RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-01649
BRANCH OF SERVICE:  Army	BOARD DATE:  20150506
SEPARATION DATE:  20040818

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Infantry) medically separated for chronic right shoulder pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty but was authorized to take an alternate physical fitness test.  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The chronic right shoulder pain condition was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were forwarded for adjudication.  The Informal PEB adjudicated “right shoulder pain,” as unfitting, rated 0%, with likely application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Since being separated I have had one surgery on my shoulder and suffer from pain and weakness radiating through my right arm.  Furthermore, while in service and consistently ignoring the true extent of my shoulder injury, I was forced to compensate in other way and I now have permanent neck and lower back problems.  A claim on the latter is currently in the appeals process with the VA.”

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:

IPEB – Dated 20040505	VA* - (~2 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder Pain	5099-5003	0%	Adhesive Capsulitis, Right Shoulder	5099-5019	10%	20041007	
Other x 0 (Not In Scope)	Other x 5	
RATING:  0%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20041114 (most proximate to date of separation (DOS))
ANALYSIS SUMMARY:

Right Shoulder Pain Condition.  The earliest note in the service treatment record dated 2 July 2003 indicated the CI complained of pain on the right shoulder for 4 months with numbness and tingling in the right arm when he put on a ruck sack or load bearing equipment.  The pain was located anterior to the right shoulder and there was no shooting pain.  The severity level was 5/10 (10 being the worst pain) up to 8/10 when he did something.  He also felt grinding and popping when the right shoulder was being rotated.  It was noted the CI “broke joint in socket and was receiving cortisone shots for two months three years ago.”  Examination revealed a full range-of-motion (ROM) with crepitus on the right rotator cuff with popping and pinpoint tenderness to palpation at the right trapezius and at the proximal bicipital tendon.  The impression was trigger point impingement and bicipital tendonitis.  Treatment consisted of piroxicam, a nonsteroidal anti-inflammatory medication, and no upper body physical training or ruck sack for 2 weeks.  At follow-up 10 days later, crepitus and tenderness at the aforementioned sites was still present.  Additionally, pain on testing the muscles of the rotator cuff and positive impingement and apprehension tests were noted.  The diagnosis of tenosynovitis of the right shoulder was made and Indocin (indomethacin-a nonsteroidal anti-inflammatory medication) replaced the piroxicam and Flexeril (cyclobenzaprine-a muscle relaxant) was prescribed.  IM (intramuscular) Stadol (butorphanol, a narcotic) was given three times over a week for the pain.  Prior to missions on which he carried a heavy combat load, he received IM Demerol (meperidine-a narcotic) six times and IM toradol (ketorolac-a nonsteroidal anti-inflammatory drug (NSAID) twice in late July and early August 2003.  Hawkins (to test the supraspinatus tendon) and Neer (to identify possible subacromial impingement syndrome) tests were positive in mid-August.  In late August he received an additional six IM Demerol injections.  Celebrex (celecoxib-a NSAID) was also introduced in late August and continued in September 2003 and Phenergan (promethazine-an antihistamine of the phenothiazine family for sleep) was prescribed.  A C7 neuropathy/facet condition was raised in mid-September 2003 and was treated with a steroid/anesthetic injection and Neurontin (gabapentin-to treat nerve pain).  Although an X-ray series of the right shoulder showed no evidence of impingement on 4 February 2004, the CI was treated for an impingement syndrome and Celebrex and physical therapy were continued.  At an orthopedic visit in late February 2004, the CI’s ROM was 180 degrees abduction and 45 degrees adduction; and possible surgery was discussed.  A magnetic resonance imaging (MRI) dated 23 February 2004 demonstrated no evidence of a SLAP (superior labral tear from anterior to posterior) lesion, but did note a lateral down-sloping acromion, which may be associated with impingement syndrome, and prominent cystic change in posterolateral aspect of the humeral head.

The MEB narrative summary dated 15 April 2004 indicated the CI complained of right shoulder pain for approximately a year in April 2003 without a specific event or injury as the cause.  Pain was exacerbated with any type of activity including lifting, jumping, and carrying.  Physical examination of the right shoulder revealed 0-180 degrees of abduction, 45 degrees of adduction of external rotation, and internal rotation to T10.  Results for the left shoulder were essentially the same except for internal rotation to T4.  X-rays and an MRI showed no gross abnormality, except that the CI had a slightly down slopping acromion.  A magnetic resonance arthrogram confirmed the diagnosis and no gross anomaly was demonstrated.  The acromioclavicular (AC) joint and the rest of the shoulder showed no significant abnormality.  The condition interfered with satisfactory performance of duty.  A permanent P3 profile was issued on 15 April 2004 with limitations of military functional activities, including the wearing of personal protective equipment, and physical fitness training and testing.  On the DD Form 2807, Report of Medical History dated 20 April 2004 for the MEB examination, the CI reported pain in the right shoulder and with worse pain “it becomes numb.”  The MEB physical examination dated 29 April 2004 noted right shoulder pain on ROM measurements, which were decreased.  The commander’s statement dated 28 April 2004 indicated the CI could perform partial duties.  He was required to carry large amounts of weight including personal protective equipment and a weapon, but the commander felt the CI would have difficulties doing so.

At the VA Compensation and Pension examination dated 7 October 2004, performed almost 2 months after separation, the CI reported he injured his right shoulder in basic training and had chronic right shoulder dull, numbing pain with an occasional stabbing type pain, which averaged about 5/10 and interfered with his daily activities including sleep, shaving, and in the bathroom.  Examination revealed forward flexion was to 180 degrees with pain at the right AC joint; and abduction was reported to 80 degrees with pain to 180 degrees.  There was no weakness, fatigue or incoordination, no palpable tenderness, no swelling, no deformity, and no additional limitation of motion with repetitive use.

The 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)	MEB ~4 Mo. Pre-Sep
	VA C&P ~2 Mo. Post-Sep
	
Flexion (180 Normal)	165,165,165	180	
Abduction (180)	145,145,145	80* (?180) w/pain to 180	
Comments	Pain between the active ROM and passive ROM.	*The 80 may be a typo for 180 degrees since pain to 180 reported;  DeLuca negative. 	
§4.71a Rating	0%	VA 10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating using code 5099-5003 based on a rating for pain of the right shoulder IAW the USAPDA pain policy.  The VA assigned a 10% rating using code 5099-5019 (bursitis) for right shoulder sprain with chronic pain.  The Board noted that the PEB’s use of the 5009 code was appropriate, but favored a 10% rating because of the noncompensable limitation of motion and evidence of painful motion.  The Board then sought a route to a higher rating, but was unable to do so in the absence of ankylosis or impairment of the humerus, clavicle, or scapula.  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 right should pain condition.

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 condition was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the right shoulder pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 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	
Right Shoulder Pain 	5099-5003	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130926, 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, AR20150011031 (PD201301649)

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			

CF: 
(  ) DoD PDBR
(  ) DVA