RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-00032
BRANCH OF SERVICE:  MARINE CORPS 	 SEPARATION DATE:  20060515

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Unit Level Circuit Switch Operator/Maintainer) medically separated for a right shoulder condition.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was placed on limited duty (LIMDU) and referred for a Medical Evaluation Board (MEB).  The “right shoulder pain and weakness” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated the right shoulder condition as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.  

CI CONTENTION:  “I had severe back pain.  The doctors tried to help by injecting steroids into my back, which caused my muscle to atrophy they gave up trying after that.  The medical doctors sent me for tests but refused to send me to specialists and just said it was pain.  I was given no support to keep me in and try to fix the problem.  I feel that further testing could have been made to help find the problem.” 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/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 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 20060307	VA* - (~44 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder	5299-5003	10%	Right Shoulder	5203	10%	20100112	
Other x 0 (Not In Scope)	Other x 8 	
RATING:  10%	RATING:  10%	
*Derived from Original VA Rating Decision (VARD) dated 20100216 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Right Shoulder Condition.  The earliest note in the service treatment record dated 23 February 2004 indicated the CI initially had low and mid-back pain, which with treatment felt better, but then she began feeling “sharp pain between shoulder blades” more on the right than the left.  The assessment was weak “scap (scapular) stabilizers (rhomboid strain).” Exercises and stretches were instituted along with Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID).  By March 2004 the assessment was revised to include trapezius muscle strain versus a tear and Tylenol #3 (codeine, a narcotic and acetaminophen, a pain reliever) was added for the pain.  Physical therapy was carried out and trigger points around the outer boundaries of the scapula were noted and were assessed to be contributory to the myofascial pain.  A neurology consultation on 21 December 2004 indicated there was isolated right trapezius atrophy, which raised the possibility of a myopathy or local muscle process.  An MRI of the cervical spine, requested for chronic right upper extremity radicular pain and trapezius atrophy, was normal.  Electrodiagnostic studies of the median, ulnar and right medial antebrachial cutaneous nerves were normal as were the biceps and triceps.  An MRI of the upper back and cervical spine were normal in March 2003.  Lidoderm (lidocaine, a local anesthetic) patches were prescribed for the pain in April 2005.  Dermatologic evaluation noted a 15mm atrophic plaque with slight scaling overlying the plaque.  The possibility of lupus panniculitis (a connective tissue disease involving the fat) was raised and a skin biopsy was performed.  The histopathology report indicated the subcutaneous adipose tissue appeared unremarkable and no characteristic changes of lupus erythematosus were identified.  Special stains for fungi were negative and the final diagnosis was skin with mild focal hyperkeratosis.  At a follow-up examination on 8 May 2005, a bony deformity was noted and the CI was tender to palpation on the right trapezius.  The CI was evaluated on 28 June 2005 with the diagnosis of myopathy complicated by a potential spinal root impingement syndrome.  The CI also complained of right shoulder drop in addition to pain.  At a neurologic follow-up examination it was noted the right shoulder dropped significantly from a prior evaluation and gentle palpation of the right upper trapezius and right posterior shoulder region produced significant pain.  There was no obvious atrophy, but there was an approximately 2-inch shoulder drop on the right side compared with the left.  No obvious fasciculation (muscle twitching) or significant cutaneous changes were noted.  However, there was a mild degree of scapular prominence on the right.  Motor examination was significantly limited by discomfort.  Hand intrinsic musculature and wrist flexors and extensors were normal.  The neurologist opined the condition could be more of a musculoskeletal or connective tissue process given the lack of any obvious muscle atrophy.  In January 2006, an internist indicated there was definite asymmetry between the right and left shoulders and tenderness of the trapezius muscle along the lower border extending from the base of the neck to the glenoid capsule (site of the articulation of the humerus and the scapula).  Strength was “4/5+” in the right versus 5/5 on the left upper extremity.  Questionable scapula winging was noted on the right and the range-of-motion (ROM) was significantly decreased on the right due to pain.  Gabapentin (for nerve pain) was prescribed.  Orthopedic evaluation on 20 January 2006 favored myofascial pain of the right shoulder as the diagnosis.  The internist’s impression in February 2006 was chronic right shoulder pain without current evidence of any rheumatologic disorder. In an undated letter to the “Staff of the Board” the CI wrote “I can’t swing my arm when I walk…then there is me, one arm noticeably longer than the other.”

The MEB narrative summary (NARSUM) dated 9 September 2005 indicated the CI had right shoulder pain and weakness for approximately 18 months, did not have any interval improvement, and was continuing to experience activity limiting pain.  There was a 1.5 cm region on the right posterior trapezius with obvious subcutaneous atrophy and hypopigmentation of the overlying skin and severe tenderness to palpation in that region, but there was no obvious deltoid or trapezius muscle atrophy.  Motor strength was limited by pain in the right arm; otherwise the neurologic evaluation was unremarkable.  An MRI of the right brachial plexus in January 2005 was normal and electrodiagnostic studies provided no evidence of a right upper extremity mononeuropathy or brachial plexopathy.  However, a suprascapular neuropathy was not suggested as a diagnosis and could not be definitively excluded due to a limited study.  MRI imaging of the underlying muscle did not indicate any obvious fatty replacement of [or] atrophy.  The examiner opined that the refractory nature of the condition suggested it would continue to cause severe activity limiting pain indefinitely and would continue to impair the CI’s military performance for an extended period of time.  A Neurology Addendum dated 1 January 2006 indicated no definitive etiology for the CI’s pain was elucidated.  She had pain localized to the posterior periscapular region, which was not responsive to all non-operative/therapeutic interventions; and, there were no surgical interventions that would benefit the CI.  A psychiatric evaluation dated 9 January 2006 indicated no active psychiatric diagnosis was found.  A PEB Addendum dated 12 January 2006 noted the CI continued to complain of significant activity limiting severe right shoulder pain that was worse with any movement.  She was unable to hold heavy objects with her right arm and she noted that her right shoulder had visibly dropped significantly since her prior evaluation.  The author opined that after an extensive neurologic workup, there were no clear or obvious neurological conditions that contributed to the muscle pain.

The nonmedical assessment dated 28 September 2005 noted the CI was not performing the duties of her primary MOS and could not deploy, but could perform duties provided there was no physical labor.  At the MEB examination dated 19 October 2005 the CI noted she had back pain, while the MEB examiner noted her “holding right shoulder rolled forward” with tenderness to palpation of the right trapezius global[ly] with “giveway” [give way] and 4/5 power shoulder strength on upper extremity flexion and extension.  A 3 mm scar was present on the right trapezius without a dimple or atrophy at the skin biopsy site. 

At the VA Compensation and Pension (C&P) examination dated 19 January 2010,  performed 44 months after separation, which has limited or no probative value, the CI, a right hand dominant individual, reported weakness, lack of endurance, tenderness and pain associated with flare-ups and a severity of the pain of 8/10 (10 being the worst pain).  On examination there was tenderness, guarding of movement, and asymmetry without subluxation or ankylosis.  The ROM measurements were flexion 165 degrees (Normal 180 degrees), abduction 147 degrees (Normal 180 degrees), external rotation 49 degrees (Normal 90 degrees) and internal rotation 62 degrees (Normal 90 degrees).  With repetition abduction was limited by 6 degrees; external rotation was limited by 4 degrees; and internal rotation was limited by 1 degree.  X-ray findings were within normal limits.  

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 ~44 Mos. Post-Sep
	
Flexion (180 Normal)	Significantly limited by patient discomfort	165	
Abduction (180)		147	
Comments	2-inch shoulder drop of the right side compared to the left with mild scapular prominence.	External rotation 49 degrees and 45 degrees on repetition; internal rotation 62 degrees and 61 degrees on repetition; limitation by pain	
§4.71a Rating	PEB 10%	10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The Navy PEB assigned a 10% rating using code 5299-5003 (degenerative arthritis) for a history of idiopathic severe right posterior shoulder pain associated with overlying cutaneous change and subcutaneous fat atrophy.  The VA assigned a 10% rating using code 5203 (Clavicle or scapula impairment) for a sprain with an idiopathic asymmetric right shoulder.  The Board sought a route for a higher rating and considered analogous code 8719 (Neuralgia of the long thoracic nerve), which addresses the CI’s inability to raise her arm prior to separation as well as having had a possible winged scapula deformity.  A 30% rating (right dominant) would be consistent with a complete inability to raise her arm above the shoulder level, while a severe condition would rate 20% and a moderate would rate 10%.  The Board is aware that electrodiagnostic studies were limited and the neurology consultants did not initially consider the lowering of the right shoulder compared to the left, but a suprascapular neuropathy could not be excluded thereby raising a possible rating of a 50% (severe), 40% (moderate), or 20% (mild) rating using code 8710 (Upper radicular group (fifth and sixth cervicals) depending on the degree of severity.  The Board then discussed the view that no obvious neurologic condition was found making the use of the aforementioned nerve codes less likely, but does not preclude use completely since electrodiagnostic testing was limited and did not address suprascapular neuropathy or the etiology of the trapezius pain.  Alternatively, using code 5301 (Group I. Function: upward rotation of the scapula; elevation of arm above shoulder level) includes the trapezius that had been consistently tender to palpation and seems to most notably capture the CI’s disability findings, with a moderately severe (30%) or severe (40%) level.  The Board then discussed the cardinal signs and symptoms of muscle disability IAW VASRD §4.56 (Evaluation of muscle disabilities), which are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement.  While codes are related to penetrating trauma, the Board agreed this was not the case for the CI, but she did both subjectively and objectively have findings consistent with the cardinal signs and symptoms including, but not limited to, a lowered right shoulder, winging of the scapula, and inability to swing her arm when walking as well as objective findings of weakness and “giveway” of the shoulder causing her to experience an inability to keep up with work requirements.

The VA’s examination was remote and offers little to no probative value since it was approximately 32 months beyond the PDBR forward look at VA examinations up to 12 months post-separation, but did show significant limitations of internal and external rotation, although flexion and abduction ROMs were reasonably satisfactory.  Using code 5299-5203 (Clavicle or scapula impairment) analogous to dislocation does capture the right shoulder being lower than the left and a 20% rating is not unreasonable as well.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) and VASRD §4.7 (higher of two ratings), the Board recommends a disability rating of 30% for the right shoulder 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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the right shoulder condition, the Board unanimously recommends a disability rating of 30%, coded 5399-5301 IAW VASRD §4.55, §4.56, and §4.73. 
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 re-characterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:  

CONDITION	VASRD CODE	RATING	
Right Shoulder 	5399-5301	30%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131221, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
	         DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 2 Dec 15 ICO XXXXXXXXXXXXXXXXXXXX
      (c) PDBR ltr dtd 23 Nov 15 ICO XXXXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 19 Nov 15 ICO XXXXXXXXXXXXXXXXXXXX.
	(e) PDBR ltr dtd 19 Nov 15 ICO XXXXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 30 Nov 15 ICO XXXXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 20 Nov 15 ICO XXXXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 20 Nov 15 ICO XXXXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 18 Nov 15 ICO XXXXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (i) are approved.

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability retired pay with a 40 percent disability rating (increased from 10 percent) with placement on the Permanent Disability Retired List effective date of discharge.

     b. XXXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability retired pay with a 30 percent disability rating (increased from 10 percent) with placement on the Permanent Disability Retired List effective date of discharge.

     c. XXXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability retired pay with a 40 percent disability rating (increased from 20 percent) with placement on the Permanent Disability Retired List effective date of discharge.

     d. XXXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability retired pay with a 40 percent disability rating (increased from 20 percent) with placement on the Permanent Disability Retired List effective date of discharge.

     e. XXXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     f. XXXXXXXXXXXXXXXXXXXX, former USN: Placement on the Temporary Disability Retired List for six months beginning the date of separation with a 50 percent disability followed by placement on the Permanent Disability 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

Retired List at the conclusion of six months with a final rating of 30 percent and entitlement to disability retired pay.

     g. XXXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability retired pay with a 30 percent disability rating (increased from 10 percent) with placement on the Permanent Disability Retired List effective date of discharge.

     h. XXXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability retired pay with a 40 percent disability rating (increased from 10 percent) with placement on the Permanent Disability Retired List effective date of discharge.
     
3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.

	XXXXXXXXXXXXXXXXXXXX
	Assistant General Counsel
	(Manpower & Reserve Affairs)