RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-01108
BRANCH OF SERVICE:  Army	BOARD DATE:  20150210
SEPARATION DATE:  20030422

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Automated Logistical Specialist) medically separated for a right shoulder condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The right shoulder condition, characterized as “chondromalacia of the right humeral head, grade 3” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded “history of deep venous thrombosis” judged to meet retention standards.  The Informal PEB adjudicated “painful right shoulder with chondromalacia of humeral head found on arthroscopy” 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:  “The Physical Evaluation Board (PEB) medically separate [sic] me with a 10% rating and I contend that it should have been more than what the medical board granted!  I should have been granted for bilateral shoulders not just the right shoulder, the blood clot were the DVA did grant Chronic Arterial Peripheral Vascular disease and the right knee Chondromalacia.  All of these would cause me to be unfit to preform my duties in the Army.  I ask the Board to review my Medical board preceding and correct the injustice that was given by granting me a medical retirement with at least a 30% rating from discharge and put on the TDRL list and then put on the PDRL with at least 60% rating for bilateral shoulders and right knee.”

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 20030312	VA* - (3 Wks. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Painful Right Shoulder with Chondromalacia of Humeral Head Found on Arthroscopy	5099-5003	10%	Degenerative Arthritis; Residuals of Arthroscopy Surgery, Slap Lesion & Chondromalacia, Right Shoulder	5010-5203	10%	20030401	
			Chronic Left Arm Arterial Peripheral Vascular Disease	8511**	20%	20030708	
Other x 0 (Not in Scope)	Other x 1 	20030401	
RATING:  10%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20030423 (most proximate to date of separation [DOS]). **VARD dated 20030812 added condition effective DOS for a combined rating of 50%

ANALYSIS SUMMARY:  Citing application of the USAPDA Pain Policy, the PEB combined the right shoulder and DVT conditions under a single disability rating, coded analogously to 5003.  The Board noted that the MEB narrative summary (NARSUM) documented that the DVT condition involved the right arm, while all service treatment record (STR) entries documented only left arm involvement with the DVT.  Board members agree that the PEB likely considered that both conditions involved the same arm and incorrectly adjudicated them together under one code.  While the PEB specifically adjudged the right shoulder condition as unfitting, the Board considered whether the left arm DVT condition is “reasonably justified” as separately unfitting using performance based fitness criteria when “unbundled” from the PEB’s combined adjudication.  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 shoulder and left arm DVT conditions are presented separately; with attendant recommendations regarding separate unfitness, and separate ratings if indicated.

Painful Right Shoulder with Chondromalacia Condition.  The evidence documents that the CI suffered a right shoulder dislocation during basic training.  He was treated by physical therapy (PT) yet had continued pain and inability to perform certain activities, especially push-ups.  He was found to have multidirectional instability and underwent an open inferior capsular shift on 10 July 2000.  In spite of extensive PT, he continued to have chronic right shoulder pain.  Plain film X-rays and magnetic resonance imaging (MRI) studies performed in September 2001 were essentially normal.  The orthopedic surgeon also documented that the CI denied a history of instability and that the CI’s shoulder was stable on physical exam.  In May 2002, the CI underwent an arthroscopic surgical procedure consisting of a sub-acromial decompression and bursectomy.  The operating surgeon commented that, “On examination he is noted to have a very stable shoulder…” and that the MRI revealed a probable SLAP (superior labrum anterior posterior) tear as well as a thinned supraspinatus tendon consistent with a partial thickness tear, but not retracted muscle.  After rehabilitation, his right shoulder pain continued and the CI was referred into the Disability Evaluation System.

The NARSUM prepared 4 months prior to separation noted continued pain and discomfort of the right shoulder.  The pertinent physical exam findings are summarized in the chart below.  At the VA Compensation and Pension (C&P) exam performed 3 weeks prior to separation, the CI reported continued daily pain of 6/10 with exacerbations to 8/10.  His pain was worse with overhead lifting, shoulder and cold weather, but was better with medications.

The goniometric range-of-motion (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.

Right Shoulder ROM (Degrees)	Ortho 7 Mos. Pre-Sep	VA C&P ~ 3 Wk. Pre-Sep	
Flexion (180 Normal)	165	160	
Abduction (180)	165	90 (“adduction”)	
Comments: Right Hand Dominant	Pos. crepitus; Normal reflexes & sensation	Pos. tenderness to palpation; Pos. crepitus	
§4.71a Rating	10% (PEB 10%)	10% (VA 10%)	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB applied the analogous VASRD code of 5099-5003 (degenerative arthritis) and rated it 10% citing criteria of the USAPDA Pain Policy.  The VA applied the combination code 5010 (arthritis due to trauma) and 5203 (impairment of the clavicle or scapula) and also rated it 10% based on painful motion.  The Board noted that both probative examinations documented non-compensable right shoulder ROM measurements.  After the CI’s capsular shift surgical procedure there was no evidence of right shoulder instability.  Although there was no specific documentation of painful motion on either exam, the STRs contains adequate evidence of painful motion.  Additionally, VASRD §4.59, (Painful Motion) contains the following statement: “Crepitation either in the soft tissues such as the tendons or ligaments, or crepitation within the joint structures should be noted carefully as points of contact which are diseased” and both probative exams document the presence of crepitus.  The VASRD code 5003 grants a 10% rating for:

“When however, the limitation of motion of the specific joint or joints involved is non-compensable under the appropriate diagnostic codes, a rating of 10 pct is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5003.  Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion.”

The Board reviewed all coding/rating options and found no appropriate pathway to a rating greater than 10% for the CI’s right shoulder condition.  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 right shoulder pain condition.

History of DVT Condition.  The evidence supports that the CI complained of left shoulder pain in June 2001.  After an ultra-sound was performed he was diagnosed with a DVT of the left brachial/axillary vein.  There was no precipitating event identified and he was treated with blood thinning agents (anticoagulation) for 3 months.  The NARSUM prepared 4 months prior to separation incorrectly noted that the CI had a DVT of his right upper extremity and noted that the CI’s right upper extremity did not meet retention standards.  The initial C&P exam did not make any mention of his history of DVT, while a subsequent C&P exam did note that history and the VA granted him service-connection and a 20% rating for “Left Arm Arterial Peripheral Vascular Disease.”  The evidence present for review did not contain any profile or duty restriction related to the left arm DVT.  The Board notes, however, that during the period of anticoagulation, the CI most likely had some level of duty restriction which would have ended upon completion of the course of anticoagulation.  The commander’s statement did not mention the history of left arm DVT.  There were no STR entries concerning the left arm DVT or its treatment within 18 months of separation.  There was no performance based evidence from the record that the left arm DVT significantly interfered with satisfactory duty performance within 18 months of separation.  After due deliberation in consideration of the fitness related evidence, the Board concluded that the history of DVT condition was not “reasonable justified” as separately unfitting and so no additional disability rating is 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 shoulder pain was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the right shoulder pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the History of DVT condition, the Board unanimously agrees that it was not unfitting and cannot recommend it for 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:

CONDITION	VASRD CODE	RATING	
Painful Right Shoulder with Chondromalacia	5099-5003	10%	
History of Deep Venous Thrombosis	Not Unfitting	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130726, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		

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 XXXXXXXXXXXXXXX, AR20150007426 (PD201301108)

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 description without modification of the combined rating or 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		     

CF: 
(  ) DoD PDBR
(  ) DVA