RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:   XXXXXXXXXXXXXX			BRANCH OF SERVICE:  Army
CASE NUMBER:  PD1100369 		                           SEPARATION DATE:  20050802
BOARD DATE:  20120217

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (52D10/Air Conditioner Mechanic), medically separated for chronic right shoulder pain.  The CI sustained a complete tear of his subscapularis tendon in June 2003 when he fell from a generator during an Iraq deployment.  He underwent surgical repairs in September 2004 and February 2005, without improvement in his pain or functional limitations.  Despite surgical intervention, physical therapy and pain medication, the CI did not respond adequately to treatment and was unable to perform within his Military Occupational Specialty (MOS).  He was issued a permanent U3 profile and underwent a Medical Evaluation Board (MEB).  Chronic right shoulder pain, chronic right subscapularis tear and status post pectoralis major tendon transfer were forwarded to the Physical Evaluation Board (PEB) as medically unacceptable IAW AR 40-501.  Posttraumatic stress disorder (PTSD) and anxiety were forwarded on the MEB submission as conditions that do not fall below retention standards.  The PEB adjudicated the chronic right shoulder pain 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% combined disability rating.

CI CONTENTION:  The CI states:  “Constant pain, loss of mobility, residual scar.”  He elaborates no specific contentions regarding rating or coding.

RATING COMPARISON:  

Service IPEB – Dated 20050701	VA (1 Mo. After Separation) – All Effective 20050803	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic R Shoulder Pain	5099-5003	10%	S/P R Subscapularis Repair	5201-5010	10%*	20050916	
PTSD	Not Unfitting	PTSD with Anxiety and Depression	9411	30%	20050916	
Anxiety	Not Unfitting					
↓No Additional MEB/PEB Entries↓	Cervical Spine Strain	5237	10%	20050916	
	Tendonitis, L Shoulder 	5099-5024	10%	20050916	
	R Wrist Strain	5215	10%	20050916	
	R Knee RPPS	5299-5260	10%	20050916	
	0% x2 / Not Service Connected x 1	
Combined:  10%	Combined:  60%*	
* Right subscapularis repair increased to 40% (coded change to 5010-5201); and added associated brachial neuritis (8699-8619) at 10% effective 20070720 (combined 80%).  Ratings increased effective 20090212 (combined 100%).

ANALYSIS SUMMARY:  The Board acknowledges the sentiment expressed in the CI’s application regarding the significant impairment with which his service-aggravated condition continues to burden him.  It is a fact, however, that the DES has neither the role nor the authority to compensate service members for anticipated future severity or potential complications of conditions resulting in medical separation.  This role and authority is granted by Congress to the Department of Veterans’ Affairs (DVA).  The DVA, operating under a different set of laws (Title 38, United States Code), is empowered to compensate service connected conditions and to periodically re-evaluate said conditions for the purpose of adjusting the veteran’s disability rating should his degree of impairment vary over time.  The Board utilizes DVA evidence proximal to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12 month interval for special consideration to post-separation evidence.  The Board’s authority as defined in DoDI 6044.40, however, resides in evaluating the fairness of DES fitness determinations and rating decisions for disability at the time of separation.  Post-separation evidence therefore is probative only to the extent that it reasonably reflects the disability and fitness implications at the time of separation.

Chronic Right Shoulder Pain.  The record indicates that the CI is right-handed.  The CI had undergone pre-service surgery on his right shoulder in October 1999 for an anterior labral tear.  That injury was considered fully recovered without sequelae at the time of entrance onto active duty in 2002.  In June 2003, while deployed in Iraq, the CI injured his shoulder as he fell from a generator.  He was initially diagnosed with a shoulder sprain and was returned to duty without limitations.  Upon redeployment of his unit in 2004, the CI was evaluated by orthopedics and diagnosed with a full-thickness perforation of the subscapularis tendon.  He underwent an open subscapularis repair in September 2004; however, the repair failed shortly after surgery, with recurrence of right shoulder pain and instability.  In an attempt to salvage shoulder function, the CI underwent a pectoralis major transfer in February 2005.  Despite surgery, he continued to have significant pain with activities involving abduction and external rotation.

There were three comprehensive shoulder evaluations in evidence, two with goniometric range-of-motion (ROM) measurements, which the Board weighed in arriving at its rating recommendation.  These were the Orthopedic Medical Board Addendum exam, the MEB exam and the VA Compensation and Pension (C&P) exam.  The findings of the orthopedic addendum, combined and presented with the MEB exam findings, and the VA C&P exam are summarized in the table below.

Goniometric ROM –R Shoulder	MEB ~2 Mo. Pre-Sep	VA C&P ~1 Mo. After-Sep	
Flexion (0-180⁰)	0-150⁰   H&P 160⁰	0-130⁰	
Abduction (0-180⁰)	0-145⁰    H&P 130⁰	0-140⁰	
Internal Rotation (0-90⁰)	0-10⁰	88⁰	
External Rotation (0-90⁰)	160 [sic- noted as 90⁰ on ortho addendum]	90⁰	
Comment:  
Last surgery ~ 6 Mo. Pre-Sep 	4/5 strength internal rotators and supraspinatus; painful motion; no instability; mild biceps Popeye deformity 	Painful motion; no atrophy; no fatigue, impaired endurance or weakened movement	
§4.71a Rating	10%	10%	

At the MEB exam, two months prior to separation, the CI complained of significant right shoulder weakness and 6-7/10 pain with overhead activities and abduction movements.  He reported being unable to lift more than 10 pounds.  The examiner noted limitation of flexion, abduction and internal rotation, with increased ROM on external rotation of the shoulder.  Additionally, the MEB exam documented weakness of 4/5 in the internal rotators and the supraspinatous.  The orthopedic addendum (three months post-operatively; three months pre-separation) noted painful motion with abduction and external rotation, but documented no instability of the shoulder joint.  

The VA C&P exam, one month post-separation, documented painful limitation of motion.  On repeat testing with a five pound weight, the C&P examiner noted no additional loss of ROM, fatigue, impaired endurance or weakened movement:  “Using the five pound weight and doing repeated active motion, the veteran evidenced painful motion at the end of elevation and abduction which is 180 degrees with no fatigue, no impaired enduiance, no weakened movement noted.  The same range of motion was noted on internal and external rotation, with pain at the end of each motion, with no fatigue, no impaired enduiance, no weakened movement noted.”  The C&P exam did not specifically document strength testing, nor did it comment on joint stability.  Plain films of the right shoulder from September 2005 showed status post surgery with orthopedic metallic tacks.  There were no degenerative changes and the AC joint appeared normal.  A July 2004 MRI arthrogram (pre-surgery) demonstrated a chronic near-complete full-thickness perforation of the subscapularis tendon, secondary moderate atrophy of the subscapular muscle, and a partial tear of the supraspinous portion of the rotator cuff.  

A note from 20 months after separation (April 2007) indicated gross instability and examiner was “able to freely dislocate his shoulder anterior/inferior and reduce it spontaneously.”  VA exam 26 months post-separation documented gradual worsening of pain since the initial VA exam and marked dysfunction of the right upper extremity and narcotic pain medication.  ROMs were limited to forward flexion of 40⁰ and abduction of 35⁰ and there was loss of muscle mass and depression of the shoulder with documented muscle weakness to 3/5.  History indicated shoulder dislocation averaging 4x/week.  This note and exam were remote from separation, indicated post-separation worsening, and were adjudged as not indicative of the CI’s condition proximate to separation. 

The PEB and the VA chose different coding options, but both codes rate as arthritis, degenerative.  The PEB coded (5099-5003) by analogy as degenerative arthritis with loss of joint motion and rated at 10%.  The VA coded (5201-5010) for shoulder limitation of motion, analogous to traumatic arthritis and rated at 10% based upon pain limited ROM “with X-ray findings that are consistent with prior surgery.”  Neither coding is predominant.  Alternate coding under 5304, group IV muscle injury, was also considered, given the  rotator cuff muscle group injury documented by MRI and at time of surgery of tendon transfer.  The 4/5 muscle strength at the MEB exam was proximate to surgery and potentially due to pain and not found at the proximate VA exam.  The Board considered alternative coding under group IV muscle injury, considering the CI’s painful motion, slight muscle weakness, muscle surgery and muscle deformity as well as functional loss.  Proximate to separation, the CI’s condition was no greater than that envisioned in the criteria for slight injury (0%).  The degree of limitation of motion documented at the service and VA exams is not compensable under the specific joint coding, but does meet the criteria for the 10% rating under degenerative arthritis coding, or with application of VASRD §4.59 (painful motion).  There was no route to rating higher than 10% under any applicable code and no coexistent pathology which would merit additional rating for the right shoulder condition under a separate code without violating the tenants of VASRD §4.14 (avoidance of pyramiding).  There was no evidence of dislocations, instability, impaired endurance or fatigue, proximate to separation.  There was no weakness noted at the VA exam.  There were no symptoms or evidence of an unfitting peripheral nerve impairment for additional rating at separation.  All evidence considered, there is not reasonable doubt in the CI’s favor supporting a change from the PEB’s 10% rating decision for the right shoulder condition.  

Other PEB Conditions.  The two conditions forwarded by the MEB and adjudicated as not unfitting by the PEB were PTSD and anxiety.  At the time of the MEB psychiatric addendum, the examiner noted that the CI had not received any treatment for his mental health condition.  The axis I diagnoses were PTSD, mild, and anxiety disorder, not otherwise specified (NOS).  The examiner assessed that the PTSD resulted in mild impairment for military duty and stated that “with treatment his prognosis is good.”  The anxiety disorder was found to cause no impairment for military duty.  The Global Assessment of Functioning (GAF) was assigned at 70, in the range of mild symptoms.  The examiner concluded, “This soldier’s axis I psychiatric conditions are not unfitting for military duty at this time.”  

At the time of the VA C&P exam, one month after separation, the CI endorsed increasing symptoms of anxiety and depression with chronic sleep impairment.  The examiner commented that the CI’s PTSD had improved without treatment since leaving Iraq; however it was noted that “chronic pain has led to depressive symptoms.”  The axis I diagnoses were PTSD, chronic, mild, and depresseive disorder, NOS.  The GAF for PTSD was assigned at 71, in the range of transient or slight impairment, while the GAF for depressive disorder and the overall GAF were assigned at 56, in the range of moderate symptoms.  The examiner concluded that the C’s symptoms should not “interfere with working at a sedentary job with minimal supervision and minimal interaction with the public.”  The Board adjudged this as post-separaton worsening and not indicative of the CI’s level of functioning during the MEB period or at time of separation.  The CI’s mental health conditions did not result in any profile or duty limitations.  No mental health conditions were implicated in the commander’s statement or noted as failing retention standards.  The conditions of PTSD, anxiety and depressive disorder were reviewed by the action officer and considered by the Board.  There was no indication from the record that any mental health condition significantly interfered with satisfactory duty performance.  All evidence considered, there is not reasonable doubt in the CI’s favor supporting recharacterization of the PEB fitness adjudication for the PTSD or anxiety disorder conditions.  

Other Contended Conditions.  The CI’s application asserts that compensable ratings should be considered for loss of mobility, and a residual scar.  The CI’s shoulder injury and subsequent surgeries did result in limitation of motion in the shoulder as discussed and rated above.  The degree of limitation of motion in the shoulder was not compensable under the specific joint coding, however the loss of mobility was considered in the overall rating for the CI’s unfitting shoulder condition.  The CI did have multiple scars on the left shoulder as a result of his prior surgeries.  There was no documentation that any of the scars interfered with the satisfactory performance of MOS duties and scars were not implicated in the commander’s statement.  The scar condition was reviewed by the action officer and considered by the Board.  Any scar impairment to the limitation of motion was considered in the above shoulder rating.  There was no evidence for concluding that the shoulder scars interfered with duty performance to a degree that could be argued as unfitting.  The Board determined therefore that the scar condition was not subject to service disability rating.

Remaining Conditions.  Other conditions identified in the DES file and the VARD within 12 months of separation, were neck pain, right wrist pain, left shoulder pain and right knee pain.   Several additional non-acute conditions or medical complaints were also documented (trouble breathing after exercise, shortness of breath, eyes burning, wears glasses/contact lenses, bilateral wrist pain, upper back pain and numbness; bilateral knees - pain, swelling, locking and giving out; bicep deformity, h/o broken nose and rotator cuff injury s/p MVA in 1999, peniciilin causes hives, short term memory loss, nervous around other people, trouble sleeping at night, depression and worry).  None of these conditions were significantly clinically or occupationally active during the MEB period, none carried attached profiles, and none were implicated in the commander’s statement.  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.  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 chronic right shoulder pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication at separation.  In the matter of the PTSD, anxiety disorder and depressive disorder conditions, the Board unanimously recommends no change from the PEB adjudications as not unfitting.  In the matter of the loss of mobility, residual scar, neck pain, right wrist pain, left shoulder pain and right knee pain 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	
Chronic Right Shoulder Pain	5099-5003	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20110425, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SFMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
 
SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 

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:

Encl