RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2014-00763
BRANCH OF SERVICE:  Army	BOARD DATE:  20140912
SEPARATION DATE:  20070508

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSG/E-6 (19D30/Calvary Scout) medically separated for right sterno-clavicular synovitis.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty satisfy physical fitness standards.  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The right steno-clavicular synovitis, right rotator cuff tendonitis, left knee patella-femoral pain syndrome (PFPS) conditions, characterized as “does not meet retention standards” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “right sterno-clavicular synovitis” combined with the “right rotator cuff tendinitis” as unfitting, rated at 0% with likely application of Veterans Affairs Schedule for Rating Disabilities (VASRD).  The left knee condition was determined to be not unfitting.  The CI made no appeals and was medically separated.  

CI CONTENTION:  “The rating was given to me for my shoulder only, none of the other conditions were considered.  Also the injury occurred during combat however my records do not reflect this for some reason.”[sic] 

SCOPE 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 those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting right sterno-clavicular synovitis and right rotator cuff tendinitis condition is addressed below; the left knee condition is an implied contention and therefore within the DoDI 6040.44 defined purview of the Board.  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 Board for Correction of Military Records.

RATING COMPARISON:  

Service IPEB – Dated 20070213 | VA - (At Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Right Sternoclavicular Synovitis | 5099-5003 | 0% | Right Sternoclavicular Synovitis with … Tendonitis | 5299-5201 | 20% | 20070529
Left knee PFPS | Not Unfitting | Left Knee PFS | 5260-5024 | 10% | 20070529
No Other Items in Scope | Other x 4 (Not in Scope) | 20070529
Combined:  0% | Combined:  60%
Derived from VA Rating Decision (VARD) dated 20070621 (most proximate to date of separation)

ANALYSIS SUMMARY:  

Right Sternoclavicular Synovitis Condition (with Right Rotator Cuff Tendinitis).  During a physical therapy appointment dated 5 August 2004, the right hand dominant CI reported that he initially noted pain in the clavicle and sternum in May 2003; he report tenderness over the right ribs and also had a positive bone scan at the anterior first rib; was thought to have costo-chrondritis (inflammation of the junction between the rib and cartilage).  On 5 January 2005 the CI reported a 3-month history of right shoulder and clavicle pain.  During examination, the CI’s range-of-motion (ROM) and strength was normal.  A diagnostic scan performed on 3 March 2005, had increased density on the right fourth rib at the costo-chondral junction consistent with costo-chondritis.  During a primary care appointment dated 5 June 2005, the CI’s strength and ROM of the right upper extremity, to include the shoulder, was normal.  At a follow-up orthopedic appointment, the motor and ROM examinations were normal other than painful motion; the shoulder was noted to be stable.  The CI was issued a permanent U3 profile dated 10 August 2005 and referred into the MEB process.  The CI continued physical therapy and conservative management.  

The MEB examination performed on 10 March 2006, the CI reported chronic right shoulder pain, but denied knee pain.  The examiner noted tenderness over the right collar bone, weakness and right shoulder pain.  The narrative summary (NARSUM) dated 5 January 2007 the CI stated that [clavicle and sternum] pain radiated into the right shoulder began in June 2003 following a fire fight and that the pain was exacerbated by any strenuous activity; also reported occasional numbness of the right index and middle fingers.  The MEB examiner observed that the CI’s right shoulder and right sterno-clavicular joint (junction of the sternum and collar bone) were tender, but he had full ROM, without signs of instability and his strength was normal.  He was thought to have right sterno-clavicular synovitis (inflammation of the joint lining) and mild right rotator cuff tendinitis (inflammation of one or more of the tendons for rotation of the shoulder).  The rotator cuff strength was documented as normal (5 out of 5) and the right upper extremity noted to be neurovascular intact.  A second MEB examination dated 17 January 2007 provided no additional information.

At the VA Compensation and Pension (C&P) examination (performed 3 weeks post separation), the CI reported that his right shoulder pain was aggravated after reporting to Fort Knox, Kentucky and playing softball again.  He denied dislocations or subluxation (partial dislocation).  The VA examiner noted that the CI had tenderness over the right shoulder, reduced ROM but both flexion and abduction were above shoulder level (135 degrees and 95 degrees, respectively).  Explanations for the decreased mobility were omitted from the records.  No signs of instability were recorded. The sensation and reflexes were normal, but the motor examination was omitted from the CI’s records as well.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder (combing the MEB conditions of right sterno-clavicular synovitis and right rotator cuff tendonitis, mild, into a single unfitting condition) at 0% and rated analogous under coded 5099-5003 (degenerative arthritis).  The VA also combined the two conditions, but rated as 20% using the analogous code 5299-5201 (limitation of motion of the arm).  The Board observed that the 20% rating under this code is for limitation of motion at the shoulder level; however, the measurements for both flexion and abduction were above the shoulder although only by 5 degrees for abduction.  The Board noted that the NARSUM’s ROM performed by an orthopedic surgeon recorded a normal ROM for the shoulder, as previous ROMs were recorded as such during multiple prior evaluations, consequently it was assigned a higher probative value for rating purposes.  

The Board also considered if the two MEB conditions were severable as separately unfitting conditions.  The disability evidenced was that of restricted use secondary to pain.  The strength, ROM and stability were all noted as normal.  Painful motion was not recorded on the NARSUM (although it was recorded on the C&P.)  However, the aggravation of his pain with activity is consistent with painful motion and reasonable doubt (VASRD §4.3) in favor of the CI is justifiable.  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 for painful motion (VASRD §4.59.).

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the left knee condition was not unfitting.  A primary care note dated 
25 August 2006, documented that the knee was painful for the past 2 days.  At a follow-up appointment 3 months later, he was noted to have persistent pain to palpation and positive testing for both anterior and posterior stability, but a normal examination otherwise.  A following examination performed by orthopedist provider 2 months later, the examiner noted that the CI complained of knee pain for approximately 3 months, complains of [knee] giving way, but no locking.  On examination, the CI [knee] was tender to palpation, but stable and was without signs of meniscal injury.  His gait was normal, had full ROM and absent of effusion.

The VA examination did note a gait which favored the left knee and painful motion.  Some weakness of the left leg was present, but without atrophy.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The knee was profiled as L2.  No specific condition was implicated in the commander’s statement.  It was judged to fail retention standards by the MEB though.  The knee condition was reviewed by the action officer and considered by the Board.  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 PEB fitness determination for the 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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the right shoulder condition, the Board unanimously recommends a disability rating of 10%, coded 5299-5003 IAW VASRD §4.71a.  In the matter of the left 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.

UNFITTING CONDITION | VASRD CODE | RATING
Right Sterno-clavicular Synovitis | 5299-5003 | 10%
COMBINED | 10%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140212, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		
XXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXX, AR20150006848 (PD201400763)

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 10% 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						     XXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA

PD-2014-00763