RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00408
BRANCH OF SERVICE:  MARINE CORPS 	SEPARATION DATE:  20060831

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve E6, Logistics Vehicle System Operator, medically separated for “chronic right shoulder pain,” with a disability rating of 10%.  

CI CONTENTION:  The applicant’s right shoulder and right wrist conditions continue to worsen and negatively impact her daily activities.  Her complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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:  

SERVICE PEB - 20060515	VARD - 20061116	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Shoulder Pain	5099-5003	10%	Status Post Arthroscopy Surgery (2x), Right Shoulder	5201-5024	10%	20060502	
Status Post Triangular Fibrocartilage Complex Repair and Ulnar Shortening…	Not Unfitting	Status Post Arthroscopic Triangular Fibrocartilage Complex Surgery and Extensor Carpi Ulnaris Tendon, Right Wrist	5214-5024	10%		
Gen Ligamentous Laxity						
Status Post Rotator Cuff Repair and Chronic Right Wrist Pain…						
COMBINED RATING:  10%	COMBIEND RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY: 

Right Shoulder Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right shoulder symptoms began approximately 3 years prior to referral for MEB.  The CI underwent a right arthroscopic acromioplasty (partial excision of acromion to decompress part of the rotator cuff) and rotator cuff repair for an impingement syndrome and rotator cuff tear.  At an orthopedic surgery follow-up, 1 year post-operatively, the CI continued to have symptoms.  The CI underwent a right subacromial decompression, rotator cuff debridement, and acromioclavicular (AC) joint excision for subacromial impingement, rotator cuff tearing, and AC joint pain.  Neurology performed an electromyography (EMG) which was normal.  It showed no evidence of right upper extremity carpal tunnel syndrome ([CTS] compression of the median nerve in the wrist carpal tunnel causing numbness and tingling of the palm side of the thumb and fingers [sparing little finger]), ulnar neuropathy (injury or irritation of a peripheral nerve), brachial plexopathy (a neuropathy of a complex network of nerves), or cervical radiculopathy (irritation or injury of a nerve root).  An orthopedic surgery right shoulder exam, 10 months post-operatively, documented no evidence of instability.  There was slight residual weakness in both abduction and external rotation and the range of motion (ROM) was slightly restricted in full overhead flexion and abduction.  A permanent limitation of not lifting over 15lbs., and no repetitive lifting, was imposed.  The examiner opined that given these limitations, the CI was suitable for return to full military service.  The NARSUM, 5 months before separation, recounted the history and interventions.  Following the second surgery, the CI complained of persistent 2/10 right shoulder pain exacerbated by activities.  The right shoulder examination revealed well healed surgical scars with no tenderness, swelling, or erythema.  The AC joint was nontender and the crossarm (assesses AC joint) test was negative.  The Neer (assesses for subacromial impingement) and Hawkins (assesses for subacromial impingement) tests caused pain and the O’Brien (assesses glenoid labrum and AC joint) test caused mild pain.  Active ROM was flexion of 180 (180 normal) and abduction of 180 (180) degrees with pain at the extremes of motion.  Except for 4+/5 strength with resisted arm abduction, strength, sensation, and pulses were normal.  Right shoulder X-rays showed postoperative changes to both the distal clavicle and AC joint and mild glenohumeral joint degenerative changes.  The assessment listed chronic right shoulder pain status post rotator cuff repair with subacromial decompression and distal clavicle excision.  The Compensation and Pension (C&P) examination recounted the history and interventions.  The CI complained of continued right shoulder pain with overhead reaching, lifting, activity (pull-ups or push-ups), and sleeping on it.  The right shoulder examination revealed six small arthroscopy scars, intact muscles, and no tenderness.  There was mild crepitus (grating sound or sensation) with motion and no evidence of impingement.  Active ROM was flexion of 170 (180) and abduction of 170 (180) degrees with pain and weakness from 90-170 degrees.  There was moderate lack of endurance and restriction, but no lack of coordination, with repetitive use.  The diagnosis listed right shoulder injury status post two arthroscopic procedures with subacromial decompression, rotator cuff repair, and partial excision of the AC joint.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5003 code (degenerative arthritis), citing chronic right shoulder pain.  The listed Category II conditions (generalized ligamentous laxity and status post rotator cuff repair with subacromial decompression and distal clavicle excision along with chronic right wrist pain) were considered to contribute to the unfitting right shoulder condition.  The VA assigned a 10% rating under the 5201-5024 codes (limitation of arm motion-tenosynovitis) based on the VA C&P examination 4 months before separation.  The VA cited rotator cuff tear, status post arthroscopy surgery (2x), subacromial decompression, rotator cuff debridement, physical therapy (PT), anti-inflammatory medication, general appearance within normal limits, no edema, no effusion, no instability, no weakness, no tenderness, no redness, no heat, no muscle wasting, ROM, mild pain and crepitus on motion, ROM additionally limited by pain, fatigue, weakness, and lack of endurance after repetitive use, and not additionally limited by incoordination.  Based upon the proximate (orthopedic surgery, NARSUM, 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 no evidence of scapulohumeral ankylosis to support a rating under 5200, and no evidence of nonunion, malunion, or dislocation of the humerus, clavicle or scapula to support a rating under 5202 or 5203.  The Board agreed there was sufficient evidence of painful motion (§4.59) and functional loss (§4.40) to support a 10% rating.  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.

Contended PEB Condition.  

Right Wrist Condition.  According to the STR and NARSUM, the right wrist symptoms began approximately 2 ½ years prior to referral for MEB.  A right wrist MRI showed findings suspicious for a tear along the ulnar (medial) aspect of the triangular fibrocartilage complex ([TFCC] major ligamentous stabilizer that suspends carpals against ulna and radius).  An orthopedic surgery encounter documented the CI failed conservative management and continued to have right wrist discomfort, pain, catching, snapping, and popping.  Because of persistent symptoms, generalized ligamentous laxity, and MRI findings suggestive of a TFCC tear, the surgeon recommended arthroscopy.  The EMG showed no evidence of right upper extremity CTS, ulnar neuropathy, brachial plexopathy, or cervical radiculopathy.  The CI underwent wrist an arthroscopic TFCC repair, an extensor carpi ulnaris stabilization, and an ulnar shortening osteotomy (surgical bone cutting or excision to shorten, lengthen, or realign).  Serial right wrist X-rays showed secure surgical hardware, good overall carpal alignment, and a healing ulnar shortening (minus about 2-3mm) osteotomy with bridging bone.  The NARSUM recounted the history and interventions.  Despite recovering well from the wrist surgery, and adequate rehabilitation, the CI had persistent 2/10 right wrist pain with strenuous activities.  The right wrist examination revealed well healed surgical scars, no swelling, no tenderness, and a nontender dorsal suture knot.  There was slightly decreased flexion and extension when compared to the left wrist.  The TFCC was nontender, appeared stable, and there was no pain with TFCC grind.  There was no ligamentous laxity over the scapholunate (SL) and lunotriquetral (LT) joints.  Strength, sensation, and pulses, and were normal.  Right wrist X-rays showed postoperative changes with intact surgical hardware, normal bony alignment, and a healed ulnar osteotomy.  The assessment listed chronic right wrist pain status post TFCC repair and ulnar shortening osteotomy with extensor carpi ulnaris stabilization.  The C&P examination recounted the history and interventions.  The CI reported her right wrist was better and there was less popping.  She complained of sharp pain with any significant use and had difficulty with her normal occupation of landscape construction.  The right wrist examination revealed a well healed 5-inch scar over the distal, lateral ulna.  There was mild tenderness on the volar aspect of the distal ulna with no wrist numbness or swelling.  Active ROM was dorsiflexion of 60 (70) and palmar flexion of 60 (80), ulnar deviation of 0 (45), and radial deviation of 30 (20) degrees with no pain and mild weakness with radial deviation.  Forearm pronation was 90 (80) and supination was 60 (85) degrees.  There was moderate lack of endurance and restriction, but no lack of coordination, with repetitive use.  The diagnosis listed status post right wrist injury with torn ligaments which were repaired. 

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5003 code (degenerative arthritis), citing chronic right shoulder pain.  The listed Category II condition (status post triangular fibrocartilage complex repair and ulnar shortening osteotomy with extensor carpi ulnaris stabilization and status post rotator cuff repair with subacromial decompression and distal clavicle excision along with chronic right wrist pain) was considered to contribute to the unfitting right shoulder condition.  The VA assigned a 10% rating under the 5214-5024 codes (ankylosis of wrist-tenosynovitis) based on the VA C&P examination citing TFCC tear, status post arthroscopic TFCC and extensor carpi ulnaris tendon surgery, PT, anti-inflammatory medication, general appearance within normal limits, no deformity, no edema, no effusion, no weakness, no tenderness, no redness, no heat, ROM, mild pain on motion,  ROM additionally limited by weakness, and lack of endurance after repetitive use, and not additionally limited by pain, fatigue, or incoordination.  While the CI underwent an ulnar shortening osteotomy, X-rays showed a healed postoperative ulnar osteotomy.  There was no ulna flail false joint for consideration under 5210 or significant loss of bone substance, marked deformity, nonunion, or malunion for consideration under 5211.  There was no impairment of supination or pronation for consideration under 5213.  Physical exams, and radiographic imaging, did not demonstrate the characteristic anatomical deformities of wrist ankylosis, unfavorable palmar flexion, ulnar deviation, or radial deviation for consideration under 5214.  The limitation of motion in the proximate exams did not attain a minimum rating under 5215.  The Board agreed a 10% rating was supported with application of VASRD §4.40 (functional loss) or §4.59 (painful motion).  After due deliberation, the Board agreed that the preponderance of the evidence with regard to the functional impairment of right wrist condition favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 5099-5003 and meets the VASRD §4.71a criteria for a 10% rating.

BOARD FINDINGS:  In the matter of the right shoulder condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended right wrist condition, the Board unanimously agrees that it was unfitting and 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.  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:

CONDITION	VASRD CODE	RATING	
Chronic Right Shoulder Pain 	5099-5003	10%	
Chronic Right Wrist Pain 	5099-5003	10%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140109, 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 28 Mar 16 ICO XXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 30 Mar 16 ICO XXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 28 Mar 16 ICO XXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 28 Mar 16 ICO XXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 31 Mar 16 ICO XXXXXXXXXXXXXXX

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

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

     a. XXXXXXXXXXXXXXX, former USN: Assignment to the Temporary Disability Retired List for six months effective date of discharge with a 50 percent disability rating followed by transfer to the Permanent Disability Retired List with a final disability rating of 30 percent.

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

     c. XXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent disability rating effective date of discharge.

     d. XXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     e. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) 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.