RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD1300805
BRANCH OF SERVICE:  Army	BOARD DATE:  20131127
Separation Date:  20061130

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (98C/Signals Intelligence Analyst) medically separated for right shoulder pain.  The CI first reported shoulder pain following swim training in June 2005.  This injury was treated conservatively (rest, physical therapy, medication and steroid injection; surgery was not advised) but could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty (MOS) or physical fitness standards.  By early 2006 he was also complaining about various mental health (MH) symptoms.  He was consequently referred for a Medical Evaluation Board (MEB).  The physical and MH conditions, characterized as “chronic right shoulder pain…” and “pain disorder associated with psychological factors and generalized medical condition.”  The PEB adjudicated “chronic right shoulder pain…” as unfitting, rated 20%, referencing the US Army Physical Disability Agency (USAPDA) pain policy.  The remaining mental health condition was determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “The injury continues to hinder daily activities.  Not being able to throw a football with my son, simple yard work, general household chores without pain or limitations impacts my day to day life and quality of living.”

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.  In addition, the CI was notified by the Army that his case may eligible for review of the military disability evaluation of any MH condition in accordance with Secretary of Defense directive for a comprehensive review of members who were referred to a disability evaluation process between 11 September 2001 and 30 April 2012 and whose MH diagnoses were changed or eliminated during that process.  Since the CI responded to this mailing, it is presumed that he has elected review by the PDBR for the MH condition although he did not specifically contend for it on the DD Form 294.  In accordance with Secretary of Defense directive for a comprehensive review of MH diagnoses that were changed during the Disability Evaluation System (DES) process, the applicant’s case file was reviewed regarding diagnosis change, fitness determination, and rating of unfitting MH diagnoses in accordance with the Veterans Affairs Schedule for Rating Disabilities (VASRD) §4.129 and §4.130.  The CI is also eligible for PDBR review of other conditions evaluated by the PEB and has elected review by the PDBR.  The rating for the unfitting right shoulder condition and any MH 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.

The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected condition continues to burden him; but, must emphasize that the DES has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.

RATING COMPARISON:

Service PEB – Dated 20060824	VA - (2 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Shoulder Pain	5099-5003	20%	Right Shoulder Impingement Syndrome	5299-5201	0%	20070201	
Pain Disorder with Psychological Factors	Not Unfitting	Dysthymia	9433	0%	20070127	
No Additional MEB/PEB Entries	Other x1	20070209	
Combined:  20%	Combined:  0%	
VA ratings taken from VA Rating Decision (VARD) dated 20040817 (most proximate to Date of Separation)

ANALYSIS SUMMARY:

Chronic Right Shoulder Pain Condition.  The CI injured his right shoulder when he was pulled out of a pool by fellow soldiers during drowning safety training in June 2005.  Three days later he was seen for right shoulder pain with findings of pain on lifting to ninety degrees, pain with flexion, extension and rotation.  The examiner diagnosed right shoulder strain.  Orthopedics evaluated the CI for right shoulder pain with exam findings of a positive O’Brien’s test shoulder, full range-of-motion (ROM), tenderness to palpation (TTP) on the anterior joint line and popping.  The examiner diagnosed right shoulder sprain and possible labral tear.  A magnetic resonance imaging (MRI) exam demonstrated mild tendonopathy and intrasubstance tear of the rotator cuff.  A repeat MRI in October 2005 demonstrated intrasubstance tendonosis of the supraspinatus tendon from its insertion to the critical zone.  Throughout 2005 and 2006, the CI continued to be followed by primary care for the right shoulder pain without improvement.  In January 2006, the physical therapist noted that the CI had undergone therapy on and off for 6 months with a steady decline in function and an increase in pain.  The commander’s statement noted that due to the CI’s Profile restrictions, he was unable to perform his MOS duties.  The MEB narrative summary (NARSUM) exam accomplished approximately 5 months prior to separation indicated that the CI underwent two right shoulder steroid injections with only temporary relief for 2 to 3 weeks.  The CI had complaints of lack of mobility and loss of strength with steady pain and tightness that extended from the right upper chest to the back of the shoulder and along the right side of the neck, made worse with activity.  The pain varied in intensity from 5/10 with 10 being the worst pain on a good day to 8-9/10 on a bad day.  He had discomfort if he slept on his shoulder and required pain medication (Tramadol) at least once daily.  He was unable to fire a shoulder type weapon, he could not wear a ruck sack or body armor, he could not do push-ups or sit-ups and the pain was worse when he ran.  The MEB NARSUM physical exam findings are summarized in the chart below.  The CI was given a permanent U3/S2 profile for chronic right shoulder pain; pain disorder associated with psychological factors and generalized medical condition with a specific restriction of no overhead work.  The VA Compensation and Pension (C&P) exam approximately 2 months after separation documented that despite a steroid injection, physical therapy (PT) and twice daily pain medication that he still had right shoulder pain.  The examiner diagnosed right shoulder impingement syndrome.  The C&P physical exam findings are summarized in the chart below.

There were two goniometric ROM evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below:

Right Shoulder ROM (Degrees)	MEB NARSUM ~5.5 Mos. Pre-Sep	VA C&P ~2 Mos. Post-Sep	
Flexion (180 Normal)	(160,162,158) 160	120	
Abduction (180)	(160,158,162) 160	120	
Comments
Right hand dominant	Mild painful motion; pain with resisted shoulder flexion when arm pronated; Pos. anterior capsule laxity; No atrophy	No localized tenderness, swelling, deformity or instability; Motor-normal; No pain on ROM; No Deluca criteria	
§4.71a Rating	20% PEB	0%	

The Board directs attention to its rating recommendation based on the above evidence.  The PEB coded the chronic right shoulder pain condition as 5099 analogous to 5003 arthritis, degenerative (hypertrophic or osteoarthritis) and rated it at 20% applying the USAPDA pain policy.  The VA coded the right shoulder impingement syndrome as 5201, limitation of motion of the arm, and rated it at 0%.  At the time of the VA exam, the CI did not exhibit any localized tenderness or painful motion and there was no compensable ROM measured.  Additionally, there was no indication that the motion was limited due to pain, weakness or fatigue on repetitive testing.  The PEB applied the USAPDA pain policy and rated the condition at 20% based on constant and moderate pain.  The MEB NARSUM exam documents painful motion, and under VASRD §4.59, painful motion, would generate a rating of 10% for the shoulder joint with otherwise non-compensable ROM measurements.  However, IAW DoDI 6040.44 the Board may not recommend a lower combined rating than that conferred by PEB.  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 chronic right shoulder pain condition.

Contended PEB Condition.  The Board determined that no MH diagnoses were changed to the CI's possible disadvantage in the disability evaluation process.  This CI therefore did not meet the inclusion criteria in the Terms of Reference of the MH Review Project.  The MH condition, pain disorder associated with psychological factors and generalized medical condition, was determined to be not unfitting by the PEB.  The Board’s charge with respect to the MH conditions referred for review that were determined to be not unfitting by the PEB is an assessment of the appropriateness of the PEB’s fitness adjudication.  The Board’s threshold for countering PEB not-unfit determinations requires a preponderance of evidence.  Although the pain disorder associated with psychological factors and generalized medical condition was profiled (S2) and implicated in the commander’s statement, it was not judged to fail retention standards by the MEB NARSUM psychiatrist or the PEB.

The MEB MH NARSUM exam approximately 5 months prior to separation documented that the CI reported feeling down at times, low energy, irritability, decreased focus and concentration and insomnia due to pain at times.  The examiner further documented that the CI became upset to know that he could not be as active as he once was nor could he play more physically challenging sports or activities due to his right shoulder condition.  The MEB psychiatrist diagnosed pain disorder associated with psychological factors and generalized medical condition based on the fact that the disorder was a reaction to other circumstances (military stressors, health issues) or conditions.  The C&P exam performed approximately 2 months after separation documented that the CI expressed a feeling of sadness because of the right shoulder pain and feelings of helplessness and problems sleeping due to the shoulder pain.  These symptoms were continuous since the accident; however these symptoms had not caused time lost from work nor hospitalizations.  He had full time employment.  The mental status exam showed that although the CI reported his mood to be depressed, the psychiatrist noted the mood to be normal or at the most very mildly depressed, the rest of the exam was normal.  The psychiatrist diagnosed Axis I: dysthymia (mild chronic depression) with a Global Assessment of Functioning of 75, if symptoms are present they are transient and expectable reactions to psychosocial stressors; no more than slight impairment in social, occupational or school functioning.
The MH condition was reviewed and considered by the Board.  There was no indication from the record that the MH condition significantly interfered with satisfactory duty performance.  The applicant never had any loss of duty time due to his MH condition, nor did he require any psychiatric hospitalizations.  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 MH condition; and, therefore, no disability ratings can be 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 the chronic right shoulder pain condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the chronic right shoulder pain condition IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended MH condition, pain disorder associated with psychological factors, the Board unanimously recommends no change from the PEB determination as not unfitting and therefore, it cannot recommend it for additional disability rating.  There were no other conditions within the Board’s scope of review for consideration.

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	20%	
Pain Disorder associated with Psychological Factors	Not Unfitting	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130528, 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 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXXXXX, AR20140003462 (PD201300805)

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