RECORD OF PROCEEDINGS
                     PHYSICAL DISABILITY BOARD OF REVIEW

NAME:                                                                 BRANCH
OF SERVICE: marine corps
CASE   NUMBER:    PD1100319                              SEPARATION    DATE:
20070701
BOARD DATE:  20120403


SUMMARY OF CASE:  Data extracted  from  the  available  evidence  of  record
reflects that this covered  individual  (CI)  was  an  active  duty  SGT/E-5
(0811, Field Artillery  Cannoneer),  medically  separated  for  “joint  pain
localized in the shoulder.”  The CI developed  symptoms  of  right  shoulder
pain and instability in 2005, without any history of trauma.  His  pain  and
instability  did  not  resolve  with   conservative   management,   and   he
subsequently underwent right shoulder arthroscopic surgery in October  2005.
 Despite the surgery and physical therapy rehabilitation,  the  CI  did  not
respond adequately to  treatment  and  was  unable  to  perform  within  his
Military Occupational Specialty (MOS) or meet  physical  fitness  standards.
He was placed on limited duty (LIMDU) and  underwent  a  Medical  Evaluation
Board (MEB).  The condition of “other chronic pain”  was  forwarded  to  the
Physical Evaluation Board (PEB) as  medically  unacceptable  IAW  SECNAVINST
1850.4E.  No other conditions  appeared  on  the  MEB’s  submission.   Other
conditions included in the Disability Evaluation System  (DES)  packet  will
be discussed below.  The PEB adjudicated the joint  pain  localized  in  the
shoulder  condition  as  unfitting,  rated  10%,  with  application  of  the
Veterans Administration Schedule for Rating Disabilities  (VASRD).   The  CI
made no appeals, and was medically separated with a 10%  disability  rating.



CI CONTENTION:  The CI states:  “I believe that the disabilities that I  was
discharged for in 2007  through  an  Abbreviated  Medical  Evaluation  Board
should  be  considered  differently   with   the   current   IDES   process.
Additionally, I don't believe there was an adequate process in  place  while
I was being evaluated to document other issues that I was experiencing  such
as post traumatic  stress  disorder  (PTSD).”   He  elaborates  no  specific
contentions regarding rating or coding.


RATING COMPARISON:

|Service PEB – Dated 20070326  |VA (2 Mo. Pre Separation) – All Effective|
|                              |Date 20070702                            |
|Condition                     |Code                             |Rating |
|Combined:  10%                |Combined:  40%                           |


ANALYSIS SUMMARY:  The Board acknowledges the CI’s assertions that “I  don't
believe there was an adequate process in place while I was  being  evaluated
to document other issues that I was  experiencing  such  as  PTSD.”   It  is
noted for the record  that  the  Board  has  neither  the  jurisdiction  nor
authority to  scrutinize  or  render  opinions  in  reference  to  the  CI’s
statements in the application regarding suspected service  improprieties  or
faulty medical care.  The Board’s role is confined to the review of  medical
records and all evidence at hand to assess the fairness  of  PEB  disability
ratings and fitness determinations as  elaborated  above.   The  Board  also
acknowledges the CI’s contention that suggests service ratings  should  have
been conferred for other conditions documented at the  time  of  separation.
The Board wishes to clarify that it is subject to the same laws for  service
disability entitlements as those under which the DES  operates.   While  the
DES considers all of the service member's medical  conditions,  compensation
can only be offered for those medical conditions that cut  short  a  service
member’s career, and then only to the degree  of  severity  present  at  the
time of final disposition.  However the  Department  of  Veterans’  Affairs,
operating under a different set of laws (Title 38, United States  Code),  is
empowered  to   compensate   all   service-connected   conditions   and   to
periodically reevaluate said conditions for the  purpose  of  adjusting  the
Veteran’s disability rating should the degree of impairment vary over  time.


Right Shoulder.  The right-handed CI  presented  with  complaints  of  right
shoulder pain with recurrent dislocations in  2005  and  bilateral  shoulder
instability.  There was no history of any shoulder trauma.  He  was  managed
conservatively with physical therapy which improved his pain  somewhat,  but
did not correct the  recurrent  right  shoulder  dislocations.   In  October
2005, the CI underwent an arthroscopic Bankhart repair to correct the  right
shoulder  instability.    Despite   the   surgery   and   physical   therapy
rehabilitation, he continued to have pain with elevation of the arm.   There
were no recurrent dislocations; however, the CI complained  that  the  right
shoulder felt like it was slipping,  limiting  his  ability  to  lift  heavy
objects, work overhead, and perform push-up or pull-ups.  It was  determined
that he was not likely to recover  and  orthopedics  determined  that  there
were no further surgical options.

There were two right shoulder evaluations with  goniometric  range-of-motion
(ROM) measurements in evidence which the Board weighed in  arriving  at  its
rating recommendation.   These  were  the  MEB  narrative  summary  (NARSUM)
examination and the VA Compensation  and  Pension  (C&P)  examination.   The
exam findings are summarized in the chart below.

|Goniometric  |MEB ~ 5 Mo. Pre-Sep|VA C&P ~ 2Mo. Pre-Sep   |
|ROM – R      |(20070212)         |(20070516)              |
|Shoulder     |                   |                        |
|Flexion      |165⁰               |130⁰                    |
|(0-180)      |                   |                        |
|Abduction    |Not reported⁰      |100⁰                    |
|(0-180)      |                   |                        |
|Comment:     |Slight weakness on |Limited and painful     |
|Surgery –    |external rotation; |motion; no swelling or  |
|20051028     |no pain with       |inflammation; no        |
|             |resisted           |instability or weakness;|
|             |supraspinatus;     |no additional limitation|
|             |neurovascularly    |due to Deluca criteria; |
|             |intact distally.   |no additional limitation|
|             |                   |with repetitive motion. |
|§4.71a Rating|10%                |10%                     |

Both exams documented limitation of right shoulder  range  of  motion,  with
the C&P exam additionally noting painful  limitation  of  motion.   The  MEB
exam revealed “slight weakness  in  external  rotation,  but  otherwise  5/5
strength” of the rotator cuff.  There was no pain  on  strength  testing  of
the supraspinatus muscle  (initiates  abduction  of  the  shoulder)  against
resistance.  The C&P exam found  no  evidence  of  shoulder  instability  or
weakness.  The right shoulder ROM was limited by pain, but was  not  limited
by fatigue, weakness, lack of endurance or incoordination  after  repetitive
use.  There was no additional limitation of motion after repetitive  motion.
 Plain films of the right shoulder  (May  2007)  were  only  remarkable  for
small lucencies in the glenoid which  likely  represented  the  location  of
previous internal fixation screws.

The PEB and the VA utilized the same coding and arrived at the  same  rating
recommendation for the right shoulder condition.  They  coded  analogous  to
impairment of the clavicle or scapula  and  rated  at  10%.   There  was  no
evidence of dislocation or nonunion of the clavicle or scapula to warrant  a
higher rating under the (5203) coding.  Under this coding,  the  VASRD  also
allows for alternative  rating  based  on  impairment  of  function  of  the
contiguous  joint;  however,  the  degree  of  limitation  of  shoulder  ROM
documented does not reach the compensable level of  limitation  at  shoulder
level (90°) under the shoulder (5201)  limitation  of  motion  coding.   The
Board considered alternate coding for impairment of the humerus (5202),  but
there was no evidence of recurrent dislocation or malunion  of  the  humerus
to arrive at a  compensable  rating  under  this  coding.   The  Board  also
considered muscle injury coding (5304, group IV); however, the  CI’s  slight
muscle disability would not meet criteria for a compensable  rating.   There
were no symptoms or evidence of an unfitting  peripheral  nerve  impairment.
Alternative coding under analogous coding using the criteria of VASRD  5003,
would not rate higher than 10%.  There is no route to  a  rating  the  right
shoulder higher than 10% under any applicable VASRD code  and  there  is  no
coexistent pathology which would  merit  additional  rating  for  the  right
shoulder pain condition under a separate  code.   All  evidence  considered,
there is not reasonable doubt in the CI’s favor  supporting  a  change  from
the PEB’s coding or rating decision for the right shoulder condition.

Left Shoulder.  Both the NAVMED 6100/2 (MEB) and the PEB  were  non-specific
as to the right,  left,  or  bilateral  shoulders  being  duty  limiting  or
unfitting.  However, it was clear from the NARSUM and record that the  right
shoulder was unfitting and rated by the PEB as discussed above.  The  NARSUM
noted “right greater than left shoulder instability” and the  PEB  worksheet
(JDETS) focused on the right shoulder, although  left  shoulder  instability
was noted.  There were scant treatment notes  for  the  left  shoulder,  the
NARSUM did not include a full left shoulder evaluation, but concentrated  on
the right shoulder.  Only the right shoulder had undergone  surgical  repair
and only the right shoulder was listed on  LIMDUs  and  cited  in  the  non-
medical  assessment  (NMA).   Although  it  would  be   possible   for   the
restrictions from  the  right  shoulder  to  overshadow  the  left  shoulder
condition limitations, it would be unduly speculative to consider  that  the
left shoulder significantly contributed to the  CI’s  duty  restrictions  or
unfitness.  After due deliberation in consideration of the preponderance  of
the evidence, the Board concluded  that  there  was  insufficient  cause  to
recommend addition of the left shoulder condition as additionally  unfitting
and rated at separation.

Other Contended Conditions.  The CI’s application asserts  that  compensable
ratings should be considered for PTSD.  At the  MEB  history  and  physical,
the CI documented a  history  of  treatment  for  nervous  trouble,  trouble
sleeping,  depression,  anxiety  and  marital  problems.    There   was   no
documentation of a diagnosis of PTSD while in  the  service  or  in  the  VA
records proximate to separation (2011 VA claim, to include PTSD)  was  noted
in the record).  There was no indication from the  record  that  any  mental
health conditions were significantly  clinically  or  occupationally  active
during the MEB period.  The  DES  mentioned  symptoms  of  nervous  trouble,
trouble sleeping, depression and anxiety;  however,  there  was  no  axis  I
diagnosed psychiatric condition.  No mental health  conditions  resulted  in
LIMDU and none were implicated in  the  NMA.   There  was  no  evidence  for
concluding that the CI’s  mental  health  conditions  interfered  with  duty
performance to a degree that  could  be  argued  as  unfitting.   The  Board
determined therefore that there were no mental health conditions  that  were
subject to service disability rating.  Additionally, the specific  condition
of PTSD was not not documented in the DES file.  The  Board  does  not  have
the  authority  under   DoDI   6040.44   to   render   fitness   or   rating
recommendations for any conditions not considered by the DES.

Other Conditions.  The condition of patellofemoral pain syndrome  was  noted
in the DES and in the VARD proximal to separation.  The  CI  had  a  lengthy
history of chronic bilateral knee pain,  with  the  right  knee  being  more
symptomatic than the left.  Plain films of both knees were unremarkable  and
a right knee MRI documented a small effusion.  The  CI  was  diagnosed  with
right  knee  patellofemoral  pain  syndrome,  with  a  left  knee  uncertain
diagnosis and was placed on a 6 month LIMDU (no  running,  no  force  march)
from  June  2006  through  December  2006,  with  the   plan   to   consider
recommendation for administrative separation (ADSEP) if symptoms  persisted.
 By the time of re-evaluation by sport medicine in November 2006,  the  knee
pain had not benefitted from a trial of LIMDU, PT  and  NSAIDs  and  the  CI
felt that he would be unable to peform adequately if returned to full  duty.
 The CI was diagnosed with right knee patellofemoral syndrome; however,  the
left knee diagnosis was unclear.  The examiner  stated,  “will  return  this
patient to full duty with regard to  his  knees  in  anticipation  of  ADSEP
processing.  If not to be ADSEPed  soon,  then  the  following  restrictions
should be observed:  no lifting > 50 pounds,  no  duties  requiring  use  of
steps, slopes  or  uneven  terrain.   He  should  PT  on  own,  no  PFT,  no
deployments.”  In further discussion of the CI’s knee condition, the  sports
medicine examiner opined, “patient’s condition is not a medical  disability;
rather it is a medical condition that  is  aggravated  by  military  service
requirements for fitness.  PFS is not a boardable condition.”  The  examiner
additionally commented that “he [the CI] is not responding  to  light  duty,
to medication, to PT, nor is it a surgical condition, for  the  purposes  of
his knees, he is considered discharged from musculoskeletal service  and  is
returned to full duty for purposes of ADSEP.”  The  determination  that  the
CI’s knee condition required referral  for  ADSEP  was  made  prior  to  the
decision to refer the CI’s shoulder condition  to  the  PEB.   Additionally,
duty restrictions  potentially  attributable  to  the  knee  condition  were
included in the CI’s        November 2006 LIMDU for the  unfitting  shoulder
condition:  “no running, marching, hiking; no walking or standing more  than
30 minutes per day.”

The patellofemoral  pain  syndrome  condition  was  identified  in  the  MEB
history, but neither the condition, nor  the  associated  duty  restrictions
were addressed in the NARSUM or forwarded  on  the  NAVMED  6100.   The  NMA
commented on duty limitations imposed by the CI’s  inability  to  stand  for
long periods of time.  The PEB worksheet (JDETs notes) remarked that the  CI
was “unable to stand for long period of time” and noted that the  limitation
was not consistent with the shoulder  injury.   Although  the  PEB  did  not
specifically adjudicate the patellofemoral pain syndrome condition,  it  was
presented in the MEB evidence before the PEB.  The Board must thus  approach
this issue as a de facto  service  determination  that  patellofemoral  pain
syndrome (and knee pain)  was  not  an  unfitting  condition.   The  Board’s
threshold for countering DES  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 MEB exam did not provide a  comprehensive  knee  evaluation.   MRI  from
February 2006 documented a small right knee joint  effusion,  and  bilateral
knee plain films were  normal.   Treatment  notes  from  the  November  2006
sports medicine evaluation documented a right knee  exam  with  findings  of
anterior mechanism pain that was  increased  with  resisted  knee  extension
(painful motion).  There was no exam evidence of  instability,  effusion  or
patellar apprehension and no indication of lower extremity motor or  sensory
loss.  The exam did not comment on range of motion.  The DVA C&P exam  prior
to separation, documented a normal gait, a stable knee joint and full  range
of motion without pain.  There was no additional limitation  of  motion  due
to pain, fatigue,  weakness,  lack  of  endurance  or  incoordination  after
repetitive use.

The Board considered the potential overlap  of  duty  limiting  restrictions
listed for the right shoulder condition that  could  be  attributed  to  the
patellofemoral pain syndrome condition, as well as the documentation in  the
STR that the knee condition required administrative separation.   The  Board
evaluated the  CI’s  functional  limitations  which  included  no  prolonged
standing; no PFT running, marching or hiking;  and  no  deployments.   After
due deliberation in consideration of the preponderance of the evidence,  the
Board majority concluded that there was insufficient cause  to  recommend  a
change in the PEB’s de facto not unfitting adjudication  for  the  right  or
left knee conditions (cannot recommend a finding  of  unfit  for  additional
service disability rating).

Remaining Conditions.  Other conditions identified  in  the  DES  file  were
tinnitus and several additional non-acute conditions or medical  complaints.
 The CI had no indications of significant hearing impairment  or  difficulty
with understanding speech.  None  of  these  conditions  were  significantly
clinically or occupationally active during  the  MEB  period,  none  carried
attached duty limitations or LIMDU, and none were  implicated  in  the  NMA.
These conditions were reviewed by the action officer and considered  by  the
Board.  It was determined  that  none  could  be  argued  as  unfitting  and
subject to separation rating.  Additionally the condition  of  thoracolumbar
strain was noted in the VARD proximal to separation, but was not  documented
in the DES file.  The Board does not have the authority under  DoDI  6040.44
to  render  fitness  or  rating  recommendations  for  any  conditions   not
considered by the DES.  The Board, therefore, has no  reasonable  basis  for
recommending any additional unfitting conditions for separation rating.


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  and  IAW  VASRD
§4.71a, the Board unanimously recommends no change in the  PEB  adjudication
at separation.  In the matter of  the  left  shoulder  and  left  knee  pain
conditions, the Board  unanimously  agrees  that  they  cannot  recommend  a
finding of unfit for additional service disability rating.   In  the  matter
of the right knee patellofemoral syndrome condition, the Board,  by  a  vote
of 2:1, agrees that they cannot recommend a finding of unfit for  additional
service disability rating.  The single voter for  dissent  (who  recommended
an unfitting right knee rating 5299-5261 at 10%) did not elect to  submit  a
minority opinion.  In the matter of the  depression  and  anxiety  symptoms;
and tinnitus conditions or any other medical conditions eligible  for  Board
consideration, the Board unanimously agrees that  it  cannot  recommend  any
findings of unfit for additional rating at separation.


RECOMMENDATION:   The  Board,  therefore,  recommends  that  there   be   no
recharacterization of the CI’s disability and separation  determination,  as
follows:

|UNFITTING CONDITION                             |VASRD CODE  |RATING  |
|Joint Pain Localized in the Shoulder (Right)    |5299-5203   |10%     |
|COMBINED    |10%     |


The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20110418, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record


                 President
                 Physical Disability Board of Review
MEMORANDUM  FOR  DIRECTOR,  SECRETARY  OF  THE  NAVY   COUNCIL   OF   REVIEW

               BOARDS

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

Ref:  (a) DoDI 6040.44
      (b) CORB letter dtd 12 Apr 12

    In accordance with reference (a), I have reviewed  the  cases  forwarded
by reference  (b),  and,  for  the  reasons  provided  in  their  forwarding
memorandum,  approve  the  recommendations  of  the   PDBR   the   following
individuals’ records  not  be  corrected  to  reflect  a  change  in  either
characterization of  separation  or  in  the  disability  rating  previously
assigned by the Department of the Navy’s Physical Evaluation Board:





      Assistant General Counsel
          (Manpower & Reserve Affairs)