RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03938
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051017

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E4, Motor Transport Operator, medically separated for “chronic pain in the left shoulder and right knee” with a disability rating of 0%.  

CI CONTENTION:  The shoulder and knee conditions continue to worsen and negatively affect daily activities.  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 - 20050922	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain in the Left Shoulder and Right Knee	5099-5003	0%	No VA Examination Proximate to Separation in Evidence	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Chronic Pain in the Left Shoulder and Right Knee.  The PEB combined the left shoulder and right knee conditions under a single disability rating, coded analogously to 5003 and rated 0%.  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 noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  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 of the PEB.  The evidence for the left shoulder and right knee conditions is presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

Left Shoulder Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s left shoulder condition began in March 2004 after carrying a heavy rucksack and radio.  X-rays of the left shoulder in April 2005 were normal as was range of motion (ROM) testing, but there was tenderness at the trapezius muscle.  At a physical therapy (PT) clinic visit on 29 April 2005, there was mild scapular winging noted, left greater than right.  All labral tests were negative, but testing for anterior shoulder pain and supraspinatus weakness were positive.  At an orthopedic clinic visit on 9 June 2005, there was tenderness along the trapezius distribution, pain was elicited by motion and an MRI demonstrated a minimal inferior bony spur of the distal clavicle into the supraspinatus, but there was no rotator cuff tendon or labral pathology present.  At an orthopedic clinic visit on 9 August 2005, there was pain elicited by motion of the left shoulder, but ROM was normal; and there was no instability or weakness.  The left shoulder was permanently profiled at “U3” and the commander’s statement indicated the CI was unable to perform military occupational specialty (MOS) tasks involving very heavy lifting and climbing in and out of tactical vehicles because of his medical condition and his physical profile.  

The 26 August 2005 MEB NARSUM examination, 2 months prior to separation, noted complaints of 3/10 left shoulder pain, which increased to 10/10 when carrying heavy loads.  Physical examination showed no redness, heat, soft tissue swelling, or ecchymosis.  The CI was tender over the trapezius distribution and minimal pain was elicited on internal rotation of the shoulder.  Hawkins' and Neer's tests (equivalent to painful motion) were both negative, and there was no instability of the left shoulder.  At the PT ROM evaluation on 12 September 2005, one month prior to separation,  goniometric left shoulder measurements were flexion of 160 degrees (normal 180) and abduction of 165 degrees (normal 180), after repetition.  No motions were limited by pain; however, symptoms (pain) were reproduced with shoulder extension and horizontal abduction.  There was no VA examination proximate to separation in evidence.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB bundled the left shoulder and right knee conditions and applied a single 0% rating, analogously coded 5099-5003 (degenerative arthritis), citing minimal and frequent pain IAW the US Army Physical Disability Agency pain policy.  

The panel first determined that the left shoulder condition, after being de-coupled from the combined condition, remained separately unfitting based on the CI’s MOS-limiting profile and commander’s statement.  The panel then turned to rating consideration and noted that 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 for satisfactory evidence of painful motion IAW VASRD §4.59.  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) or 5203 (clavicle or scapula, impairment) codes.  After due deliberation, and considering all the evidence, the panel recommends a separately unfitting determination with a disability rating of 10% for the left shoulder condition, coded 5099-5003.  

Right Knee Pain.  According to the STR and MEB NARSUM, the CI’s right knee condition began in 2003 with no specific injury or incident.  X-rays of the left knee in April 2005 showed a benign bone island in the proximal tibia.  There was no evidence of fracture, dislocation, arthritis, or inflammatory change.  The joint space was well maintained and there was no effusion.   At a clinic visit on 13 April 2005, examination revealed right knee pain was elicited by motion.  During a PT visit on 29 April 2005, all specialty tests were negative for right knee pathology.  At a primary care clinic visit on 25 May 2005, he had full ROM of the right knee without crepitus.  

During an orthopedic examination on 2 June 2005, the CI reported aggravation of right knee pain with carrying heavy loads or wearing body armor.  On examination the right knee ROM was 0-130 degrees (normal 0-140) without erythema or swelling.  There was no instability, laxity, or joint line tenderness.  At a PT clinic visit on 14 June 2005, active ROM was within functional limits.  Normal right knee motion was noted at an orthopedic clinic visit on 9 August 2005. The right knee was permanently profiled at “U3” and the commander’s statement indicated the CI was unable to perform the MOS tasks involving very heavy lifting and climbing in and out of tactical vehicles because of his medical condition and his physical profile.

During the MEB NARSUM examination the CI complained of intermittent 6/10 right knee pain aggravated by carrying heavy loads or wearing a flak vest.  Physical examination showed no redness, heat, soft tissue swelling or ecchymosis.  However, there was tenderness on the anterior aspect of the knee overlying the patella.  Provocative testing showed no evidence of right knee instability or meniscal pathology.  There was no ligamentous laxity or joint line tenderness noted.  
At the 12 September 2005PT ROM evaluation, goniometric right knee measurements were flexion of 142 degrees (normal 140) and extension of -2 degrees (normal 0) without pain.  

The panel directed attention to its rating recommendation based on the above evidence.  The panel first determined the right knee condition, after being de-coupled from the combined shoulder condition, remained separately unfitting based on the CI’s MOS-limiting profile and commander’s statement.  Turning next to rating, the panel determined there was no evidence of painful motion with functional loss to support a 10% rating (based on §§4.59, 4.40 and 4.45).  There likewise was no limitation of motion which attained a 10% rating under the diagnostic codes for limitation of flexion or extension (5260 or 5261).  There was no history or evidence of a 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).  No additional functional limitation was evidenced by the examinations.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for the right knee condition, coded 5099-5003.  

BOARD FINDINGS:  In the matter of the left shoulder condition, the panel recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the right knee condition, the panel recommends a disability rating of 0%, 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 the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Pain in the Left Shoulder	5099-5003	10%	
Chronic Pain in the Right Knee	5099-5003	0%	
COMBINED	10%	

AR20190010915,  

Dear XXXXXXXXXXXX:

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.