RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00063
BRANCH OF SERVICE:  Army  	SEPARATION DATE:  20060815

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6 (Combat Engineer) 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 conditions, characterized as “right shoulder pain status post rotator cuff repair with subacromial decompression,” “adhesive capsulitis and “chronic regional pain syndrome (CRPS) of the right upper extremity” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated chronic right dominant shoulder pain and stiffness (which included adhesive capsulitis and the CRPS) as unfitting rated 10%, with likely application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.  

CI CONTENTION:  “His condition continues to worsen and negatively impact his daily activities.  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 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 20060530	VA* - (~3 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Dominant Shoulder Pain and Stiffness...	5099-5003	10%	Residuals, Right Shoulder Injury, Status-Post Surgery, with Adhesive Capsulitis and Scaring	5299-5201	30%	20061113	
Other x 1 (Not In Scope)	Other x 3 	
RATING:  10%	RATING:  70%	
*Derived from VA Rating Decision (VARD) dated 20061121 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Right Shoulder Condition.  The service treatment record (STR) documents that the right-hand dominant CI sustained a right shoulder injury in 2001.  He fell on the obstacle course onto his extended right upper extremity.  Because of persistent right shoulder pain, the CI sought care and received two corticosteroid (cortisone) injections.  A magnetic resonance imaging (MRI) study showed mild rotator cuff tears as well as arthrosis (joint degenerative disease) of the acromioclavicular joint.  Failing conservative therapy, the CI underwent an open surgical repair of the right rotator cuff with a subacromial decompression in May 2005.  Postoperatively, he did not have resolution of his symptoms, but experienced progressively increasing pain and stiffness.  In July 2005, an MRI showed a severely retracted rotator cuff tear with extensive debris.  On 20 July 2005, the CI underwent a right shoulder arthroscopy and extensive debridement.  The orthopedic surgeon encountered significant capsular adhesions and was unable to sufficiently mobilize the cuff to repair it arthroscopically.  The surgeon referred the CI to a sports medicine specialist/shoulder specialist for a possible large open repair.  On 24 October 2005, the CI underwent manipulation under anesthesia with an arthroscopic lysis of adhesions, capsular release, and revision rotator cuff repair.  At the 3 January 2006 physical therapy (PT) encounter, the CI complained of 2 days of increasing right shoulder pain and “popping.”  He experienced a significant increase in pain, an increased need for narcotic medications, and lost range-of-motion (ROM).  At the 15 February 2006 orthopedic surgery evaluation, the CI complained of significant pain with ROM and a sense of crepitation (grating sensation or sound) in his joint.  The physical exam showed significantly decreased ROM from the last postoperative visit.  The CI had no palpable crepitus, but complained of a grinding inside his shoulder with ROM.  Plain X-rays showed no loose bodies.  A February 2006 MRI showed no evidence of loose bodies in the joint, but did suggest a rupture of the supraspinatus tendon at the repair site.  The CI had some evidence of complex regional pain syndrome ([CRPS] chronic pain syndrome following injury with pain out of proportion to severity of initial injury) and was given a consultation to the pain service regarding this concern.  At the 16 February 2006 interventional pain clinic encounter, the CI complained of three weeks of right shoulder pain, cracking, and grinding.  He reported associated hand erythema (redness), increased skin temperature, and palmar sweating.  The diagnosis listed right shoulder pain with symptoms of CRPS.  The physician started a narcotic (methadone/Methadose), an anticonvulsant (gabapentin/Neurontin), and a tricyclic antidepressant (nortriptyline/Pamelor).  The narrative summary (NARSUM), five months before separation, recounted the history and interventions to date.  The CI complained of right shoulder pain, stiffness, and difficulty with active motion.  He noted significant improvement with the pain clinic medication regimen and had a sympathetic nerve block scheduled to treat the suspected CRPS.  The right shoulder physical exam showed a well-healed incision and no significant trophic changes (eg, hair, nail, skin manifestations) consistent with CRPS.  He had positive drop arm (assesses for rotator cuff [supraspinatus] tears) an external rotation lag (assesses integrity of rotator cuff [supraspinatus and infraspinatus] muscles) signs, and 4/5 supraspinatus and infraspinatus strength.  The right shoulder goniometer measured ROMs are summarized in the chart below.  The 29 March 2006 plain X-rays showed no evidence of a loose body, glenohumeral joint arthritis, or significant high riding of the humeral head.  The CI’s pain, per the AMA pain rating guidelines, was a constant (as it occurs more than 75% of the time) frequency and a severe (significantly limits his activities of daily living) intensity.  The examiner included in the current status, takes multiple, daily narcotic pain medications, cannot actively move his arm above his shoulder, cannot perform overhead tasks, and cannot lift more than 5 pounds with his right arm.  The diagnoses listed right shoulder pain after rotator cuff repair with subacromial decompression, adhesive capsulitis (frozen shoulder), and right upper extremity chronic pain syndrome.  The examiner opined the CI was expected to eventually have resolution of his CPRS complaints.  The adhesive capsulitis was expected to improve gradually over an unpredictable and variable time course.  Without further intervention, he was not expected to have increased active ROM, regain significant strength, or have resolution of his chronic pain.  On 21 April 2006, the interventional pain clinic performed a stellate ganglion block (local anesthetic injected into mass of sympathetic nervous tissue) in and attempt to relieve sympathetically mediated pain/bursitis.  At the 21 June 2006 PT encounter, the CI reported the pain management injection provided some temporary relief.  The relief lasted a couple of days and slowly returned to the baseline pain.  The PT measured right shoulder ROMs are summarized in the chart below.  A 9 September 2006 right shoulder MRI showed postoperative changes, a full thickness tearing of the supraspinatus tendon, and suspected tearing of the infraspinatus tendon.  The general medical compensation and pension (C&P) exam, 3 months after separation, recounted the history and interventions to date.  The CI complained of chronic right shoulder pain and stiffness.  He reported any use of the right arm exacerbated the pain, and consequently he had “stopped using the right arm.”  Because of the adhesive capsulitis, he was “unable to raise the right arm more than about just a few degrees away from the side.”  The CI did not use a brace or a splint and denied inflammatory arthritis.  He denied symptoms of giving way, locking up, or recent episodes of dislocation or subluxation.  He was taking a non-steroidal anti-inflammatory (Motrin) and a narcotic (Vicodin).  He had no adverse effects from the medications but had no significant symptom relief.  The CI was not working, but his condition resulted in no problems with his activities of daily living.  The right shoulder exam revealed a 7cm non-tender scar.  There was a very slight tissue defect (1mm) under the scar in the deltoid muscle.  The right shoulder motor exam showed decreased strength (3/5), in flexion and extension, compared to the left.  Motor and sensory exams of the right hand, forearm, and elbow were normal.  The right shoulder ROMs, with pain, are summarized in the chart below.  There was no change in the shoulder exam with repetitive motion (no increase in fatigue or decrease in motion due to fatigue, etc.).  The diagnoses listed right rotator cuff tear, status post reconstruction x3, and adhesive capsulitis with residuals.

The ROM evaluations which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

DOS 20060530
Right Shoulder ROM
(Degrees)	MEB ~5 Mo. Pre-Sep
(20060329)	PT ~2 Mo. Pre-Sep
(20060621)	VA C&P.~3 Mo Post-Sep
(20061113) 	
Flexion (180 Normal)	60	43	~30	
Abduction (180)	50	37	~30	
Comments	Goniometer Used	AO	Pain	
§4.71a Rating	30%	30%	30%	

The Board directed attention to its rating recommendation based on the above evidence.  The informal PEB, 3 months before separation, rated the right shoulder condition at 10% (VA code 5099-5003; rating by analogy-degenerative arthritis).  The PEB cited a rotator cuff tear, status post arthroscopic repairs, chronic (moderate/frequent) pain, mechanical limitation of ROM, pain with ROM, and no degenerative joint disease by imaging.  The VA rating decision (VARD), citing the C&P exam 3 months after separation, rated the right shoulder condition at 30% (5299-5201; rating by analogy-arm, limitation of motion of).  The VARD cited a rotator cuff tear, multiple surgeries, chronic pain exacerbated by use, decreased strength, limitation of ROM (could only raise right arm to 30 degrees), and pain with ROM.  There was sufficient evidence of painful motion (§4.59) and functional loss (§4.40) to support a 10% rating, but Board members considered if a higher rating was justified.  The limitations of motion documented in the proximate (MEB, PT, and C&P) exams were consistent with the 30% rating (midway between side and shoulder level) under 5201.  There was no evidence of scapulohumeral ankylosis to support a rating under 5200, and no evidence of malunion of the humerus, clavicle or scapula, or of dislocation, to support a rating under 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 30% for the right shoulder condition (5299-5201).

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 right shoulder condition was operant in this case and the condition was adjudicated independently of that policy/ instruction by this Board.  In the matter of the right shoulder condition, the Board unanimously recommends a disability rating of 30%, coded 5299-5201 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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:

CONDITION	VASRD CODE	RATING	
Chronic Right Dominant Shoulder Pain and Stiffness	5299-5201	30%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131212, 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 XXXXXXXXXXXXXXXXXX, AR20160000325 (PD201400063)

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 recharacterize 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