RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-05337
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050507

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Motor Transport Operator, medically separated for “left knee pain” and “left shoulder pain,” rated 10% each, with a combined disability rating of 20%.  “Asthma” was determined to have existed prior to service (EPTS) and was not rated.  

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’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 - 20050202	VARD - 20050525	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Pain	5257	10%	Left Knee Instability	5257	10%	20050322	
			Left Knee S/P ACL Reconstruction	5260	10%	20050322	
Left Shoulder Pain	5099-5003	10%	Left Shoulder Strain	5201-5203	10%	20050322	
Asthma	6602	EPTS	Asthma	6602	NSC	20050322	
Migraine	Not Unfitting	Migraine	8100	NSC	20050322	
Hiatal Hernia with Reflux	Not Unfitting	Hiatal Hernia/Reflux	7346	10%	20050322	
Left Hearing Loss	Not Unfitting	Tinnitus	6260	10%	20050322	
Induced Anxiety	Not Unfitting	Depressive Disorder, NOS	9499-9434	NSC	20050316	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Left Knee Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent ACL reconstruction, but the operative report was not in evidence.  Subsequent records only cite the ACL repair and do not record meniscal pathology.  STR from orthopedics noted intermittent subjective and objective instability.  The CI was offered a revision of the ACL surgery because of some laxity noted in his graft; however, he declined due to concerns regarding postoperative pain and the effect on his job requirements.  During the 5 October 2004 MEB examination (recorded on DD Forms 2807 and 2808), 7 months prior to separation, the CI reported locking and hyperextension of the left knee.  The physical examination showed the left knee had limited range of motion (ROM) with pain.  The heel and toe walk was normal.  

At the 10 November 2004 MEB NARSUM examination, 6 months prior to separation, the CI reported pain and instability.  The physical examination showed pain, crepitus and subjective instability with hyperextension.  No effusion or gross deformity was noted.  The ROM showed left knee flexion of 135 degrees (normal 140) compared to 155 on the right.  A test for integrity of the ACL showed some laxity, but with a solid endpoint consistent with the repair.  A positive pivot shift test (test for instability) was demonstrated.  There was no significant pain with patellar grind and no joint line tenderness (signs of kneecap or meniscal disease).  The general NARSUM was dated 13 November 2004.  It noted a stable knee other than slight laxity of the ACL.  Flexion was 130 degrees and extension was normal at 0 degrees.  

At the 22 March 2005 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported a feeling of instability and reported occasional left knee buckling.  A prescribed brace was used occasionally.  On examination, the gait was normal and he could walk on his heels and toes as well as squat to 80 degrees before stopping from discomfort.  There was laxity on anterior drawer testing with a solid end-point.  Provocative testing for a meniscal pathology was negative.  In the sitting position he was able to flex to 120 degrees and extend to 0 degrees.  Flexion was not additionally limited following five repetitions.  No soft tissue swelling or joint effusion was noted.  Crepitus was present on flexion and extension.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10%, coded 5257 (knee, other impairment of), citing a 2+ Lachman’s with a solid end point, positive pivot shift and full ROM.  Pain and instability were present.  The VA also rated the left knee condition 10%, coded 5257 based on the C&P examination, citing slight recurrent subluxation or lateral instability of the knee, and 10%, coded 5260 (leg, limitation of flexion) citing flexion in the standing position limited to 80 degrees with pain, and flexion limited to 120 degrees in the sitting position.  The panel observed that the laxity was due to the ACL insufficiency and that this was used to rate under two codes.  The panel determined that this was pyramiding and violated VASRD §4.14.  

The examinations proximate to separation demonstrated the presence of ligamentous instability or laxity (5257).  However, there was no evidence of moderate subluxation or lateral instability to support a 20% rating under the 5257 code.  There was no limitation of motion (5260, 5261), no history of surgery to remove a meniscus (5259) and no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) to support a rating under the respective codes.  Finally, 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).  No additional functional limitation was evidenced by the examinations.  There is therefore no VASRD §4.71a rating higher than the 10% adjudicated by the PEB under any applicable code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the left knee condition.  

Left Shoulder Pain.  According to STR and the MEB NARSUM, the right-hand dominant CI’s left shoulder condition began in 2001 when his left shoulder dislocated while changing a 350-pound tire.  The only examination in evidence prior to entering the MEB process was an orthopedic evaluation on 10 May 2004 which noted subluxation (slippage, but not dislocation) of the left shoulder.  On 13 September 2004 in orthopedics, the CI was noted to have left shoulder impingement despite treatment.  Difficulty with overhead work was reported.  The MEB examination (recorded on DD Forms 2807 and 2808) 8 months prior to separation, showed decreased ROM with point tenderness at the acromio-clavicular joint.  

During the MEB NARSUM examination, 6 months prior to separation, the CI complained of daily pain and difficulty executing overhead activities.  An MRI noted some inflammation of a shoulder tendon, but was suboptimal due to motion.  The physical examination showed full active ROM.  Pain was noted with abduction and forward elevation greater than 120 degrees.  Muscle strength was normal.  Testing for instability was negative.  He was thought to have an impingement syndrome.  Two weeks later, the general NARSUM noted pain-limited flexion to 115 degrees (normal 180) and pain-limited abduction to 110 degrees (normal 180).  

At the C&P evaluation, 2 months after separation, the CI reported no significant daily or occupational impact from the shoulder condition.  The physical examination showed no obvious muscle wasting.  The ROM testing revealed both flexion and abduction to 150 degrees.  The function was not additionally limited by pain, fatigue, weakness or lack of endurance following five repetitions of the left shoulder.  Some grinding and crepitus with rotational motion of the left shoulder with palpation during motion was present.  X-rays were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 10%, coded 5099-5003 (analogous to degenerative arthritis) citing pain with use, flexion limited to 115 degrees and abduction to 110 degrees.  The VA also rated the left shoulder condition 10%, coded 5201-5203 (arm, limitation of motion-clavicle or scapula, impairment of), and based on the C&P examination, citing limited ROM with pain.  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.  Although there was insufficient limitation of motion to support a rating under the 5201 code, panel 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 the 5202 code and no nonunion with loose movement of the clavicle to warrant the next higher 20% rating under the 5203 code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the left shoulder condition.  

Asthma.  According to STR and the MEB NARSUM, the CI was treated for asthma prior to service, with allergies beginning at age 10 and asthma at age 14.  His symptoms improved in high school and he passed basic training.  This was not disclosed at accession.  In 1999, during field training exercises, the CI noticed shortness of breath, wheezing and chest tightness.  The CI continued to have recurrent asthma attacks whenever he returned to the field.  A chest X-ray was normal.  Allegra, Albuterol and Advair were used to control his symptoms.  On 15 October 2005, pulmonary function test showed FEV1/FVC of 77% and FVC of 96%.  

The MEB NARSUM examination, 6 months prior to separation, noted the CI was asymptomatic but reported monthly attacks during the past year.  Asthma attacks were associated with field duty.  At the VA C&P evaluation, the CI reported a long history of sinus/allergy problems dating back to his childhood with episodic wheezing.  On physical examination, the lungs were clear to auscultation and the respiratory rate was normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the asthma condition as “existed prior to enlistment,” coded 6602 (asthma) citing exacerbations under field conditions and required Advair daily and albuterol as needed.  The CI concurred with this adjudication.  The VA rated the asthma condition “not service connected,” coded 6602 (asthma) based on the C&P examination, citing evidence showing the condition existed prior to service and was not aggravated as a result of service.  The panel considered the evidence and concurred that the asthma condition was EPTS and not permanently aggravated by the service.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the asthma condition.  

Contended PEB Conditions:  Migraine, Hiatal Hernia with Reflux, Left Hearing Loss and Induced Anxiety Disorder.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled.  The commander’s statement noted that the CI was unable to drive any vehicle due to the medications taken for the mental health condition.  The panel noted that the mental health condition was attributed to substance abuse.  With the exception of migraine headaches, all of the conditions were judged to meet retention standards.  It was noted these had been present since high school and were exacerbated by field duty.  Although the headaches failed retention standards, the CI had not undergone an adequate trial of therapeutic options.  There was no record of emergency room visits or placed on quarters for the migraine condition.  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 any of the contended conditions and so no additional disability ratings are 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 left shoulder condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the asthma condition and IAW VASRD §4.100, the panel recommends no change in the PEB adjudication as EPTS.  In the matter of the contended migraine, hiatal hernia, left hearing loss, and anxiety disorder, the panel recommends no change from the PEB determinations as not unfitting.  There were 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:

Exhibit A.  DD Form 294, dated 20170510, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180007399, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	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.

Sincerely,					      
Enclosure