspecific back pain that was aggravated by repetitive bending and lifting without limiting ambulation or resulting in any incapacitation. The physical examination recorded a normal gait and spinal contour, “slight” tenderness, no spasm, and normal neurological findings. Measured ROM revealed flexion to 40 degrees with a combined ROM of 140 degrees, with pain during flexion but no increased functional impairment with repetition.

The panel’s main charge is to assess the fairness of the PEB’s determination that the lumbar spine condition was not unfitting. There was no adequate performance-based evidence from the record that it significantly interfered with satisfactory duty performance at separation, and no functional limitations that could be ascribed specifically to the spine without undue speculation, given the superimposition of other conditions and probative value mitigation by conflicting evidence and possible psychological overlay. After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication of the lumbar spine condition and so no additional disability rating is recommended.

Contended PEB Condition: Other Chronic Pain. As alluded to above with the other conditions, there was clinical suspicion that the CI’s complaints were not fully accounted for by objective findings. She reported numerous complaints (headache, chest pain, total body pain, multiple peripheral neurological symptoms, vertigo, and multiple others) with the orthopedic diagnoses, and underwent thorough evaluations with appropriate consultations and ancillary studies, all with negative findings and unidentified or speculative etiologies. The neurosurgeon opined that she had a “very severe systemic pain syndrome” and mentioned fibromyalgia or myofascial pain as possibilities. A pain management consultant included a “fibromyalgia type syndrome” in the differential assessment, but diagnosed “multiple pain generators” and listed the various orthopedic issues and symptom complexes. The specialist opined that the CI “has a significant emotional component to her pain, which far outweighs the physical component,” and recommended a behavioral health evaluation. There was no evidence of a rheumatology consult by the service. The CI underwent a psychiatric evaluation, that included psychological testing on 23 September 2007, and the provider opined that the testing revealed “a classic conversion pattern” and “suggests that her physiological problems are psychological based and rooted in her personality.” The Axis I diagnoses were somatization disorder and recurrent depression with an Axis II diagnosis of histrionic personality disorder. A VA psychologist arrived at similar conclusions in an evaluation of 27 February 2008, 3 months after separation, diagnosing “psychological factors affecting physical condition” and a personality disorder. A general VA C&P examination on the same day as the pre-separation joint C&P diagnosed fibromyalgia with documentation of the requisite trigger points, although the examiner was not a rheumatologist (as required for a service diagnosis). The VA conferred the highest 40% rating for constant and refractory symptoms under code 5025 specific to fibromyalgia.

As with the lumbar condition, the panel was charged with assessing the fairness of the PEB fitness determination. Given the interplay with the orthopedic diagnoses (some of which were not in scope) and overlay of the psychiatric diagnoses (none in scope and personality disorder is not service ratable), the panel agreed that there was no performance-based evidence that could be attributed to the overall chronic pain condition with a reasonable degree of specificity or certainty. The panel is not empowered to change a MEB diagnosis, but even if the chronic pain condition were coded analogously to fibromyalgia, there would remain the same inability to assign to it any specific unfitting functional impairment. The PEB’s unfitting conditions cannot be eliminated and they overlap extensively with the disability and symptoms applicable to rating under analogous fibromyalgia criteria. Therefore, even if rating of the pain syndrome under any code were conceded, it would be impossible to tease out unfitting and ratable symptoms without violating VASRD §4.14 (avoidance of pyramiding). After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication of the chronic pain condition.

BOARD FINDINGS: In the matter of the bilateral knee, left shoulder, and left ankle conditions the panel majority recommends no change in the PEB’s combined overall effect adjudication. The single voter for dissent recommends a modification to 20% (10% each for separately unfitting left knee and left shoulder conditions) and did not elect to submit a minority opinion. In the matter of the contended lumbar spine and chronic pain conditions, the panel recommends no change from the PEB de facto determinations as not unfitting. There are no other conditions within the panel’s scope of review for consideration. Therefore, the panel recommends that there be no modification or re-characterization of the CI’s disability and separation determination.

DEPARTMENT OF THE NAVY
SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309
WASHINGTON NAVY YARD, DC 20374-5023

IN   REPLY  REFER  TO,
1850
CORB: 003 20May20

From: Director, Secretary of the Navy Council of Review Boards

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW  (PDBR)

Ref:	(a) DoDI 6040.44
(b) PDBR ltr <ltd 14 Nov 19

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation (reference (b)) to the Department of the Navy on 5 Mar 2020 for appropriate action.

2.	On 20 March 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) accepted the recommendation of the PDBR of no change to your characterization of separation or disability rating assigned by the Department of the Navy's Physical Evaluation  Board.

3.	The Secretary's decision on your PDBR application is final and is not subject to appeal or additional review by the Board for Correction of Naval Records.