RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD1300808
BRANCH OF SERVICE:  Army	BOARD DATE:  20140221
SEPARATION DATE:  20051130

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty Army SGT/E-5 (92F20/Petroleum Supply Specialist), medically separated for chronic pain, left shoulder and right elbow.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The orthopedic conditions, characterized as “left shoulder pain and stiffness after arthroscopic left shoulder reconstruction and revision reconstruction with probable degree of mild arthritis of the left glenohumeral joint” and “ruptured right elbow ulnar collateral ligament resulting in pain and laxity,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB (IPEB) adjudicated “chronic pain, left shoulder and right elbow” as unfitting and rated 0%, citing criteria in accordance with (IAW) U.S. Army Physical Disability Agency Pain Policy (USAPDA).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Have hearing loss in right ear, tore ligaments in right elbow.  Elbow still bothers me during any type of activity. Military doctors had never performed such surgery + now want to send me to a VA 5 Hrs away.  PTSD as well.”  

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 rating for the unfitting chronic pain, left shoulder and right elbow condition is addressed below.  Posttraumatic stress disorder (PTSD) is also considered to be within the defined purview of the Board IAW Secretary of Defense directive for a comprehensive review of Service members who were referred to a disability evaluation process between 11 September 2001 and 30 April 2012 and whose mental health (MH) diagnoses were changed during that process.  The CI’s case file was reviewed regarding diagnosis change, fitness determination, and rating of unfitting MH diagnoses IAW VASRD 4.129 and 4.130.  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 20051026	VA - (2 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	C&P Exam	
Chronic Pain, Left Shoulder And Right Elbow	5099 5003	0%	Status-Post Bankhart Repair, Left Shoulder	5201	20%	20050928	
			Right Elbow Condition	5205	NSC	20050928	
No Additional MEB/PEB Entries	Additional Diagnosis x1	
Combined:  0%	Combined:  20%	
Derived from VA Rating Decision (VARD) dated 20060127 (most proximate to date of separation [DOS]).  NSC - not service connected.

ANALYSIS SUMMARY:  The PEB combined the chronic pain left shoulder and chronic pain right elbow 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. IAW DoDI 6040.44 the Board must follow suit 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 a 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 left shoulder and right elbow conditions are presented separately; with attendant recommendations regarding separate unfitness and separate rating if indicated.

Chronic Pain Left Shoulder (Non-Dominant):  The right-handed CI had multiple left shoulder injuries prior to enlistment which caused anterior left shoulder dislocations and emergency room visits for reductions.  On 21 January 2000, a year prior to enlistment, he had a left shoulder reconstruction/capsular shift and Bankart repair (joint capsule is sewed to the detached glenoid labrum).  On 10 July 2001, a month prior to enlistment, he had a surgical follow-up which stated the CI was participating in sports, exercising, and doing construction work without any problems and the CI was cleared to undergo strenuous physical activity.

On 12 August 2004, the CI was seen in the emergency room for injury after lifting weights and hearing a pop, he was diagnosed with a rotator cuff tear.  On 13 September 2004, the CI was seen in orthopedic clinic.  Magnetic resonance imaging (MRI) showed a complete tear of the supraspinatus tendon.  On 15 December 2004, he had a revision arthroscopic Bankart repair surgery.  He underwent physical therapy.  On 7 June 2005, a physical therapy visit noted a pain level at rest of 1/10, and the CI stated that “it’s as good as it’s gonna get.”  At the VA Compensation and Pension (C&P) exam performed on 28 November 2005, 3 months prior to separation, the CI reported pain, lack of movement and strength, numbness in entire arm at times, and “popping and squeaking in shoulder joint,” intermittently as often as 3 to 4 times per week and lasting 2 to 4 hours.  The condition did not cause incapacitation.  The condition worsened in cold or rainy weather, caused difficulty lifting objects.  He was treated with steroid injection in May 2005.  Physical examination showed a left shoulder appearing within normal limits.  ROM testing is summarized in chart below, limited by pain upon repetitive use, and not additionally limited by fatigue, weakness, lack of endurance or incoordination following repetitive use.  The narrative summary (NARSUM) on 6 October 2005, a month prior to separation, notes the CI improved somewhat after the second surgery, but had ongoing shoulder pain with over-head movement, lifting, and throwing a ball.  Physical examination showed a well healed arthroscopic portal scars, tenderness over the bicipital groove, Neer’s test was positive for subacromial impingement, and negative apprehension sign for anterior glenohumeral instability, stable load shift testing for capsular laxity.  Range-of-motion (ROM) testing is summarized below.

The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below:

Left Shoulder ROM
(Degrees)	VA C&P ~ 2 Mo. Pre-Sep
	
MEB NARSUM ~ 1 Mo. Pre-Sep
	
Flexion (180 Normal)	175	130	
Abduction (180)	150	175	
Comments	Limited by pain	Tenderness over bicipital groove
Positive Neer’s	
§4.71a Rating	10%	10%	

The Board first considered if the left shoulder condition met the Board’s threshold for separate rating (as elaborated above).  The commander’s statement mentioned only the chronic shoulder problems as preventing the reasonable performance of military duties, such as handling large petroleum hoses and pipelines, issue and collect heavy cases of ammunition, mounting and dismounting tactical vehicles, and vehicle maintenance.  The profiled limitations were upper extremities level three (U3); unable to carry and fire individual assigned weapon, unable to move with a fighting load at least 2 miles, unable to wear protective mask and all chemical defense equipment, unable to construct an individual fighting position, unable to do 3 -5 second rushes under direct and indirect fire, unable to deploy, unable to perform army physical fitness test, able to walk alternate test, unlimited walking, run bike, lower weight training at own pace, no swimming.  No ruck marching, no Kevlar, no flak vest or load bearing equipment and lifting a maximum of 25 pounds.  Members agreed, therefore, that the left shoulder condition was reasonably justified as separately unfitting and that it met VASRD §4.71a criteria for separate rating.  Accordingly, it should be afforded separate disability rating.

The Board directs attention to its rating recommendation based on the above evidence.  The Board considered VASRD diagnostic code 5099 (analogous rating to) – 5003 (degenerative arthritis) used by the PEB for a 0% rating relying on the USAPDA pain policy.  There was evidence of painful motion with ROM testing, with non-compensable ROM limitations for a 10% minimal rating under this code in consideration of functional loss lAW VASRD §4.10 (functional impairment), §4.40 (functional loss), §4.45 (DeLuca), and §4.59 (painful motion).  The Board next considered the VA chosen code 5201 (arm, limitation of motion of) used by the VA for a 20% rating.  The ROMs were above the shoulder level (90 degrees or above), and measured at 150 and 175 degrees, thus not meeting VASRD criteria for a 20% rating.  The Board also considered code 5202 (humerus, other impairment of:) and did not find any evidence of loss of the humeral head, non-union, fibrous union, recurrent frequent or infrequent episodes of dislocation at the scapulohumeral joint with guarding of movement at shoulder level, or malunion with deformity for a higher rating.  The Board also considered the 5304 code (Group IV muscles which includes the rotator cuff muscles) and agreed the evidence clearly supports a moderate 10% rating for pain described as 1/10, but did not approach the moderately severe level for a higher 20% 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 chronic pain left shoulder condition.

Chronic Pain Right Elbow (Dominant):  The first entry on the record was on 2 August 2004, 15 months prior to separation, when the CI presented to the family practice clinic for a 2-week history of right elbow pain while playing softball and was given a non-steroidal anti-inflammatory and a 10 day profile.  On 25 May 2005, 5 months prior to separation, he was seen by orthopedics and the CI stated he fell on it a year ago while in Iraq, and noticed pain recently when trying to throw a soft ball.  An MRI followed on 3 June 2005, which showed a torn ulnar collateral ligament (ULC).  The UCL is important because it stabilizes the elbow from being abducted, specific overhead movements like those that occur during baseball pitching, tennis serving or volleyball spiking increase the risk of UCL injury If intense or repeated bouts of valgus stress occur on the UCL, injury would most likely transpire.  Poor mechanics along with high repetition of these overhead movements can cause irritation, micro-tears or ruptures of the UCL.  Injuries to the ULC in baseball players are rarely due to one-time, traumatic events.  Rather, they are more often due to small chronic tears that accumulate over time.  On 17 June 2005, he was followed-up by orthopedics, and a stress radiograph showed a three millimeter medial opening with valgus stress at the elbow.  He had pain especially with throwing a softball, and associated numbness of right forearm and wrist, he wanted to continue to play competitive softball, and had to change his position from outfield to second base because he could not throw a long ball.  Surgery was scheduled for July, which he subsequently declined, a decision that was deemed reasonable at the time by the treating physician.

The NARSUM on 6 October 2005, a month prior to separation, notes the CI reported that he injured his right elbow in April 2003, while serving in Operation Iraqi Freedom when he rolled off the hood of a Humvee and landed on his right elbow.  He had swelling and bruising.  He completed his deployment, and sought medical attention after returning.  He reported pain approximately half the day at the elbow, unable to throw with right arm, trouble lifting with his right arm.  Examination of the right elbow showed a ROM of 5 degrees extension (normal is zero), and 110 flexion, with moderate booking medially with valgus or radial directed stress with the elbow at 30 degrees of flexion.  At the VA C&P exam performed on 28 November 2005, 3 months prior to separation, the CI reported he did not seek medical attention after his right elbow injury because he could tell it was not broken.  He had symptoms of limited strength and throwing ability,  numbness of upper arm at times, occurring intermittently as often as every few months, lasting for a day, limiting his movement and strength in right arm, not causing incapacitation, not causing time lost from work.  Functional impairment was inability to lift heavy objects and numbness in entire arm when throwing objects such as a ball.  Physical examination revealed a right elbow with a general within normal limits appearance, ROM of 0% extension (normal), and flexion of 145 degrees (normal) bilaterally, without additional limitations due to pain, fatigue, weakness, lack of endurance or incoordination after repetitive use.

The Board first considered if the right elbow condition met the Board’s threshold for separate rating (as elaborated above).  The commander’s statement did not mention the right elbow condition.  The profiled limitations were not additionally limited from a prior permanent profile for only the left shoulder pain on 12 August 2005.  The right arm injury was not mentioned on the DD Form 2807-1 on 16 May 2005 6 month prior to separation.  There were no additional indications for unfitness in the record such as periods of incapacitation, prolonged absence from duty or hospitalizations for this condition.  The CI continued fulfilling his military duties after the injury while deployed, and was also capable of playing competitive softball and lifting weights, which is how he injured his left shoulder, after the right elbow injury.  Members agreed, therefore, that the chronic pain right elbow condition was not reasonably justified as separately unfitting; and, accordingly, it cannot be recommended for separate disability rating.

Mental Health (MH) Condition:  There were no MH conditions referred to the Disability Evaluation System.  The profile did not list an MH condition and was a psychiatric level one (S1), without any MH limitations.  The MEB NARSUM did not list any MH conditions, the MEB did not list any MH conditions, and the PEB did not list any MH conditions.  The commander’s statement did not mention any MH impairments.  There were no MH problems mentioned on the post-deployment health assessment.  On the MEB DD Form 2807 on 16 May 2005, 6 months prior to separation, the CI reported that he had trouble sleeping since returning from Iraq, and that he was feeling worried and depressed when his unit and friends redeployed, he did not seek MH treatment or evaluation.  There were no treatment notes in the record and no diagnoses made.  There were no other indications of possible unfitness, such as emergent psychiatric care, prolonged psychiatric hospitalizations, or prolonged absences from duty in the treatment record.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend an addition of any MH diagnoses, claimed as PTSD, 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 was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the chronic pain left shoulder condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the contended chronic pain right elbow condition, the Board unanimously agrees that it is not individually unfitting, and cannot recommend it for additional disability rating.  In the matter of the contended MH condition (claimed as PTSD), the Board unanimously agrees that it was not unfitting and cannot recommend an additional disability rating.  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	
Chronic Pain Left Shoulder (Non-Dominant)	5099-5003	10%	
Chronic Pain Right Elbow	Not Unfitting	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130607, 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 XXXXXXXXXXXXXXXXXX, AR20140007580 (PD201300808)

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 10% 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