RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-01738
BRANCH OF SERVICE:  Army	BOARD DATE:  20150212
SEPARATION DATE:  20040713

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6 (Wheeled Vehicle Mechanic) medically separated for chronic pain of the left knee and right shoulder.  The conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent U3 L3 profile and referred for a Medical Evaluation Board (MEB).  “Retropatellar pain syndrome” and “right shoulder tendinitis,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “chronic pain, left knee and right shoulder” as unfitting, rated 0%, citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  “I feel the rating should be changed because I have to live with pain in both knees, right shoulder, and right foot.  I have had several procedures done on the right foot and problem still persist.  Also my life is limited due to the disabilities that I have.  In order to survive I have to work and in doing so I am forced to tolerate the pain.  It really is bad when my son was in high school and was playing football I could not throw the ball around…”

SSCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited 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 PEB, but determined to be not unfitting.  Any conditions outside the Board’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/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board 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, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:

IPEB – Dated 20040610 | VA* - (~1 Mos. Pre-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Chronic Pain, Left Knee and Right Shoulder | 5099-5003 | 0% | DJD L Knee with Bone Cyst | 5010 | 10% | 20040616
| | | R Shoulder Strain | 5203 | 10% | 20040616
Right Knee | Implied Not Unfitting | Healed R Knee LMT with Residuals of Stiffness and DJD | 5010 | 10% | 20040616
Other x 0 (Not In Scope) | Other x 4
RATING:  0% | RATING:  30%
*Derived from VA Rating Decision (VARD) dated 20040722 (most proximate to date of separation (DOS)).

ANALYSIS SUMMARY:  The PEB combined the left knee and right shoulder conditions under a single disability rating, coded analogously to 5003.  Although Veterans Affairs Schedule for Rating Disabilities (VASRD) §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  The Board must follow suit (IAW DoDI 6040.44) if the PEB combined adjudication is not compliant with the latter stipulation, provided that each “unbundled” condition can be reasonably justified as separately unfitting in order to remain eligible for rating.  If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  To that end, the evidence for the left knee and right shoulder conditions are presented separately; with attendant recommendations regarding separate unfitness, and separate rating if indicated.

Left Knee.  The first record in evidence is a primary care note dated 24 September 2002 with documented 2-year history of bilateral knee pain.  X-rays of both knees were normal other than a benign growth of the left knee.  An orthopedic evaluation on 6 November 2002 diagnosed a probable right side lateral meniscus (outside cartilage cushion in the knee joint) tear (LMT) while noting greater pain on the left side.  A magnetic resonance imaging (MRI) of the left knee on 12 January 2004, over a year later, was normal.  The CI was diagnosed with patella-femoral pain syndrome (PFPS) a month later in orthopedics.  He was treated in physical therapy (PT), but had continued pain.  A bone scan on 23 March 2003 was normal.  A primary care note dated 20 April 2004 documented chronic left knee and right shoulder pain.  A repeat X-ray of the left knee on 20 May 2004 was unremarkable other than the previously noted benign growth.  At the MEB examination on 18 May 2005, the examiner noted good range-of-motion (ROM) of the knees with patella-femoral guarding.  The CI reported constant pain and a sensation of “give away” bilaterally.  The narrative summary (NARSUM) was dated 2 days later, less than 2 months prior to separation.  The CI reported a 2-year history of pain which began in 2003 while deployed (note, the record indicated that he was seen for left knee pain prior to deployment).  On examination, he had a normal gait and was without an effusion or signs of instability.  A patellofemoral grind (indicative of PFPS) was positive.  No ROM was recorded.  The diagnosis was changed to RPPS, terms which are frequently used interchangeably.  At the VA Compensation and Pension (C&P) examination performed a month prior to separation, the CI reported bilateral knee pain since 1999 (over 4 years).  He stated that it had not resulted from an injury and denied incapacitation or time lost from work.  On examination, his gait and posture were normal.  He did not use an assistive device nor show abnormal wear of his shoes.  The appearance of the joint was normal but the ROM reduced to 112 degrees of flexion (140 is normal), limited by pain, with normal extension.  The knee was stable to examination.  Degenerative arthritis was seen on X-ray.

The Board first considered if the left knee was an unfitting condition separate from the right shoulder condition.  It noted that the commander noted the knees as impairing duty performance.  The knees were profiled and RPPS was noted to fail retention standards by the MEB (it was not specified if this was only the left knee or both).  The CI was seen on a regular basis the last 12 months of active service for the left knee.  The Board determined that evidence reasonably justifies the left knee was a separately unfitting condition at the time of separation.  The Board then directed its attention to its rating recommendation based on the above evidence.  There was no evidence of a meniscal injury or instability.  The ROM limitation was not compensable, but was painful.  On X-ray, degenerative joint disease was present.  This supports a 10% rating using the VA code 5003 (degenerative arthritis).  The VA also rated the left knee at 10%, but used the code 5010 for traumatic arthritis.  These are rated using the same criteria and neither provides an advantage over the other.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left knee condition using the code 5003.

Right Shoulder.  The record shows that the CI was seen for right shoulder impingement and AC (acromio-clavicular) joint involvement (where the collar bone attaches to the shoulder blade) on 6 January 2003.  He apparently improved with PT and was not seen again until 21 November 2003 when he reported that he had re-aggravated the shoulder while doing pushups over the previous month.  X-rays were negative.  In primary care a week later, the ROM was normal, but painful, and impingement present.  He was referred back to PT.  Repeat X-rays on 17 February 2004 were again negative as was a bone scan on 23 March 2003.  Injections were not successful in resolving his pain.  At the MEB examination, the MEB examiner noted good ROM with a positive impingement sign.  At the NARSUM, the CI reported that the right shoulder pain impaired overhead lifting, but did not affect his job.  He had difficulties with push-ups.  The examiner noted both full range-of-motion and full range-of-motion to 90 degrees with forward extension 35, and normal internal and external rotation.  These statements are inconsistent and the probative value is accordingly reduced.  It was noted that there were signs of impingement, but the strength was normal.  The commander noted that the shoulder contributed to the duty impairment and a U2 profile was issued.  The MEB noted that it did not meet retention standards.  At the VA C&P examination performed a month prior to separation, the right dominant CI reported constant pain, but no incapacitation from the shoulder.  The appearance of the shoulder was normal.  Both abduction (away from the body) and forward flexion (lifting the arms straight out in front) were reduced from the normal 180 degrees to 100 degrees.  On repetition, there was additional limitation from pain but it was not quantified.  An X-ray was negative.

The Board first considered if the right shoulder was an unfitting condition separate from the left knee condition.  The commander noted the shoulder as impairing duty performance.  It was profiled, albeit U2, and right shoulder tendinitis was noted to fail retention standards by the MEB.  The CI was seen on a regular basis the last 12 months of active service for the right shoulder.  The Board determined that evidence reasonably justifies the right shoulder was a separately unfitting condition at the time of separation.  The Board then directed its attention to its rating recommendation based on the above evidence.  The VA rated the right shoulder at 10% using the code 5203 (impairment of the clavicle or scapula [collar bone, shoulder blade]).  The Board considered the coding options available and determined that the code 5201, limitation in motion, best described the disability evident at separation.  However, the limitation present is not compensable.  Painful motion does support a 10% rating though using the 5203 code analogously IAW VASRD §4.59 (painful motion).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right shoulder condition using the VASRD code 5299-5203.

Contended PEB Conditions: Right Knee.  The Board’s main charge is to assess the fairness of the PEB’s implied determination that right knee was not unfitting.  The Board’s threshold for countering a fitness determination requires preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The CI had problems with his right knee dating back to 1989 during his first enlistment.  He was allowed to reenlist with the problem, but had increased pain in 2002 which lead to the diagnosis of a LMT on the right which was confirmed on MRI on 3 October 2002.  He was then seen by orthopedics on 6 November 2002 and the diagnosis of a probable right LMT.  This was repaired at surgery on 5 February 2003.  The surgeon recommended that he not deploy for 4 months, but the CI was deployed 6 weeks later on 22 March 2003 and redeployed on 8 December 2003.  He reported that he had pain while in theater.  The records show that he was seen on 1 December 2003 (the Board noted the date discrepancy) at his home station for pain in both knees and the right shoulder.  He was again seen on 6 February 2004 and noted to have painful but full ROM in both knees.  At both of these visits, the CI was also evaluated for the two unfitting conditions.  There were no other visits other than two X-ray reports until separation.  The Board noted that there were numerous visits for the left knee and the right shoulder during the same time period.  The Board considered the evidence.  There was no performance based evidence from the record that the right knee, independent of the two unfitting conditions, significantly interfered with satisfactory duty performance at the time of separation sufficiently to be separately unfitting.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the implied PEB fitness determination for right knee condition and so no additional disability rating is recommended.

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 left knee and right shoulder conditions was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the left knee condition, the Board unanimously recommends a disability rating of 10%, coded 5003 IAW VASRD §4.71a.  In the matter of the right shoulder condition, the Board unanimously recommends a disability rating of 10%, coded 5299-5203 IAW VASRD §4.71a.  In the matter of the right knee condition and IAW VASRD §4.71a, 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:

CONDITION | VASRD CODE | RATING
Left Knee | 5003 | 10%
Right Shoulder | 5299-5203 | 10%
Right Knee | Not unfitting
COMBINED | 20%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, not dated, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX     
President 
Physical Disability Board of Review

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXX, AR20150009927 (PD201301738)

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			     XXXXXXXXXXXXXXX
				     Deputy Assistant Secretary of the Army
				         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA

PD-2013-01738