PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	 CASE:  PD-2013-01426	
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20050225		 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a drilling Army National Guard E-4 (Motor Transport Operator) medically separated for left shoulder, right shoulder, neck and anxiety disorder conditions.  These conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent U3L2S4 profile and referred for a Medical Evaluation Board (MEB).  Left shoulder adhesive capsulitis, chronic neck pain due to myofascial pain, anxiety disorder, not otherwise specified, and right shoulder avascular necrosis of the humeral head syndrome, were forwarded to the Physical Evaluation Board (PEB) in IAW AR 40-501.  The MEB also forwarded three medically acceptable conditions (cervical DJD and DDD, lumbar spine DJD, and bilateral knee osteoarthritis.  The Informal PEB (IPEB) adjudicated chronic left shoulder pain secondary to adhesive capsulitis as unfitting rated 10%, and chronic neck pain due to myofascial pain as unfitting also rated 10%.  The IPEB further determined that chronic right shoulder pain and anxiety disorder, not otherwise specified existed prior to Service (EPTS) without permanent service aggravation (PSA), and therefore they were not compensable.  The CI made no appeals and was medically separated.  

CI CONTENTION:  The CI elaborated no specific contention in his application.  

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 20041201	VA - (~ 7 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Shoulder Pain Secondary to Adhesive Capsulitis	5201	10%	Impingement Syndrome Left Shoulder, Status Post Arthroscopy Surgery	5299-5203	20%	20050927	
Neck Pain Due to Myofascial Pain Syndrome	5099-5003	10%	Cervical Spine Degenerative Disc Disease	5237	10%	20050927	
Anxiety Disorder, Not Otherwise Specified	9413	EPTS 	Depressive Disorder	9434	70%	20040408	
Right Shoulder Pain 	5009-5003	EPTS 	Right Shoulder Condition due to Steroid and Cortisone Shots	5299-5203	NSC	20050927	
Cervical DJD and DDD	Not Unfitting	Included Under 5237 above	
Other MEB/PEB Conditions  x 2 (Not in Scope)	Other x 4 	
COMBINED RATING:  20%	COMBINED RATING:  80%	
Derived from VA Rating Decision (VARD) dated 20060221 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Chronic Left Shoulder Pain Secondary to Adhesive Capsulitis.  The narrative summary (NARSUM) noted that the right-handed CI injured his left (minor) shoulder in 1998 (formal LOD=Yes).  Imaging indicated damage to the shoulder joint and ligaments (MRI in December 2000 showed "an avulsion-type tear of the anterior inferior glenoid labrum and anterior glenohumeral ligament [Bankart lesion].  There also appeared to be a superior labral abnormality consistent with a type I or II SLAP lesion").  The CI underwent left shoulder surgery (acromioplasty and partial bursectomy) in April 2001.  Despite physical therapy (PT), massage therapy and steroid injections he developed adhesive capsulitis.  Orthopedic notes through 2003 indicated tenderness and pain-limited motion with slight weakness with external rotation (4/5) and other shoulder girdle muscles (4+/5) as well as positive impingement and instability signs (+Hawkins and O’Brien’s).  

At the MEB exam, dated 24 September 2004, approximately 5 months prior to separation, the CI reported constant pain in the left shoulder and scapula (shoulder blade) that interfered with sleeping.  He experienced feelings of instability “like it is popping out of joint” and had worse pain with activities or lifting over 20 pounds.  He needed assistance pulling on his shirt over his head and was taking anti-inflammatory medications.  The MEB physical exam noted well healed scars.  There was no effusion, swelling, or redness and there was no muscle atrophy.  The CI could not reach behind his back or his head.  Range-of-motion (ROM) was painful, limited and is summarized below.  

At the VA Compensation and Pension (C&P) exam dated 26 March 2004, approximately 11 months before separation (preceded the above MEB exam) the CI reported inability to lift his left arm above 90 degrees and had arm weakness.  Pain was 3-9/10 with increase on repetitive use, lifting, twisting or reaching.  The CI was on narcotic and non-narcotic pain medications.  Pain-limited ROMs are summarized below.  

At the VA C&P exam performed approximately 7 months after separation the CI continued claims of instability and weakness with transient use of a sling.  Symptoms included the shoulder feeling like it was “slipping” and was stiff and “frozen.”  Exam documented painful ROMs as below with decreased strength and ROM on repetition of motion.  Imaging documented contact sclerosis and subacromial spurring (bone changes) consistent with chronic impingement syndrome. 

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 ~11 Mo. Pre-Sep	MEB ~5 Mo. Pre-Sep	VA C&P ~7 Mo. Post-Sep	
Flexion (180 Normal)	0-165	105,107,110	0-155	
Abduction (180)	0-100	87,88,86	0-155	
Comments	“Pain with anything above 90”	Pain limited	Additional loss of 15 degrees after repetition; weakness, fatigability and diminished endurance also increased by 10%	
§4.71a Rating	10%-20% (VA 20%)	20% (PEB 10%)	10%-20% (VA 20%)	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB disability description cited abduction of 86 degrees limited by pain with a 10% rating coded 5201 (arm, limitation of motion of).  However, VASRD code 5201 does not have a 10% rating level and limitation at shoulder level (90 degrees), would justify a 20% rating.  The PEB 10% rating was potentially IAW AR 635-40, B-29 for rating on mechanical limitation of motion only.  The VA 20% ratings of each of their exams were analogous to code 5203 (impairment of the clavicle or scapula [shoulder joint]), equivalent to “with loose movement” for shoulder impingement.  

The Board discussed the probative values of the exams in evidence and adjudged the MEB exam, which was closest to the date of separation, had the highest probative value for rating.  Since the CI was right-hand dominant, the left shoulder is considered “minor” for rating under the joint codes.  IAW VASRD disability code 5201 arm limitation from “midway between side and shoulder level” (approximately 45 degrees) to “at shoulder level” would be ratable at 20%.  There was no evidence that the CI’s left shoulder was limited to 25 degrees from the side for any rating higher than 20%.  Alternate use of code 5203 and consideration of weakness and functional loss with significant shoulder (clavicular and scapular) impairment would alternatively justify a 20% rating, but not warrant a rating higher than 20% as that is the maximum VASRD rating under code 5299-5203.  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.  

Chronic Neck Pain Due to Myofascial Pain Syndrome Condition (Including Cervical DJD and DDD).  The cervical DJD and DDD conditions (found not unfitting by the PEB) were not separable from the neck condition and are therefore discussed below.  The NARSUM noted the onset of neck pain in 1998 along with the left shoulder injury discussed above.  The CI had multiple specialty evaluations for neck pain with radiating symptoms.  Electrodiagnostic testing (EMG/NCV) showed no evidence of peripheral nerve deficits.  The described cervical pathology of bulging discs, degenerative disc disease (DDD) and degenerative joint disease (DJD) on imaging (MEB diagnosis #4) adjudged as both EPTS and less productive of the CI’s pain and disability than the primary pathology of myofascial pain syndrome.  The CI had continued activity-limiting neck pain despite multiple treatment modalities including physical therapy, home exercise program, chiropractic manipulations, trigger point injections and epidural steroid injection (ESI).  

At the NARSUM exam, the CI reported sharp neck pain daily with radiating pain down the back up to 10/10 with activity and pain interfering with his sleep.  The NARSUM physical exam documented tenderness to palpation over the bottom of the cervical spine (C-7) and right shoulder with no muscle spasm.  Strength at the elbows, hands and wrists were normal as was the upper extremity neurologic exam.  The MEB DD Form 2808, Report of Medical Examination, noted decreased right hand grip strength (4/5) with mild thenar (thumb pad) muscle atrophy.  
At the VA C&P exam performed 11 months before separation, the CI reported neck pain described as dull to sharp with an intensity of 3-9/10 and weakness.  Precipitating factors were repetitive use, lifting, twisting and reaching.  Alleviating factors were rest, heat, narcotic pain medication and anti-inflammatory medications.  He denied any paresthesias (abnormal sensations of the peripheral nerves). 

At the VA C&P exam performed approximately 7 months after separation the CI reported stiffness in his neck on attempting to look towards the ceiling.  Pain limited ROMs from this exam, the MEB exam, and the VA exams are summarized below.  

Cervical ROM
(Degrees)	VA C&P ~11 Mo. Pre-Sep	PT ~ 5 Mo. Pre-Sep	VA C&P ~7 Mo. Post-Sep	
Flex (45 Normal)	35	45	40	
Combined (340)	Over 170; under 335	Over 170; under 335	255	
Comment:  	Painful motion	Tenderness; pain limits	Pain at end ROM	
§4.71a Rating	10%	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  Note that the PEB condition of cervical DJD and DDD was not separable from the primary unfit condition of chronic neck pain for rating determination of the cervical spine.  All exams in evidence warranted a 10% rating under the general spine formula for combined cervical ROM greater than 170 degrees but not greater than 335 degrees.  There were no periods of physician-prescribed bed rest; muscle spasm or guarding severe enough to result in an abnormal spinal contour; or forward flexion limited to 30 degrees (or less) for any higher rating.  Pain (whether or not it radiates), stiffness, or aching is considered under the general spine rating formula.  There was no evidence of any fixed peripheral nerve deficit, and therefore no peripheral nerve rating was warranted.  

Ideal coding would have been 5299-5237 (analogous to cervical strain) using the spine formula; however, analogous coding under 5003 [arthritis, degenerative (hypertrophic or osteoarthritis)] provided the same 10% rating, but would not be a normal application of the VASRD.  

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 10% adjudication for the neck pain condition, but that coding should be changed to 5299-5237 and the cervical DDD and DJD should be subsumed under the unfitting cervical spine condition.  

Chronic Right Shoulder Pain [EPTS].  The NARSUM noted onset of right shoulder pain “about 4 months ago” (approximately 9 months prior to separation) with no specific injury noted.  The CI was found to have avascular necrosis of the right humeral head (AVN-dying of the upper arm bone due to inadequate blood flow).  At the time of the NARSUM, the CI was recommended for corrective surgery (total replacement).  At the MEB exam, the CI complained of severe sharp pain 9/10 with radiation into his wrist and paresthesias (abnormal sensations) in his right fingers and pain interfering with sleep.  The MEB physical exam noted limited motion with an inability to formally test the ROM due to pain.  

At the VA C&P exam performed 11 months before separation, there were no right shoulder complaints or exam.  The 7 month post-separation VA exam indicated the CI had undergone right shoulder surgery (hemiarthroplasty; partial joint replacement) and the CI complained of 10/10 pain, weakness, paresthesias and poor sleep.  He had indicated by his claim that the right shoulder condition was secondary to cortisone (steroid/ESI) shots.  Right (dominant) shoulder forward flexion was 105 degrees and abduction was limited to 85 degrees (normal 180 for flexion and abduction).  

The Board directed attention to its recommendation based on the above evidence.  The PEB found the right shoulder condition to be unfitting, but non-compensable due to EPTS without permanent service aggravation.  The VA denied service connection for the right shoulder (VARD dated 21 February 2006).  There was no positive LOD finding for any right shoulder injury and the CI’s onset of pain was not following duty-related trauma or during an active duty period.  Medical literature indicates that the etiology of AVN is usually due to trauma or diseases, but that high-dose use of corticosteroids (such as prednisone) is the most common cause of AVN that isn't related to trauma.  The CI’s record indicated the CI did have injections of steroids, but source documents for amounts and frequency of injection(s) were not available.  There was no indication that the CI had high dose systemic steroids or any other systemic or injection-site adverse reactions to local steroid injections due to military service.  The evidence did not demonstrate that the right shoulder condition was related to service or permanently aggravated by service.  After due deliberation, considering all of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right shoulder condition.  

Anxiety Disorder, Not Otherwise Specified.  The record indicated that the CI had onset of psychiatric symptoms while on active duty in 1984.  He was hospitalized at the military psychiatric ward for 6 days for diagnoses of depression and anxiety.  He was discharged a year later (1985) without a mental health diagnosis.  

At the time of the Psychiatric NARSUM Addendum, dated 26 October 2004, approximately 4 months prior to separation, the CI was being treated by a civilian psychiatrist for “Panic Disorder with Agoraphobia, Post Traumatic Stress Disorder (PTSD), and R/O (rule out) obsessive compulsive disorder.”  The examiner stated:  “The (CI) is not considered a reliable historian.  He changed his story in some areas upon subsequent interviews.”  

The CI indicated “that he was functional until an episode in 2000 ‘triggered’ the initial trauma from 1984 when he began seeing a therapist who helped him to become ‘aware’ of his trauma-related anxiety symptoms.”  The episode in 2000 was during a non-duty period when the CI reportedly became suicidal following his passing infidelity information to a female that led to her killing her boyfriend/husband.  The CI had emergency treatment for a reported suicide attempt, but refused hospitalization.  The CI endorsed depressive symptoms and passive suicidal thoughts.  Mental status exam was essentially normal except for anxious mood and affect.  Civilian treatment indicated the CI had “shown mild improvement in anxiety and depressive symptoms on current medications.”  Current findings were:  “The patient endorses several criteria for many disorders, but appears to be mostly affected by an anxiety disorder with resultant depressive symptoms which may or may not have been long-standing.”  The diagnosis was anxiety disorder not otherwise specified, with “definite” impairment for social and industrial adaptability, an additional diagnosis of alcohol dependence and an overall GAF of 55 (in the moderate range).  The final NARSUM determination was LOD “No, EPTS.”  

There were two VA C&P mental disorder exams in evidence prior to separation.  The exam 16 months prior to separation indicated a diagnosis of depressive disorder not otherwise specified and the examiner provided a medical opinion that “it is at least as likely as not that the (CI’s) current mental health condition is related to his treatment in the service in 1984.”  The exam 10 months prior to separation diagnosed major depressive disorder.  

The Board directed attention to its recommendations based on the above evidence.  The Board deliberated if the CI’s unfitting mental health condition was compensable or non-compensable.  It was clear that the CI had onset of a mental health condition during an active duty period in 1984 (in line of duty) with resolution of symptoms and no evidence of a mental health diagnosis or symptoms at the ETS exam in 1995.  The CI was not on a subsequent duty period when he had an event (“trigger”) that led to the onset of mental health symptoms in 2000.  The Board considered DoDI 1332.38, E3.P4.5.3. (Prior Service Impairments), and deliberated if the CI’s unimpaired functioning until a stressful event in 2000 was equivalent to a new injury precipitating a new impairment or a recurrence of his prior mental health condition.  However, if it were adjudged a “recurrence,” any recurrence from 2000 was not “during later service or authorized training.”  The Board adjudged that although the 1984 mental health condition may have predisposed the CI to additional mental health conditions, the separate events in 2000 constituted a significant new event (not during a duty period), that led to the onset of unfitting symptoms.  

After due deliberation in consideration of the evidence, the Board concluded that there was insufficient evidence to recommend that the anxiety disorder recurred or was permanently aggravated during later service (compensable).  The Board concluded therefore that this condition could not be recommended for additional disability 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.  As discussed above, reliance on AR 635-40 for rating the left shoulder condition was likely operant in this case and the condition was adjudicated independently of that regulation by the Board.  In the matter of the left shoulder condition, the Board unanimously recommends a disability rating of 20%, coded 5201 IAW VASRD §4.71a.  In the matter of the neck condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB ‘s adjudicated 10% disability rating, but recommends including the diagnosis of cervical DDD and DJD in the disability and with a coding change to 5299-5237.  In the matter of the anxiety disorder condition, the Board unanimously recommends no change in the PEB adjudication as not compensable.  In the matter of the right shoulder condition, the Board unanimously recommends no change in the PEB adjudication as not compensable.  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; and, that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:  

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Left Shoulder Pain Secondary to Adhesive Capsulitis	5299-5201	20%	
Chronic Neck Pain Due to Myofascial Pain Syndrome (Including Cervical DJD and DDD)	5099-5237	10%	
Anxiety Disorder, Not Otherwise Specified	9413	EPTS	
Chronic Right Shoulder Pain Beginning in 2004 … 	5099-5003	EPTS	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130911, 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 XXXXXXXXXXXXXXXXXXX, AR20160000015 (PD201301426)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.  

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:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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:

			      
						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA