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AF | PDBR | CY2013 | PD-2013-01807

Original file (PD-2013-01807.rtf) Auto-classification: Denied

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX CASE: PD-2013-01807
BRANCH OF SERVICE: Army BOARD DATE: 20141223

SEPARATION DATE: 20050331

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E-4 (Light Wheeled Vehicle Mechanic) medically separated for right knee, left arm and neck conditions. These conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS), although he was cleared to walk for alternate physical fitness testing. He was issued a permanent U3/L3/H3 profile and referred for a Medical Evaluation Board (MEB). Chronic right knee pain; brachial plexus neuritis/Parsonage-Turner syndrome; sensorial hearing loss and cervical spondylosis conditions, characterized as medically unacceptable, were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded one other condition (degenerative joint disease [DJD]). The Informal PEB adjudicated chronic pain, right knee and left arm conditions as unfitting, rated 10% with cited application of the US Army Physical Disability Agency (USAPDA) Pain Policy; and chronic subjective neck pain and left arm pain conditions as unfitting, rated 10% with presumed application of the VA Schedule for Rating Disabilities (VASRD). The remaining conditions (sensorial hearing loss and DJD ) were determined to be not unfitting. The CI made no appeals and was medically separated.

CI CONTENTION: “Because today all the medical problems that I have, Im still getting treatment for & none of the issues have been resolved.”

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 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 :

Service IPEB – Dated 20050303	VA* - (~10 Mos. Post-Separation)
Condition	Code	Rating	Condition	Code	Rating	Exam
Chronic Pain, Right Knee and Left Arm and Brachial plexus neuritis / Parsonage-Turner Syndrome	5009-5003	10%	Right Knee s/p Meniscectomy…	5260	10%	20060206
			Left Arm Condition	5203	NSC	20060206
			Residuals Neurological Infection	8699-8615	NSC	20060206
Chronic Subjective Neck and Left Arm Pain	5009-5003	10%	Cervical Spondylosis	5240	NSC	20060206
Sensorial Hearing Loss	Not Unfitting	Bilateral Hearing Loss	6100	0%	20060123
Degenerative Joint Disease	Not Unfitting	No VA Entry
Other x 0	Other x 10
Combined: 20%	Combined: 20%

* Derived from VA Rating Decision (VARD) dated 200 60227 (most proximate to date of separation (DOS))

ANALYSIS SUMMARY: The PEB combined the right knee pain and left arm conditions under a single disability rating, coded analogously to 5003. Although 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 right knee pain and left arm conditions are presented separately; with attendant recommendations regarding separate unfitness, and separate rating if indicated.

Chronic Right Knee Pain. The CI’s right knee was profiled prior to entry into the Disability Evaluation System (DES) around the time of his surgical procedure. Although the commander’s statement does not mention any specific condition, the restrictions annotated on the profile would have prevented the CI from performing duties within his MOS. There was documented right knee pathology that would logically be associated with significant duty limitations. The CI developed right knee pain while deployed in mid-2003. In November 2003, he underwent a magnetic resonance imaging (MRI) study that revealed a tear in the right medial meniscus. He experienced pain, swelling, and intermittent locking of that knee. On 10 February 2004, he underwent an arthroscopic procedure that removed the damaged area of the right medial meniscus. The narrative summary (NARSUM), prepared 6 months prior to separation, documented the CI’s right knee pain was mild and frequent. The knee pain did significantly impact the amount of physical work he could do at that time. The physical exam revealed a noticeable limp and a mild effusion of the right knee. The range-of-motion (ROM) was “full” and “slightly painful” with tenderness over the right medial joint line. A physical therapy (PT) exam performed 5 months prior to separation documented ROM measurements of 10 degrees of extension (0 normal) and 110 degrees of flexion (140 normal) both limited by pain.

The VA Compensation & Pension (C&P) exam performed 11 months after separation documented occasional daily right knee pain with the use of a right knee brace. Additionally, he reported running 2 miles on a daily basis. The physical exam revealed a normal gait. The ROM was full extension of the right knee to 0 degrees. Flexion was noted to 135 degrees (140 normal) on active ROM, and he has full flexion on passive ROM at 140 degrees with pain at end ROM. There was no limitation with repetition of ROM.

There was popping and there was instability of the collateral ligaments to varus/valgus stress in the 0-degree position, but no instability at 30 degrees (that is normal). Drawer test and McMurray's test are negative (tests of instability and meniscal pain respectively). Plain film X-ray of the right knee was normal.

The Board directed attention to its rating recommendation based on the above evidence. The PEB combined the right knee and left arm pain conditions under to same 5099-5003, degenerative arthritis, code and rated them at 10% citing the USAPDA pain policy. The Board first considered if the right knee condition, having been de-coupled from the combined PEB adjudication, remained itself unfitting as established above. Members agreed that the functional limitations in evidence justified the conclusion that the condition was integral to the CI’s inability to perform his MOS and, accordingly a separate rating is recommended.

The VA applied VASRD code 5260, limitation of leg flexion, and rated it 10% citing the presence of painful motion. The evidence supports that after the CI’s partial right medical meniscectomy procedure there were no more locking episodes and there was never any knee instability. With respect to the ROM data, there was only on compensable ROM measurement present in evidence, the 10 degree extension measurement documented on the pre-separation PT exam. That measurement would be appropriately coded 5261 (limitation of leg extension) and rated at 10%. Additionally, the evidence adequately documents the presence of painful motion, IAW VASRD §4.59, which would be rated at 10% under code 5003. Board members agree that application of code 5003 is more appropriate than code 5261, as there was only one compensable ROM measurement while there were numerous entries documenting painful motion; either code would result in a 10% rating. 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 knee condition.

Chronic Left Arm Pain. The CI’s left arm pain was not specifically profiled prior to entry into the DES. The U3 profile completed at DES entry documented left arm pain; however, the CI was able to carry a weapon and the profile contained the following statement in the other functional limitations section, “Recommend MEB, Soldier's knee injury precludes him from 2-mile march with fighting load.” The commander’s statement accomplished 6 months prior to separation did not specifically mention any condition. The MEB characterized the left arm pain condition as “Brachial plexus neuritis/ Parsonage-Turner syndrome medically unacceptable.” The evidence documents that the CI developed left arm pain the day after the right knee surgical procedure, 13 months prior to separation. Over the ensuing month, the left neck, shoulder and arm pain worsened and he developed weakness of the left arm. He was evaluated by orthopedics and neurology with the following studies: neck MRI (performed to rule out radiculopathy) revealed cervical degenerative disc disease C4 through C7; electromyography (EMG)/nerve conduction studies (NCS) that were consistent with an acute brachial neuritis (or Parsonage-Turner syndrome) and no suspected radiculopathy. The neurologists documented diffuse left arm weakness and in conjunction with the acute onset of symptoms following surgery and the EMG/NCS results noted above, made the following diagnosis “Brachial Plexitis, manifested by acute onset L [left] shoulder pain and weakness, with subsequent improvement in pain and residual LUE [left upper extremity] weakness.” (Brachial Plexitis is synonymous with acute brachial neuritis also called Parsonage Turner Syndrome.) The neurologist made the following recommendation, “Continue Gabapentin 400mg PO tid [by mouth three times daily sic] for neuropathic pain. Increased dosages (up to 1200mg PO tid) may be considered as needed; however, the patient's pain has been improving, and is expected to subside in the next few weeks.”

The NARSUM documented the following:

He saw orthopedic surgeon who performed an arthroscopic repair (right knee) on 15 Feb 04. The next day, his arm was locked out of place with severe pain. The pain continued for about 30 days. Orthopedist saw the shoulder and ordered a cervical MRI, which was essentially normal. He was then followed by neurologist, who diagnosed him with a brachial plexitis.

The physical exam documented “The left deltoid, left biceps and triceps have full 5 out of 5 muscle power. The left flexor and extensor and intrinsic muscles have 5 out of 5 muscle power. Deep tendon reflexes were 2+ and symmetrical. No pathologic reflex.” The present status section of the NARSUM contained the following statements:

“The shoulder does not have any interference and activities of daily living. He also has ability to work with the left restriction and the pain in his left shoulder. He also has significant weakness in the left arm with resistance noted on examination by primary care manager.”

The next entry concerning the left arm condition was on 17 February 2005 (2 months prior to separation) when the CI was re-evaluated by the neurologist. The neurologist’s report documented the CI stated some weakness was noted in the left arm, but much of the weakness noted was associated with pain and yielding to pain. Most of the pain was centered in the left arm with no significant improvement noted over the past 6 months. The physical exam revealed “Patchy strength deficits that did not fit with any muscle, nerve, or brachial plexus pattern - also, much of the strength deficits were ‘give way’ with yielding appearing to occur about the same time resistance was applied.” The neurologist documented that he was unable to accurately grade the CI’s strength due to “yielding.” Repeat EMG/NCS performed that day was completely normal; there was no evidence of any left arm neuropathy or radiculopathy condition.

The Board directed attention to its rating recommendation based on the above evidence. The PEB combined the right knee and left arm pain conditions under to same 5099-5003 code (degenerative arthritis) and rated them at 10% citing the USAPDA pain policy. The Board first considered if the left arm pain condition, having been de-coupled from the combined PEB adjudication, remained reasonable justified as separately unfitting. The commander’s statement only noted “physical impairments” prevented the CI from performing within his MOS. The profile prepared at DES entry (the only profile noting the left arm condition) only identified functional restrictions related to the lower extremity condition. At the time of separation, the CI’s left arm weakness had resolved and the previously abnormal EMG/NCS studies had returned to normal. That is consistent with the natural history of Parsonage-Turner syndrome which commonly follows a surgical procedure and is generally a self-limiting condition without any functional deficits. The NARSUM examiner documented normal left arm strength; however, referred to an exam performed by the CI’s primary care physician that documented “significant left arm weakness with resistance.” That exam was not available for review by the Board. The neurologist’s exam performed 2 months prior to separation documented “give-way” weakness. The finding of “give-way” weakness is an equivocal sign of diminished strength, since it is not infrequently caused by pain response or voluntary withdrawal of effort rather than lack of muscle strength. Member consensus was that the probative value of the evidence for give-way weakness was insufficient to confirm functionally significant motor weakness. Additionally, Board precedence requires a functional impairment linked to fitness to support a disability for a peripheral nerve rating. There was no evidence of a sensory deficit, and the motor impairment was either intermittent or relatively minor and cannot be linked to significant functional consequence at the time of separation. Member consensus was that the functional limitations in evidence do not justified the conclusion that the left arm pain condition was integral to the CI’s inability to perform his MOS and, accordingly cannot recommend it for a separate rating.

Chronic Subjective Neck Pain. There was no neck injury noted in the evidence and the CI only complained of neck pain in conjunction with the parsonage-turner Syndrome. During the evaluation of that condition, a MRI of the cervical spine was accomplished and revealed degenerative disc disease (DDD) primarily affecting C4-7. There was no EMG/NCS evidence of a radiculopathy related to the DDD. There were no service treatment record (STR) entries directly related to the cervical spine. The NARSUM did not document any neck pain and noted the neck to be “supple with full range of motion.” The C&P exam noted the following:

“The veteran has full range of motion of the cervical spine and lumbosacral spine with no limitation on repetition of range of motion. No postural abnormalities or fixed deformities appreciated on examination. No tenderness to palpation of the spine. The veteran has normal position of the head and normal posture.”

Plain film X-rays revealed the cervical spine showed disc space narrowing and degenerative change at multiple levels specifically C5-6 through C6-7. The osteophytes encroaching upon the intervertebral foramina at those levels were smaller than expected.

The Board directed attention to its rating recommendation based on the above evidence. The PEB applied the analogous VASRD code of 5299-5237 (cervical strain) and rated it 10%. The VA applied code 5240 (ankylosing spondylitis) and did not grant service-connection. The General Rating Formula for Diseases and Injuries of the Spine uses ROM measurements and some subjective complaints (pain or tenderness) to apply ratings for spine conditions. There are no ROM measurements or subjective complaints related to the cervical spine to be used for a rating recommendation in this case. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the neck pain condition.

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that sensorial hearing loss and DJD conditions were not unfitting. 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 and requires a preponderance of evidence. The sensorial hearing loss condition was profiled and judged to fail retention standards; however, it was not implicated in the commander’s statement as causing any duty limitation. All STR entries were reviewed by the action officer and considered by the Board. There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance. 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 any of the contended conditions and so no additional disability ratings are 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 right knee and left arm pain was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the right knee pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a. In the matter of the left arm pain condition, the Board majority agreed that it was not separately unfitting and cannot recommend it for additional disability rating. In the matter of the chronic neck pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.
In the matter of the contended sensorial hearing loss and DJD conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting. There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION: The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131024, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXXXXX
President
DoD 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 , AR20150008344 (PD201301807)

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 and hereby deny the individual’s application.
This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

BY ORDER OF THE SECRETARY OF THE ARMY:

Enc l                                                  XXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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AF | PDBR | CY2013 | PD-2013-01807

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