RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1200749 SEPARATION DATE: 20030916 BOARD DATE: 20130228 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty CPT/O-3 (25AD0/Maintenance & Automation Officer), medically separated for right shoulder and left knee pain. Despite physical therapy and medication, the CI did not improve adequately to meet the physical requirements of his Military Occupational Specialty (MOS) or to satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded 1) Right shoulder pain, status post distal clavicle fracture and acromioclavicular (AC) joint separation, status post distal clavicle resection and coracoclavicular ligament reconstruction and 2) Left knee pain, status post traumatic patellar tendon laceration and subsequent repair as the only conditions for Physical Evaluation Board (PEB) adjudication. The PEB adjudicated the right shoulder and left knee pain conditions as unfitting, rated 10%, with application of the US Army Physical Disability Agency (USAPDA) pain policy. The CI initially appealed but then withdrew his appeal and he was medically separated with a 10% disability rating. CI CONTENTION: “Speech and thought impairments due to head injury.” SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings for unfitting conditions will be reviewed in all cases. The unfitting right shoulder and left knee pain conditions meet the criteria prescribed in DoDI 6040.44 for Board purview, and are accordingly addressed below. The requested speech and thought impairments due to head injury conditions are not within the Board’s purview. Any condition or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Army Board for Correction of Military Records. RATING COMPARISON: Service IPEB – Dated 20030115 VA (~5 Mos. Pre-Separation) – All Effective Date 20030917 Condition Code Rating Condition Code Rating Exam Right Shoulder, Left Knee Pain 5009- 5003 10% Residuals Right Shoulder Injury with Clavicle Fracture and Joint Separation s/p Repair 5201 20% 20030407 Surgical Scar from Right Clavicle Resection 7805 0% 20030407 Residuals of Left Knee Injury with Reconstruction of Patellar Tendon 5260 10% 20030407 Surgical Scar of the Left Knee 7805 0% 20030407 Residual Scar, Left Knee Abrasion 7805 0% 20030407 No Additional MEB/PEB Entries Residuals of Right Knee Injury with LCL Strain 5260 10% 20030407 Scar due to Chest Tube Placement Right Trapezius 7804 10% 20030407 Tinea Versicolor 7813-7806 10% 20030407 Right Hand Impairment due to Head Trauma 8045-8516 10% 20030407 Left Hemisphere Traumatic Lesion 8045-9304 10% 20030327 0% X 5 others / Not Service-Connected x 1 20030407 Combined: 10% Combined: 60%* (BLF 1.9 for 5260, 5260) * No change to subsequent VARD ratings and effective dates ANALYSIS SUMMARY: The Board’s authority as defined in DoDI 6040.44, resides in evaluating the fairness of Disability Evaluation System (DES) 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 rated right shoulder pain and left knee pain under the single analogous 5003 (degenerative arthritis) code. This coding approach is countenanced by AR 635-40 (B.24 f.), 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 itself. Right Shoulder Pain Condition. The Board first considered if the right shoulder pain condition, having been de-coupled from the combined PEB adjudication, was reasonably justified as independently unfitting. The permanent profile prohibited push-ups and limited lifting to forty pounds and the CI’s commander stated these limitations prohibited him from performing his required duties in a combat environment. The service treatment records (STRs) document ongoing treatment for type II distal clavicle fracture, chronic and type V AC separation, chronic with continued pain and decreased range-of-motion (ROM) both before and after surgical reconstruction. All of the members agreed that the right shoulder pain condition, as an isolated condition, would have rendered the CI incapable of continued service within his MOS, and accordingly merits a separate rating. The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below. Right Shoulder ROM PT ~17 Mo. Pre-Sep MEB NARSUM ~10 Mo. Pre-Sep VA C&P ~5 Mo. Pre-Sep Flexion (0-180°) 150 (pain at extremes) 150 150 (pain at 100) Abduction (0-180°) 150 (pain at extremes) 110 (limited by pain) 110 (pain at 80) Comments Goniometer not noted; pain on extremes; motor trapezeii 3+/5, ER 4/5, IR 4+/5 Goniometer not noted; TTP at clavicle but reduced and joint stable; strength 5/5 IR, ER, abduction; no deltoid atrophy Goniometer utilized; painful motion; tender to palpation at distal clavicle and AC area; significant pain with attempts of both apprehension and drop arm testing; repetitive motion produced fatigability and increased pain §4.71a Rating 10% 10% 10% (20% VA rating) The CI was involved in a motorcycle accident in August 2000 and was treated with rehabilitation for right shoulder separation and pain. In March 2001, he underwent a right distal clavicle resection and reconstruction of coracoclavicular ligaments as treatment for his Type II distal clavicle fracture, chronic and type V AC separation, chronic. An evaluation by physical therapy completed 17 months prior to separation, noted decreased ROM and motor weakness. At the MEB narrative summary (NARSUM) exam, 10 months prior to separation, the CI reported pain in the right shoulder, primarily with overhead lifting and carrying heavy objects. He also complained of night pain, decreased ROM secondary to pain and easy fatigue in the trapezius muscle. Intra-operative and post-operative X-rays in 2001 confirmed appropriate reduction and the NARSUM noted the clavicle was well reduced and stable. Physical findings, including normal motor strength, are in the ROM chart above. The VA Compensation and Pension (C&P) exam approximately 5 months prior to separation noted pain, weakness, stiffness, fatigue, and lack of endurance of the right shoulder. ROM measurements and physical findings are in the chart above. The Board directs attention to its rating recommendation based on the above evidence. The PEB combined the two conditions of left knee pain and right shoulder pain under 5099-5003 at 10%, reflecting application of the USAPDA pain policy for rating. The VA rated the residuals of the right shoulder injury at 20% using VASRD code 5201 (Arm, limitation of motion) based on abduction limited to 110 degrees with painful motion at 80 degrees. The minimum compensable limitation of motion for the shoulder under 5210 is at shoulder level, or 90 degrees, for both flexion and abduction. While the CI did have pain at 80 degrees of abduction, abduction to 110 degrees was possible. Therefore, the minimum compensable ROM is exceeded. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 Reasonable doubt and §4.59 Painful motion, the Board recommends a disability rating of 10% for the right shoulder condition. Left Knee Pain Condition. The Board first considered if the left knee pain condition, having been de-coupled from the combined PEB adjudication, was reasonably justified as independently unfitting. The permanent profile prohibited forced running, rucksack marching, and marching, and any type of jumping activity. It also limited marching to two miles and walking, running, bicycling, swimming, and walking or running in the pool to the CI’s own pace and distance. The CI’s commander stated these limitations prohibited him from performing his required duties in a combat environment. The service treatment records (STRs) document ongoing treatment for the left knee pain with physical therapy and activity limitations. All of the members agreed that the left knee pain condition, as an isolated condition, would have rendered the CI incapable of continued service within his MOS, and accordingly merits a separate rating. The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below. Left Knee ROM MEB NARSUM ~10 Mo. Pre-Sep VA C&P ~5 Mo. Pre-Sep Flexion (140° Normal) 125 130 (Pain at 120) Extension (0° Normal) 0 0 Comment Goniometer not noted; patellar tendon intact; guard significantly during exam; positive patellar grind; no ligamentous instability; no effusion, meniscal or other intraarticular injury; excellent quadriceps tone Goniometer utilized; painful motion at 120 degrees; tender to palpation inferior to patella, patella periphery, and patella tendon areas; no ligament instability; no effusion, no swelling; normal gait and posture; repetitive motion produced fatigability and increased pain §4.71a Rating 10% 10% The CI was involved in a motorcycle accident in August 2000 and underwent immediate surgical repair of a traumatic left patellar tendon rupture in a German hospital. No operative report is available for review. Left knee X-ray was normal in January 2001 and magnetic resonance imaging (MRI) of the left knee in April 2001 revealed a continued abnormality of the patellar tendon. The MEB NARSUM completed 10 months prior to separation noted the CI had anterior knee pain with prolonged sitting or standing, with running, and with climbing. A neoprene sleeve helped somewhat with his pain. The physical exam findings are noted in the chart above. Of note, while painful motion was not specifically mentioned, the examiner noted the presence of significant guarding during the examination. The C&P exam 5 months prior to separation noted pain, weakness, stiffness, fatigue, and lack of endurance of the left knee. The physical exam findings are noted in the chart above. The Board directs attention to its rating recommendation based on the above evidence. The PEB combined the two conditions of left knee pain and right shoulder pain under 5099-5003 at 10%, reflecting application of the USAPDA pain policy for rating. The VA rated the left knee pain condition at 10% using VASRD 5260 Leg, limitation of flexion of based on pain limited motion. Both the MEB NARSUM and the VA examinations support the finding of pain-limited motion and neither examination documented any joint instability. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) and VASRD §4.59 (painful motion), the Board recommends a disability rating of 10% for the left knee 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 right shoulder and left knee was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the contended right shoulder pain condition, the Board unanimously agrees that it was separately unfitting and by a vote of 2:1 recommends a disability rating of 10%, coded 5003-5024 IAW VASRD §4.71a. The single voter for dissent (who recommended a disability rating of 20% coded 5201) did not elect to submit a minority opinion. In the matter of the contended left knee pain condition, the Board unanimously agrees that it was separately unfitting and unanimously recommends a disability rating of 10%, coded 5260 IAW VASRD §4.71a. 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 Right Shoulder Pain 5003-5024 10% Left Knee Pain 5260 10% COMBINED 20% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120605, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxx, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxxx, AR20130007513 (PD201200749) 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 rating to 20% without 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 xxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)