RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2013-01847
BRANCH OF SERVICE:  Army	BOARD DATE:  20140801
SEPARATION DATE:  20050808

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PFC/E-3 (19K/Armor Crewman) medically separated for chronic right shoulder pain.  The condition 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 U3 profile and referred for a Medical Evaluation Board (MEB).  The right shoulder capsular contractures with activity related provocative pain, characterized as “medically unacceptable,” were the only condition forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.   The Informal PEB adjudicated “chronic right shoulder pain” 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:  “Arthrites, loss of strength and mobility, cronic pain numbness, elbow pain, shoulder instability.” [sic]

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 shoulder pain condition is addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board.  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 20050615	VA - (2 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam*	
Chronic Right Shoulder Pain	5099-5003	10%	Status Post Right Shoulder Reconstruction	5201	30%	20050517	
			Scar, Status Post Right Shoulder Reconstruction	7805	0%	20050517	
Other x 0 (Not In Scope)	Other x 1 (Not in Scope)	20050517	
Combined:  10%	Combined:  30%	
Derived from VA Rating Decision (VARD) dated 20050912 (most proximate to date of separation [DOS]).*Exam is not in evidence but is referenced in the VARD.

ANALYSIS SUMMARY:  IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VA Schedule for Rating Disabilities (VASRD) standards, based on ratable severity at the time of separation.

Chronic Right Shoulder Pain Condition.  Service medical records show that the right-hand dominant CI initially injured his right shoulder in October 2003 while engaged in pugel stick combative training.  Blunt trauma caused the shoulder to "pop out,” but he was able to self-reduce this dislocation and completed basic training without further difficulty.  He experienced subsequent recurring episodes of right shoulder subluxation and self-reduction.  X-rays were normal.  Due to inadequate response to physical therapy and pain medication, arthroscopic surgery was performed on 4 October 2004.  Although a re-injury a few weeks following the surgery involved a shoulder subluxation and the need for self-reduction, the shoulder no longer felt like it was “loose.”  However, ongoing pain led to the need for arthroscopic revision surgery on 14 February 2005.  Post-operatively, pain was decreased, but significant improvement in range-of-motion (ROM) was not achieved.

At the MEB narrative summary (NARSUM) on 30 April 2005 (10 weeks after surgery and 3 months prior to separation), the CI complained of right shoulder pain and stiffness.  He denied pain at rest, but certain activities caused pain.  He complained of difficulty reaching overhead or lifting anything heavy.  Physical examination showed no atrophy or tenderness.  Although one test for possible shoulder instability was positive (apprehension test), other maneuvers did not confirm the presence of instability.  X-rays reportedly showed no evidence of arthritis.

The VARD was based on a Compensation and Pension (C&P) exam performed on 17 May 2005 (2.5 months prior to separation) that was not in evidence.  The CI reportedly complained of constant stiffness and weakness, but was not receiving any treatment.  The examination reportedly showed right shoulder swelling and scarring.  Painful motion was noted at the limits of ROM (reflected in the chart below).  Furthermore, “The examiner noted that your joint function was additionally limited by pain, fatigue, weakness, lack of endurance, with pain having a major functional impact after repetitive use.”  The VA rater did not indicate if a goniometer was used for measuring ROM; did not specify if any motion beyond the onset of pain was attempted; did not state if the examiner observed repetitive motion, or if observed, how many repetitions were performed and to what measured degree motion was additionally reduced by repetition.  The rater  was also silent regarding complaints and examination findings of shoulder instability.  At a VA exam in February 2007 (almost 2 years after separation), the CI stated that he had not experienced any dislocation events since his surgery.

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 ~ 3 Mos. Pre-Sep	VA C&P ~ 2 Mos. Pre-Sep**	
Flexion (180 Normal)	70*	85	
Abduction (180)	80*	85	
Comments	+Painful motion	+Painful motion; additional limitation with repetition	
§4.71a Rating	20% (PEB 10%)	20% or 30% (VA 30%)	
		*Passive, not active, ROM was measured with a goniometer
		**Examination not in evidence

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder condition 10% under an analogous 5003 code (degenerative arthritis) citing USAPDA pain policy.  The VA arrived at a 30% rating under the 5201 code (arm, limitation of motion of) by noting that limitation of motion warranted 20%, and by justifying an additional 10% based on further functional impairment caused by “pain after repetitive use.”  While there was sufficient evidence of painful motion (§4.59) and functional loss (§4.40) to support the PEB’s 10% rating, Board members considered if there was evidence of limitation of motion to warrant a higher rating.  In this regard, the Board was challenged by the fact that the NARSUM examiner did not measure active ROM, while the VARD did not reflect important information that may or may not have been present in the missing C&P exam.  The VASRD §4.71a threshold for compensable ROM impairment is “at shoulder level”, i.e., 90 degrees; and the examinations demonstrated motion near this level.  The next higher 30% rating for a dominant arm requires motion limited to “midway between side and shoulder level.”  The Board agreed that the available evidence most closely approximated the 20% criteria.  The application of VASRD §4.45 was also debated, which allows for a higher rating if evidence of additional functional loss is present and was the justification used by the VA for the next higher rating.  In addition to important missing information from the C&P exam, including silence regarding the use of a goniometer, the Board considered there was no evidence that any reduction in ROM after repetition was actually measured.  The Board concluded that there was not sufficient evidence to justify application of §4.45 and therefore the next higher 30% rating was not justified on this basis.  The Board finally concluded that there was no evidence of recurrent dislocations after surgery to support a rating under the 5202 code (humerus, other impairment of) and no justification for rating under the 5200 (scapulohumeral articulation, ankylosis of) or 5203 (clavicle or scapula, impairment of) codes.  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 chronic shoulder 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 the chronic shoulder pain condition was operant in this case and the condition was adjudicated independently of that policy.  In the matter of the chronic shoulder pain condition, the Board unanimously recommends a disability rating of 20% 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:

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Shoulder Pain	5099-5003	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131020, 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, AR20150001228 (PD201301847)

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:

Encl						     

CF: 
(  ) DoD PDBR
(  ) DVA