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AF | PDBR | CY2013 | PD-2013-02335
Original file (PD-2013-02335.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX  CASE: PD-2013-02335
BRANCH OF SERVICE: Army  BOARD DATE: 20140717
SEPARATION DATE: 20050923


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard SGT/E-5 (12B10/Combat Engineer) medically separated for chronic pain right shoulder and bilateral knees. The conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent U3/L3 profile and referred for a Medical Evaluation Board (MEB). The chronic bilateral knee pain and chronic right shoulder pain conditions characterized as “medically unacceptable” were the only conditions forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The Informal PEB adjudicated “chronic pain right shoulder and bilateral knees” as unfitting, rated 10%, citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals and was medically separated.


CI CONTENTION: “I was not made aware of the fact that my Board was only reviewing some of the conditions in which I was being treated for during my Deployment to IRAQ. Their ruling was based on evaluation of my Bilateral Knee problems, and my Right Shoulder, but did not include anything dealing with my Lower back or Left Elbow which occurred at Camp Shelby during our per-deployment training and continued throughout my deployment as well as to this day”.


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 ratings for the unfitting chronic pain, right shoulder and bilateral knee conditions are addressed below; no additional conditions are 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 20050901
 VA - (3 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Pain, Right Shoulder and Bilateral Knees 5099-5003 10% Right Shoulder Status Post Interior Capsule Shift With Sprain and Scar (also claimed as chronic pain, synovitis shoulder, acromioclavicular joint and joint
instability)		 Not Avail 10% Not Avail
Left Patellofemoral Syndrome Not Avail 10% Not Avail
Right Patellofemoral Syndrome Not Avail 10% Not Avail
Other X 0 (Not In Scope)
 Other x 7
Combined: 10%
 Combined: Unknown
Derived from VA Rating Decision (VA RD ) dated 200 60705 ( most proximate to date of separation ). That rating decision and subsequent decisions in the file did not contain a rating decision, therefore, the only data available was that found in the VARD Decision paragraph.

ANALYSIS SUMMARY: The VA Compensation and Pension (C&P) exam was not available in evidence before the Board and could not be located after appropriate inquiries. Further attempts at obtaining the relevant documentation would likely be futile and introduce additional delay in processing the case. The Board further noted that the VA Rating Decision (VARD) referenced in detail the results of this exam in the explanation of its rating decision. The Board unanimously agreed that the evidence referenced in the available VARD was sufficiently probative such that the missing document would not materially affect the Board’s final recommendation. The PEB combined the right shoulder and right and left knee conditions under a single disability rating, coded analogously to 5003. The Board’s main charge is to assess the fairness of the PEB’s determination that the right shoulders as well as both right and left knee conditions were not individually unfitting. The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, is based on a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

Chronic Right Shoulder Condition. The narrative summary (NARSUM) notes that this left hand dominant CI underwent successful repair of a right shoulder rotator cuff injury in 1996. The CI did well without apparent symptoms until deployment to Iraq in 2004. At that time right shoulder pain recurred without history of recurrent direct trauma. Routine X-rays of the right shoulder taken on May 2005, revealed degenerative changes of the left AC joint. Examination of the right shoulder performed on June 2005, revealed normal forward flexion (FF) and abduction (ABD) of the right shoulder with pain (normal for both 180 degrees). Motor strength of the shoulder and arm was normal. At the MEB NARSUM evaluation dated 25 July 2005, 2 months before separation, the CI reported difficulties with overhead activity because of right shoulder pain. The MEB physical exam noted marked tenderness to palpation of the anterior right shoulder joint without swelling. A well healed surgical scar without defined tenderness was present. ROM was “full” in all directions with marked tenderness reported at limits of all ROM. No shoulder instability was present. At occupational therapy (OT) evaluation for the MEB dated 19 August 2005, ROM of the right shoulder was FF of 165 degrees and ABD of 175 degrees with pain. The VA C&P exam performed 3 months after separation, was not available to the Board as noted above. The VARD dated 5 July 2005, referenced data from this C&P exam in its rating discussions. The data quoted for the right shoulder condition are: FF and ABD both 140 degrees with pain, no DeLuca, well healed, non-tender shoulder scar. The PEB combined the shoulder condition and right and left knees conditions and rated en gros, 10%, code 5003, as noted above. The VA rated the shoulder condition 10%, for a code not available for review by the Board.

The Board directs attention to its fitting and rating recommendations based on the above evidence. The Board unanimously agreed the record in evidence reasonably supported the shoulder condition to be unfitting. The Board undertook to rate the shoulder condition under code 5201 (limitation of motion) IAW §4.71a. A 20% rating, the lowest rating under this code, requires limitation of FF or ABD to the shoulder level, but no higher. The Board agreed the preponderance of evidence in record supports no compensable rating under this code. The Board agreed that the condition was not ratable under code 5202 (humerus impairment) for instability or code 5200 for alkalosis. The Board agreed the record did not support a rating for the shoulder condition under codes 5212 (muscle injury) or code 7804 (painful or unstable scar) from the surgical procedure. The Board unanimously agreed the record supported a rating of 10% coded 5003 for painful motion IAW §4.40 and §4.59. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a rating of 10% coded 5099-5003 for the shoulder condition.

Right and Left knee conditions. The Board will discuss the clinical findings of both conditions together, as they are combined in the record, but then separate them for fitting and rating considerations. The CI had a long history of bilateral knee pain, the right greater than the left, with an associated congenital variation of the right knee cap. Symptoms from the knees were described as “minimal” until return from deployment to Iraq in 2005, where knee pain became intense, right greater than left. In May of 2005, the CI was examined for bilateral knee pain. Orthopedic examination at that time revealed bilateral knee grind without pain. Magnetic Resonance Imaging (MRI) of the right knee, obtained 2 June 2005 for unresolved right knee, revealed a small inconsequential Baker’s cyst and a mild right joint effusion (fluid). All ligaments, tendons and menisci were normal. On an orthopedic evaluation performed on 8 June 2005, a month before the NARSUM, the examiner noted only the right knee to be tender. ROM for both knees was flexion 130 degrees (normal: 140 degrees) and normal extension with no mention of painful motion for either. Routine knee X-rays revealed the right knee to have mild degenerative changes and the left to be normal. At the MEB NARSUM examination performed on 25 July 2005, 2 months before separation, the CI reported being unable to do prolonged walking and increased pain with squatting and bending. The MEB physical exam noted the CI to have a normal gait. Bilateral patellar tenderness and joint line tenderness was present on palpation. On occupational therapy consultation for the MEB dated 10 August 2005, gait was normal. Flexion and extension of the right and left knee were 130 degrees flexion and normal extension. The CI claimed constant bilateral knee pain but no change with repetition of active ROM. The VA C&P exam performed 3 months post-separation was not available to the Board, as noted above. The VARD dated 5 July 2006, referenced data from this C&P exam in its rating discussions. The data quoted were: normal gait; flexion of 140 degrees with normal extension without DeLuca; no instability and crepitus but not pain on motion for each knee. The PEB combined the shoulder condition and right and left knees conditions and rated en gros, 10%, coded 5003, as noted above. The VA rated each knee 10%, for a code not available for review by the Board, citing painful motion as demonstrated by findings of crepitus on motion.

The Board directs attention to its fitting and rating recommendations based on the above evidence. The Board unanimously agreed the record in evidence reasonably supported that both knee conditions were unfitting. The Board agreed that the record in evidence did not support a rating for either knee for instability or decreased ROM under codes 5257, 5260 or 5261. The Board considered a rating under 5003 IAW §4.40 and §4.59 for painful motion. The Board agreed that both knee conditions were mild with the preponderance of evidence supporting the right knee to be the more symptomatic. The Board unanimously agreed that the right knee condition rose to the 10% rating under these codes but the left did not. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommended a rating of 10% for the right knee condition and a rating of 0% IAW §4.30 (zero rating) for the left knee condition. In précis, the Board, after the unbundling process, recommends a rating of 10% for the shoulder condition, 10% for the right knee condition and 0% 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 DoDI 1332.39 for rating was operant in this case and the conditions were adjudicated independently of that policy by the Board. In the matter of the right shoulder condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a. In the matter of the right knee condition and IAW VASRD §4.71a, the Board unanimously recommends a disability rating of 10%, coded 5099-5003. In the matter of the left knee condition and IAW VASRD §4.71a, the Board unanimously recommends a disability rating of 0%, coded 5099-5003 IAW VASRD §4.71a and §4.30. 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 5099-5003 10%
Right Knee 5099-5003 10%
Left Knee 5099-5003 0%
COMBINED (w/ BLF) 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131111, 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, AR20150002580 (PD201302335)
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                                                  XXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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