RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXXX		CASE:  PD-2013-01315
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040324

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4, Military Police, medically separated for left shoulder pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “instability, left shoulder” and “impingement syndrome” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded one other medically unacceptable condition (idiopathic thrombocytopenic purpura) for PEB adjudication.  The Informal PEB adjudicated his left shoulder pain as unfitting, rated 0%, citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The remaining condition was determined to be not unfitting.  The CI made no appeals and was medically separated.  

CI CONTENTION:  His condition was rated 0% at discharge, but is now rated at 20%.  His complete submission is at Exhibit A.

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 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 Administrations 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:  

IPEB - Dated 20040220	VA* - based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left (Non-Dominant) Shoulder Pain…	5099-5003	0%	Residual, Left Shoulder Acromio-Clavicular separation with Impingement Syndrome…	5201-5202	0%	STR	
Other MEB/PEB Conditions x 1 (Not In Scope)	Other x 4 	
RATING:  0%	RATING:  0%	
*Derived from VA Rating Decision (VARD) dated 20041124 (most proximate to date of separation [DOS]).  
ANALYSIS SUMMARY:  

Left Shoulder Condition.  The service treatment record (STR) documented that the CI sustained a left shoulder injury during a riot control training exercise.  The CI experienced acute shoulder pain when stuck while holding a riot control shield with his left arm.  He was struck anteriorly with his arm internally rotated and flexed at the elbow.  At a primary care encounter the following day, the CI reported marked improvement in shoulder pain with increased range-of-motion (ROM).  The physical exam revealed tenderness at the acromioclavicular (AC) joint and the impression listed left AC sprain.  At a physical therapy (PT) encounter the CI complained of persistent, 7-8/10 left shoulder pain.  The ROM measurements were flexion of 100 and abduction of 90 degrees with significant discomfort at the ends of ROM.  At a primary care encounter the CI complained of left shoulder pain that was worse when he raised his arm.  He had intermittent tingling of the left hand.  The CI denied sustained improvement with rehabilitation exercises, NSAIDs, or muscle relaxants.  The physical exam documented full ROM with pain with forward flexion > 160 degrees.  The assessment listed AC joint dysfunction and bicipital tendonitis (inflammation of long head of the biceps tendon).  A left shoulder MRI was normal except for some distal peritendinous edema (swelling from excess tissue fluid) of the supraspinatous tendon.  The CI reported he reinjured his left shoulder when he fell onto his left hand while running.  He experienced no relief from a subacromial steroid (cortisone) injection.  The physical exam recorded full, tender ROM and the assessment listed tendonitis.  Electrodiagnostic studies were within normal limits.  A primary care left shoulder exam revealed no AC joint tenderness or scapula winging.  The Neer and Hawkins (assess for subacromial impingement) and Speed’s (assesses long head of biceps) tests were positive and the shoulder apprehension (assesses anterior shoulder instability) and drop arm (assesses for rotator cuff tears) tests were negative.  The active ROM measurements were flexion of 90 and abduction of 90 degrees.  There was painful motion at terminal internal and external rotation.  Motor function was intact and the assessment listed left shoulder impingement.  A left shoulder arthrogram (joint imaging following contrast injection) MRI showed a Bankart lesion/Perthes lesion (anterior/inferior glenoid labrum injury due to anterior shoulder dislocation) and a loose body.  The narrative summary (NARSUM) by orthopedic surgery recounted the history and interventions to date.  The right hand dominant CI complained of left shoulder pain and popping since injuring it in 2002.  Pain involved the posterior, and less so the lateral and anterior, aspects of the shoulder.  Pain was exacerbated by shoulder movement, heavy lifting, push-ups, sit-ups, and overhead motions and was relieved by stopping activities.  The CI reported his left shoulder and arm went numb with push-ups, sit-ups, and lying on the shoulder.  He denied a history of dislocation or that the shoulder felt like it slipped out of joint.  The CI experienced no sustained improvement with activity modification, PT, steroid injections, or medications and refused left shoulder arthroscopic surgery.  The left shoulder exam revealed no atrophy (wasting) or scapula winging.  There was tenderness at the AC joint, long head of the biceps, and lateral and posterior shoulder.  The shoulder impingement (assesses for subacromial impingement) test was positive and the shoulder apprehension and Speed’s tests were negative.  Active ROM was flexion of 110 and abduction of 90 degrees with painful motion in all axes (greatest at terminal ROM).  The supraspinatus strength (5/5) was normal.  The diagnosis listed possible left shoulder instability, impingement syndrome, and MRI findings consistent with a previous left shoulder dislocation and loose body.  A left shoulder MRI was unremarkable except for mild AC joint arthropathy (joint disease).

The Board directed attention to its rating recommendation based on the above evidence.  The informal PEB, one month before separation, rated the left shoulder condition at 0% (VA code 5099-5003; disability rating by analogy-degenerative arthritis).  The PEB cited non-dominant shoulder pain, reported instability, impingement syndrome, intermittent use of pain medications, abduction to 180 degrees, normal strength (5/5), and rated for pain IAW USAPDA pain policy.  The PEB’s rating of 0% analogously to 5003 (degenerative arthritis) does not comport with the VASRD §4.71a stipulation for a 10% rating under 5003 for “2 or more major joints”, the latter without regard to ROM limitation or other factors.  The VA rating decision (VARD), eight months after separation, rated the left shoulder condition 0% (5201-5202; arm, limitation of motion of:  minor-humerus, other impairment of).  The VARD evidence included service medical records as no compensation and pension (C&P) exam was in evidence.  The VARD cited it had not received requested medical evidence to show the current level of disability.  Board members agreed there was sufficient evidence of painful motion (§4.59) and functional loss (§4.40) to support a 10% rating.  The limitation of motion in abduction in the NARSUM exam was consistent with the 20% rating (at shoulder level [90 degrees]) under code 5201.  There was no evidence of scapulohumeral ankylosis to support a rating under code 5200, and no evidence of malunion of the humerus, clavicle or scapula, or of dislocation, to support a rating under codes 5202 or 5203.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the left shoulder condition (5201).

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 AR 635-40 DoDI 1332.39 for rating the left shoulder condition was operant in this case and the condition was adjudicated independently of that policy/ instruction/regulation by this Board.  In the matter of the left shoulder condition, the Board unanimously recommends a disability rating of 20%, coded 5201 IAW VASRD §4.71a.  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	
Chronic Left Shoulder Pain	5201	20%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130910, 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 XXXXXXXXXXXXXXXXXXXXX, AR20150018980 (PD201301315)

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:

CF: 
(  ) DoD PDBR
(  ) DVA