RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1200822 SEPARATION DATE: 20040120 BOARD DATE: 20130301 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard SSG/E-6 (12C30/Bridge Crewmember); medically separated for chronic pain, right knee, right shoulder and right elbow, and chronic back pain without neurologic abnormality. In 1997 while performing physical training on active duty, the CI sustained a twisting injury to the right knee. The CI was treated with activity restriction, non- steroidal anti-inflammatory drugs (NSAIDS) and arthroscopic surgery in 2002. In January 2003, the CI was mobilized, evaluated by orthopedics, and treated with a different NSAID and physical therapy (PT). The CI suffered a traumatic injury to the right shoulder in July 1997 while on active duty. He had significant pain associated with his shoulder even after rehabilitation, and underwent distal clavicle resection of the right shoulder in 1998. Right elbow pain began in June 2003 with insidious onset. He was treated with rest and NSAIDs. The first record of low back pain (LBP) noted in the service treatment record (STR) occurred in October 1991 when the CI sustained a twisting injury to his back while playing basketball while on active duty. The CI was on active duty from 10 May 1990 to 9 July 1994, from 10 March 1995 to 9 March 1998, and 21 January 2003 to 20 January 2004. Despite extensive PT, several different NSAIDs, and orthopedic evaluations for his conditions, the CI failed to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent P2 U2 L3 profile for right knee pain, chronic LBP, chronic right shoulder pain, and pseudofolliculitis barbae and he was referred for a Medical Evaluation Board (MEB). The MEB forwarded retropatellar pain syndrome right knee status post (s/p) arthroscopy, chronic LBP with L5-S1 degenerative joint disease (DJD) nonradiating, right shoulder acromioclavicular (AC) joint separation Type II s/p right shoulder AC joint resection in 1997, and right elbow pain olecranon bursitis associated with small olecranon spur to the Physical Evaluation Board (PEB) for adjudication. The MEB noted all of these conditions had existed prior to service (EPTS) and had not been permanently aggravated by service. The MEB forwarded no other conditions for adjudication. The PEB adjudicated the 1) chronic pain, right knee, right shoulder, and right elbow as unfitting rated 10% with application of the US Army Physical Disability Agency (USAPDA) pain policy and 2) chronic back pain without neurologic abnormality as unfitting with application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD) rated at 10%. Both conditions were considered to have EPTS and not permanently aggravated by service but were compensable IAW 10 USC 1207a. The CI submitted an undated rebuttal stating that his disabilities each resulted from separate incidences that occurred during previous periods of active duty. He requested the PEB provide separate evaluations of each condition as the VA had done. A December 2003 USAPDA response to this rebuttal stated the DA 199 had been administratively changed to reflect that the back condition was service related and items 3d, 3e, and 3f had been changed to yes for the back condition. It also stated that item 8b, paragraph 3, and was changed to: "The disabilities rated IAW 5003 existed prior to service and are not permanently aggravated by service, but are compensable in accordance with 10 USC 1207a." There is no clear evidence of any rating deduction related to service aggravation. The CI was medically separated with a 20% disability rating. CI CONTENTION: “Check medical and VA medical records“ SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 6040.44 (4.a) is limited to those conditions that were determined by the PEB to be specifically unfitting for continued military service; and, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The unfitting conditions chronic pain, right knee, right shoulder and right elbow and chronic back pain without neurologic abnormality meet the criteria prescribed in DoDI 6040.44 for Board purview and are addressed below. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the service Board for the Correction of Military Records. RATING COMPARISON: Service IPEB – Dated 20031113 VA (3 Mos. Post-Separation) – All Effective Date 20040121 Condition Code Rating Condition Code Rating Exam Chronic Pain, Right Knee, Right Shoulder and Right Elbow 5099- 5003 10% Meniscal Disease Status Post Arthroscopic Repair, Right Knee, 5260- 5020 10%* 20040419 Acromioclavicular Arthritis Status Post Mumford Procedure, Right Shoulder 5201- 5010 10%** 20040419 Right Elbow Condition 5019 NSC*** 20040419 Chronic Back Pain without Neurologic Abnormality 5299- 5237 10% Lumbar Spondylosis 5299- 5295 10% 20040419 No Additional MEB/PEB Entries 0%**** X 3 / Not Service-Connected x 7 20040419 Combined: 20% Combined: 30% *Increased to 20% effective 20050202 based on VA treatment records and C&P exam 20050709. **Increased to 20% effective 20060828 based on C&P 20061118. ***Initially NSC based on no diagnosis of a chronic elbow condition, but the 20061204 VARD determined it was service connected and rated 5019 at 10% effective 20040121 based on the original C&P 20040419 and intervening VA treatment records ****All three 0% ratings were effective 20040331 ANALYSIS SUMMARY: The Board’s authority as defined in DoDI 6040.44, resides in evaluating the fairness of Disability Evaluation System fitness determinations and rating decisions for disability at the time of separation. The Board utilizes VA evidence proximal to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12-month interval for special consideration to post-separation evidence. Post-separation evidence is probative only to the extent that it reasonably reflects the disability and fitness implications at the time of separation. The PEB combined the chronic pain, right knee, right shoulder and right elbow conditions as a single unfitting condition, coded 5099 analogously to 5003 and rated 10%. This coding approach is countenanced by AR 635-40 (B.24f), but IAW DoDI 6040.44 the Board must apply only VASRD guidance to its recommendation. The Board must therefore apply separate codes and ratings in its recommendations if compensable ratings for each joint are achieved IAW VASRD §4.71a. If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each “unbundled” condition was reasonably justified as unfitting in and of it. The DA Form 3947 documented that the retropatellar pain syndrome right knee status post (s/p) arthroscopy, chronic LBP with L5-S1 DJD non-radiating, right shoulder AC joint separation Type II s/p right shoulder AC joint resection in 1997, and right elbow pain olecranon bursitis associated with small olecranon spur conditions were all EPTS and not permanently aggravated by service. However, the PEB determined that the back pain condition was service related. It also determined that while the chronic pain, right knee, right shoulder, and right elbow condition was EPTS and was not permanently aggravated by service, it was compensable in accordance with 10 USC 1207a. The Military Entrance Processing Station physical exam findings in January 1990 documented normal upper extremities (shoulders, elbows), normal lower extremities (knees) and normal spine. Back, right knee, right shoulder, and right elbow injuries were all determined to have occurred in the line of duty as documented on two separate DA Form 2173s, dated 22 and 23 December 2003. Chronic Right Knee Pain Condition. The Board first considered whether the chronic pain right knee condition, having been de-coupled from the combined PEB adjudication, remained independently unfitting as established above. The CI was issued a permanent profile related to the right knee pain in May 2003 and his commander’s statement from June 2003 noted that the CI was physically incapable of reasonably performing his duties required for his MOS due to his right knee pain and LBP. Service treatment records (STRs) document ongoing care for right knee pain and decreased motion from 1998 to 2003. All Board members agreed that chronic pain right knee, as an isolated condition, would have rendered the CI incapable of continued service within his MOS and it accordingly merits a separate rating. There were range-of-motion (ROM) evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below. Right Knee ROM (Degrees) Ortho ~9 Mo. Pre-Sep MEB NARSUM ~4 Mo. Pre-Sep VA C&P ~3 Mo. Post-Sep Flexion (140 Normal) - - 120* Extension (0 Normal) - - 0 Comment Retro patellar Tenderness to palpation; + theater sign-pain with prolonged sitting; “pain with stairs” DD2808 noted right knee RPPS-chondromalacia with persistent pain No ROMs in STR except 0-130 degrees 20020701 and 0-120 20020819 and both were before surgery; (exams from 20030514 and 20030618 not in STR) *With pain; Hinged knee brace; positive McMurray’s test; motor 5/5 bilateral, reflexes normal; no gait abnormalities §4.71a Rating 10% 10% 10% Decreased ROM with flexion limited to 130 degrees and 120 degrees, along with tenderness along the medial patellar facet and medial joint line were noted prior to surgery. Magnetic resonance imaging performed in July 2002 revealed no significant abnormalities. The CI underwent a right knee arthroscopy, synovectomy, and chondroplasty in August 2002. No ROM measurements were made by the service after this surgery. A right knee X-ray was normal. Orthopedics evaluated the CI‘s knee approximately 9 months prior to separation and noted pain with going up and down stairs. The orthopedic physical exam findings are summarized in the chart above. The MEB narrative summary (NARSUM) examination approximately 4 months prior to separation noted ongoing complaints of right knee pain exacerbated by sitting, standing for prolonged periods, lifting, and climbing. The NARSUM physical exam findings are summarized in the chart above. The VA Compensation and Pension (C&P) examination 3 months after separation indicated that there was pain, weakness, stiffness, instability and fatigability, and an additional motion functional impairment of up to 25% with flares weekly caused by stooping or crawling with running, bending walking on uneven surfaces. Bilateral knee x-rays were normal. The C&P physical exam findings are summarized in the chart above. The Board directs attention to its rating recommendation based on the above evidence. The PEB combined the three conditions of right knee, right shoulder, and right elbow pain under 5099-5003 at 10%, reflecting application of the USAPDA pain policy for rating. The VA evaluated meniscal disease s/p arthroscopic repair, right knee using VASRD 5260 leg, limitation of flexion of combined with 5020 synovitis and assigned a 10% rating based on pain-limited motion. Service exams and the STR document a history of painful motion although pain with motion is not specifically stated on the NARSUM exam. No exams noted any instability. Although it was completed 3 months after separation, the VA examination is more complete as it documents both ROM measurements and the presence of painful motion and it was therefore given greater probative value by the Board. The knee could not be reasonably rated higher than 10% using any exam proximate to separation or any alternate coding schema. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 Resolution of reasonable doubt and VASRD §4.59 Painful motion, the Board concluded that the chronic right knee pain was reasonably justified as separately unfitting and recommends a disability rating of 10% for the right knee pain condition. Chronic Right Shoulder Pain Condition. As previously stated, the Board must first consider whether the chronic pain right shoulder condition remains separately unfitting, having been de- coupled it from the combined PEB adjudication. The CI was issued a permanent profile related to the right shoulder pain in June 2003 that prohibited wearing a backpack and lifting greater than 40 pounds. The addendum to the NARSUM prepared in August 2003 noted the CI was unable to perform push-ups, pull-ups, or lift greater than 30 pounds due to his right shoulder and right elbow pain. The commander’s statement does not specifically mention this condition but it was written prior to the date the permanent profile for the right shoulder was written. The STRs document ongoing but intermittent treatment for a Grade II AC joint separation with shoulder pain, decreased ROM, and weakness that began after an injury in July 1997 and continued after a distal AC joint resection surgery in 1998. A majority of the members agreed that the chronic right shoulder pain condition, as an isolated condition, would not have rendered the CI incapable of continued service within his MOS and, therefore, no separate service rating is warranted. Chronic Right Elbow Pain Condition. As previously stated, the Board must first consider whether the chronic pain right elbow condition remains separately unfitting, having been de- coupled it from a combined PEB adjudication. In analyzing the intrinsic impairment for appropriately coding and rating the chronic right elbow pain, the Board is left with a questionable basis for arguing that it was indeed independently unfitting. The CI had an insidious onset of right elbow pain that was noted to be daily persistent pain. However, while some restrictions could be attributed to the right elbow, the condition is not mentioned on the permanent profile. The commander’s statement does not specifically mention this condition but it was written prior to the date of the NARSUM addendum describing the elbow condition. A right elbow X-ray was normal except for a very small spur formation at the insertion of the triceps tendon on the right side. The VA did not initially service-connect this condition due to a lack of evidence of a chronic condition. However, after VA treatment records documented ongoing pain, the condition was service-connected and rated at 10% (based on painful motion) effective the day after separation. All members agreed that the chronic right elbow pain condition, as an isolated condition, would not have rendered the CI incapable of continued service within his MOS and no separate rating is warranted. Chronic Back Pain without Neurologic Abnormality Condition. There were two goniometric ROM evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below. Thoracolumbar ROM (Degrees) MEB Addendum ~ 2.5 Mo. Pre-Sep VA C&P ~ 3 Mo. Post-Sep Flexion (90 Normal) 70° 90° Extension (30) 5° 10°* R Lateral Flexion (30) 10° 30°* L Lateral Flexion (30) 15° 30° R Rotation (30) 30 °(35) 30° L Rotation (30) 30° 30° Combined (240) 160° 220° Comment Measurements other than rotation made with baseline bubble inclinometer placed at L1; Rotation measured with goniometer; Toe walking, tandem gait normal; pain with heel walking; strength 5/5, sensation intact to light touch and pinprick; proprioception, vibratory normal; patellar and ankle reflexes normal *With pain; Negative straight leg raise; no tenderness; slight pain increase with repetitive motion of spine; no gait abnormalities; motor 5/5 bilateral, reflexes normal §4.71a Rating 10% 10% The CI was issued a permanent profile for chronic LBP. The commander’s statement indicated that the CI was physically incapable of performing his duties due to his LBP. The NARSUM examination approximately 4 months prior to separation noted a history of non-radiating LBP and a history of an epidural steroid injection. It also noted a positive straight leg raise at 45 degrees bilaterally. A lumbar spine X-ray done at this time was negative. A NARSUM addendum was completed approximately 2 months prior to separation physical exam findings are summarized in the chart above. The C&P examination completed 3 months after separation indicated that the CI had undergone a trigger point injection. However, pain persisted and he had intermittent pain worse in the morning with stiffness and weakness that would progressively improve throughout the day. The examiner further noted that the CI could only walk approximately one-fourth of a mile without pain and that he had pain while walking up and down stairs. An X-ray performed at the time of this exam revealed spondylotic spaces between L4-S1 with normal lordosis. The C&P physical exam findings are summarized in the chart above. The Board directs attention to its rating recommendation based on the above evidence. The PEB coded the chronic back pain without neurologic abnormality coded analogous to 5237 lumbosacral strain and rated 10%. The VA coded the lumbar spondylosis analogous to 5295 lumbosacral strain: With characteristic pain on motion rated at 10%. The Board cannot explain why the VA chose to code under the old spine rules when the CI’s VA exam was in April 2004 and the new Spine rules went into effect September 26, 2003. The PEB and the VA chose different coding options. The PEB coding uses “The General Rating Formula for Diseases and Injuries of the Spine.” These rating criteria consider the CI’s pain symptoms “With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease.” The MEB exam proximate to separation meets the 10% criteria based forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees. The VA exam also supports a 10% rating, but this rating is based on painful motion, not limited flexion. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 Resolution of reasonable doubt and VASRD §4.59 Painful motion, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic back pain without neurologic abnormality condition. BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. As discussed above, PEB reliance on the USAPDA pain policy for rating the chronic pain right knee, right shoulder, and right elbow conditions bundled together was operant in this case and the conditions were adjudicated independently of that policy by the Board. In the matter of the chronic right knee pain condition and IAW VASRD §4.71a, the Board unanimously agrees that it was separately unfitting and unanimously recommends a disability rating of 10%, coded 5003 IAW VASRD §4.71a. In the matter of the chronic right shoulder pain condition and IAW VASRD §4.71a, Board consensus determined that it was not separately unfitting and therefore, no separate disability rating can be recommended. In the matter of the chronic right elbow pain condition and IAW VASRD §4.71a, Board consensus determined that it was not separately unfitting and therefore, no separate disability rating can be recommended. In the matter of the chronic LBP without neurologic abnormality, the Board unanimously recommends no change in the PEB adjudication. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation: UNFITTING CONDITION VASRD CODE RATING Chronic Right Knee Pain 5003 10% Chronic Back Pain without Neurologic Abnormality 5299-5237 10% COMBINED 20% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120606, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxx, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxx, AR20130004599 (PD201200822) 1. I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation to modify the individual’s disability description without modification of the combined rating or recharacterization of the individual’s separation. This decision is final. 2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum. 3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures. BY ORDER OF THE SECRETARY OF THE ARMY: Encl xxxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)