RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00352
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070131

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Special Electronics Devices Repairer) medically separated for a right shoulder condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic right shoulder pain” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “chronic pain right shoulder” as unfitting, rated 20%, citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.  

CI CONTENTION:  The applicant makes no specific contention in his application.  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 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 20061128	VA* - (~5 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain Right Shoulder	5099-5003	20%	Supraspinatus Tendinopathy Right Shoulder	5299-5201	20%	20070627	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 5 	
RATING:  20%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20071017 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:

Right Shoulder Condition.  The service treatment record (STR) documents that the right hand dominant CI fell 7 feet from a truck onto his right shoulder while deployed to Afghanistan.  Diagnostic imaging showed disruption of the acromioclavicular (AC) joint (junction of acromion process of scapula [shoulder blade] and clavicle [collar bone]).  His shoulder separation was characterized as Grade II (complete tearing of the AC ligament) and he was treated conservatively with a shoulder sling, opioid (Vicodin), and physical therapy (PT).  A right shoulder MRI showed a probable AC joint separation, minimal supraspinatus tendinopathy (chronic tendon degeneration without inflammation) and no evidence of a full thickness rotator cuff tear.  The CI underwent right shoulder arthroscopy and a distal clavicle excision (Mumford procedure).  A right shoulder CT showed a comminuted (multiple fragments or splinters) fracture involving the acromion process and the articulating surface of the distal clavicle.  A right shoulder MRI showed postoperative changes and no specific evidence of a rotator cuff tear.  There was a separate anterior acromion fragment representing a prior fracture.  Bony anatomical alignment was otherwise maintained.  The narrative summary (NARSUM) by orthopedic surgery, 3 months before separation, recounted the history and interventions.  The CI complained of chronic right shoulder pain that worsened following surgery.  Pain was exacerbated by activity and repetitive motions and interfered with his sleep.  Pain was incompletely relieved by an opioid-like analgesic (Tramadol) and an antidepressant (Trazodone) was used off-label for insomnia.  The right shoulder exam revealed tenderness, slight subacromial crepitus (grating sound or sensation), and weakness due to pain with resisted abduction.  Active range-of-motion (ROM) was flexion of 160 and abduction of 165 degrees.  Active ROM was accompanied by grimacing.  An X-ray showed a very wide AC distance with some bony fragments in the area.  The surgeon listed the condition as stable, pain as moderate and constant, and prognosis as good with a relatively sedentary lifestyle.  The diagnosis listed chronic right shoulder pain due to iatrogenic (medical disorder resulting from treatment) acromion fracture.  The compensation and pension (C&P) exam, 5 months after separation, recounted the history and interventions.  The CI complained of chronic right shoulder pain that was characterized as tight, pinching, and stabbing.  It was associated with a pins and needles sensation.  Pain was exacerbated by overhead activity (7-8/10) and prolonged driving and relieved with ice and medications (Aleve, and acetaminophen).  He reported snapping and palpable crepitus throughout the arc of ROM and that his ROM was “severely impaired.”  The CI denied flare-ups, subluxation (incomplete or partial dislocation), dislocation, giving out, injury, or fracture.  The right shoulder exam showed normal anatomy, reduced arm swing, and healed arthroscopic scars.  There was no keloid (abnormal/excessive scar tissue) formation, edema (swelling from excess tissue fluid), swelling, or tenderness.  Right shoulder apprehension (assesses anterior shoulder instability), Hawkin's (assesses for subacromial impingement), and cross arm (assesses AC joint) tests were positive.  Active ROM was flexion of 115 and abduction of 110 degrees.  Upon repetitive use, the ROM was additionally limited by pain.  The examiner “could not force the right shoulder to show fatigue, weakness or lack of endurance.”  Right shoulder strength (-4/5), light touch sensation, and reflexes were reduced compared to the left.  The diagnoses listed right shoulder chronic pain, supraspinatus tendinopathy, and impingement syndrome status post Mumford procedure and bursectomy (resection of joint fluid-filled sac).

The Board directed attention to its rating recommendation based on the above evidence.  The informal PEB rated the right shoulder condition at 20% (VA code 5099-5003; disability rating by analogy-degenerative arthritis).  The PEB cited chronic pain due to iatrogenic acromion fracture, status post Mumford procedure, narcotics did not relieve pain, pain interfered with sleep, required Trazodone to sleep, diffuse and marked tenderness, flexion of 160 degrees, and abduction of 165 degrees.  The pain was rated as marked (based on interference with sleep and activities of daily living), constant, and IAW USAPDA pain policy.  The VA rating decision (VARD), citing the C&P exam 5 months after separation, rated the right shoulder condition at 20% (5299-5201; rating by analogy-arm, limitation of motion of).  The VARD cited supraspinatus tendinopathy, impingement syndrome, status post Mumford procedure and bursectomy, insomnia related to right sided pain, limitation of ROM secondary to pain, flexion of 115 degrees, abduction of 110 degrees, and apprehension, Hawkin's, and cross arm tests positive.  The Board agreed there was sufficient evidence of painful motion (§4.59) and functional loss (§4.40) to support a 10% rating.  Based upon the proximate (MEB and C&P) exams, there was no compensable limitation of motion for consideration under 5201 (at shoulder level [90 degrees] is minimum 20% rating).  There was evidence of pathology at the articulating surface of the clavicle and acromion process for considerations under 5203.  While there was MRI evidence of nonunion (acromion fragment representing prior fracture), there was no malunion (bony anatomical alignment maintained), or dislocation for consideration under 5203.  The nonunion was consistent with the 10% rating (without loose movement) as there was no instability consistent with the 20% rating (with loose movement).  There was no evidence of scapulohumeral ankylosis to support a rating under 5200, and no evidence of impairment, malunion, or dislocation of the humerus to support a rating under 5202.  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 adjudication 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.  As discussed above, PEB reliance on the USAPDA pain policy AR 635-40 DoDI 1332.39 for rating the right shoulder was operant in this case and the condition was adjudicated independently of that policy/ instruction/regulation by this Board.  In the matter of the right shoulder condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140107, 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 XXXXXXXXXXXXXXXXXXXXXXXX, AR20160000436 (PD201400352)

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 and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA