RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXX	CASE:  PD-2017-04100
BRANCH OF SERVICE:  army	SEPARATION DATE:  20070122

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E4, Cannon Crewmember, medically separated for “chronic left knee pain and instability” with a disability rating of 20%.

CI CONTENTION:  Review requested of the left knee, left shoulder, low back, and anxiety disorder as well as additional conditions not identified by Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20061220	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Instability and Pain	5257	20%	No VA Examination Proximate to Separation in Evidence	
Low Back Pain	Not Unfitting		
Anxiety Disorder			
Left Shoulder Labral Tear			
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:

Chronic Left Knee Instability and Pain.  According to the service treatment record (STR) and MEB NARSUM, the CI sustained a twisting knee injury in May 2004 while participating in combative training. He subsequently underwent an anterior cruciate ligament (ACL) reconstruction with partial synovectomy (removal of issue around the knee joint) in July 2005, and a second ACL reconstruction in October 2005.  However, the left knee instability and pain persisted.  At the 9 August 2006 MEB physical therapy (PT) examination, 6 months prior to separation, left knee flexion was to 130 degrees (normal 140) and extension was “full” (normal 0), but painful motion and instability were not addressed.  At the 16 August 2006 MEB NARSUM examination,  the CI reported left knee instability.  Physical examination (PE) noted left knee flexion to 135 degrees and extension to 0 degrees.  Painful motion was not addressed.  Clinical tests noting joint instability were positive for a soft end point and greater than 10 mm translation.  

During the 21 September 2006 MEB NARSUM examination, 4 months before separation, the CI reported left knee instability.  The PE noted left knee flexion to 130 degrees and “full” extension; painful motion was not addressed.  The examiner also referenced the aforementioned positive instability examination findings.  The 6 December 2006 MEB NARSUM addendum, 2 months prior to separation, noted complaints of functional instability with daily living and physical activities.  The CI reported only being able to ambulate, climb stairs, or perform other physical-type activities with the use of an ACL brace.  The PE revealed left knee flexion to 100 degrees and extension to 0 degrees.  Painful motion was not addressed.  Anterior drawer and Lachman’s instability testing was 2+, and varus and valgus instability testing was stable.  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 rated the left knee condition 20%, coded 5257 (knee, other impairment), citing residuals of instability and painful motion.  The panel agreed there was no evidence of “severe” subluxation or lateral instability to support a 30% rating under code 5257 code.  Additionally, there was no limitation of motion (5260, 5261); history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258); or fracture, nonunion or malunion of the femur or tibia to support consideration under the codes for knee impairment related to long bone conditions (5255, 5262).  The panel also considered an additional rating (dual code) by means of non-compensable limitation of motion of a major joint, but there was no X-ray evidence in the STR of arthritis and or satisfactory evidence of painful motion (VASRD §4.59) to support an additional 10% rating.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommends a change in the PEB adjudication for the left knee condition.  

Contended PEB Conditions:  Low Back Pain (LBP), Anxiety Disorder, and Left Shoulder Labral Tear.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  The LBP and anxiety disorder were not profiled or implicated in the commander’s statement, and did not fail retention standards.  There was no performance-based evidence from the record that either of these two conditions significantly interfered with satisfactory duty performance at separation.  

According to the STR and MEB NARSUM, the CI’s left shoulder condition began in October 2004 when his left arm was torqued during hand-to-hand combat training causing the left shoulder to pop.  Years of conservative treatment failed to resolve the left shoulder pain, especially during overhead reaching and lifting, and he subsequently underwent surgery in February 2006 to correct a shoulder impingement.  Left shoulder X-rays performed in August 2006 were unremarkable, and a primary care visit on 20 June 2006, 8 months prior to separation, documented “normal” left shoulder motion, with no pain, instability or weakness.  

During the 16 August 2006 MEB NARSUM examination, the CI reported left shoulder pain, but that surgery had resolved 90 percent of his symptoms and he could conduct activities as tolerated.  The PE revealed flexion and abduction to 180 degrees (normal); painful motion was not addressed.  There was no left shoulder impingement or acromioclavicular joint arthopathy (joint cartilage starts to wear out), and no weakness.  The CI’s final profile dated 12 December 2006, 1 month prior to separation, did not allow him to swim or perform push-ups during the fitness test, and limited lifting up to 40 pounds, which was well below his cannon crewmember specialty requirements.

The panel deliberated and determined there was a preponderance of performance-based evidence from the record that the left shoulder condition significantly interfered with satisfactory duty performance at separation.  Panel members then considered a rating recommendation for the unfitting left shoulder condition, but agreed that there no limitation of shoulder motion to support a rating under diagnostic code 5201 (arm, limitation of motion), or satisfactory evidence of painful motion or other evidence of functional loss to support a 10% rating IAW VASRD §4.59, §4.40 or §4.45, as reported on the STR and MEB NARSUM examinations proximate to separation.  Additionally, there was no malunion, deformity, or recurrent dislocation of the humerus to justify a rating under code 5202 (humerus, other impairment); and no nonunion or malunion of the clavicle or scapula to warrant any rating under code 5203 (clavicle or scapula, impairment).  Consequently, there was no rating advantage to the CI.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended LBP, anxiety disorder, and left shoulder condition, so no additional disability rating is recommended.

BOARD FINDINGS.  In the matter of the left knee condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended low back pain, anxiety disorder, and left shoulder condition, 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.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

	PD-2017-04100

AR20190012037, XXXXXXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXX

	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.

	PD-2017-04100