RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00951
BRANCH OF SERVICE: Army 	                        SEPARATION DATE:  20081123 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6, Infantryman, medically separated for a “left shoulder pain” and “cognitive disorder, NOS, due to TBI,” rated 10% and 10%, respectively, with a combined disability rating of 20%.  

CI CONTENTION:  The applicant made no specific contention. The CI’s 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 - 20081024	VARD - 20081204	
Condition	Code	Rating	Condition	Code	Rating	Exam	

Chronic Left Shoulder Pain
	5099-5003	10%	Left Shoulder S/P Labral Tear Surgical Repair	5201	10%	20080912	
			Left Shoulder Nerve Impingement Associated w/ Left Shoulder S/P Labral Tear Surgical Repair	8615	10%	20080912	
TBI	8045	10%	TBI	8045	70%	20080910	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:  

CHRONIC LEFT SHOULDER PAIN.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left shoulder pain condition began in June 2007 after a land mine explosion in Iraq.  He reported an immediate complaint of back pain, headache and bilateral shoulder pain worse on the left than the right.  He was medically evacuated for further treatment.  A repair of a part of the left shoulder was performed in December 2007 with good reduction of pain but no improvement in range of motion (ROM.)  Imaging May 2008 showed the left shoulder and acromioclavicular joints to be normally aligned.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated May 2008, 6 months prior to separation, an examination of the left shoulder showed no tenderness to palpation, decreased internal rotation, no wasting and no impingement signs and negative Neer sign (indicates impingement.)  Strength was decreased as compared to the right. 

The NARSUM examination of the left shoulder showed ROM taken with a goniometer of flexion 145,150, 150 degrees (normal 180) with painful limitations, and abduction 120,120,120 degrees (normal 180) limited by pain.  He reported intermittent sharp pain with decreased ROM.  Flare-ups of pain occurred monthly and last 3 hours.  Medications and rest decreased the pain.  He was unable to handle firearms or weapons. In the VA Compensation and Pension (C&P) examination performed 2 months before separation, the CI reported pain level of 9/10 (the worst.)  Physical activity resulted in pain, which was relieved by rest, pain medication and ice.  He could function with medication.  Examination showed flexion of 150 degrees and abduction of 125 degrees.  Pain had the major functional impact.  Fatigue, weakness, lack of endurance and incoordination were not additionally limiting.  X-rays of the left shoulder were negative.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating for chronic left shoulder pain under the 5099-5003 code (degenerative arthritis) due to good stability, some weakness due to pain and abduction functionally limited by pain to 120 degrees.  The VA assigned a 10% rating for left shoulder, status post labral repair using the 5201 code (arm, limitation of motion of) based on the VA C&P examination 2 months before separation, based on objective proof of painful motion in all planes of motion.  The VA also assigned a 10% rating for left shoulder nerve impingement using the 8615 code (neuritis.)  Consideration was also given to other VASRD shoulder codes, but absent objective ankyloses or fibrous union of the humeral head, no alternatives supported a higher rating than the PEB’s 10%.  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 chronic left shoulder pain condition.  

TBI.  According to STR and the MEB the May 2008 Cognitive Disorder and PTSD Addendum noted the CI’s TBI condition began in June 2007 after the explosion in Iraq that injured his shoulder.  He reported he did not recall losing consciousness (LOC).  Over the months he noted diminished mental capacity.  He reported difficulty with concentration, memory retention, and forgetting things.  Imaging studies were unremarkable.  He was able to perform his assigned duties without difficulty.  He had a stable marriage, secure family and validating professional relationships.  Mental status examination (MSE) was unremarkable.  

At the updated neuropsychological evaluation, the CI reported ringing in his ears, hearing loss, severe headaches, memory loss and the loss of the ability to perform math calculations in his head.  Testing showed gross discrepancy between his superior intellectual quotient (IQ) and his language, attention, and memory functioning.  Diagnoses of cognitive disorder NOS and PTSD were rendered.  The examiner opined that he had mild to moderate symptoms of TBI.  There was decreased job performance due to diminished language, memory and attention functioning.  His mental status examination was unremarkable.  In terms of work, the examiner opined he should avoid jobs that required “new learning” and he required more time to complete tasks in general.  He was able to multi-task, make executive decisions and use a device to assist his memory. The commander noted he had done an excellent job as the Training Room Non-Commissioned Officer (NCO.)  

At the VA C&P Clinical examination performed 1 month before separation, the CI reported being dazed and confused after the blast with a LOC lasting 1-20 minutes.  He reported headaches averaging 4 times per week, lasting 24 hours, bilateral, constant and debilitating.  The headaches allowed him to perform some household chores but not go to work.  He had problems with memory, attention, concentration, reading, hearing and anxiety.  He had difficulty with falling and staying asleep for a year.  He had no problems with fatigue, slowed thought, vision, taste or smell, sensitivity to light, or sound.  He had not received any treatment.  MSE showed normal attention, memory, recall and orientation.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating for TBI under the 8045 code (residuals of traumatic brain injury) based on the level of impairment of the memory facet of 1, noting that his functional status places his rating nearer level of impairment 1 than 2.  The VA assigned a 70% rating for TBI, using the same 8045 code based on the QTC clinical examination 1 month before separation, for which indicated the highest severity of “3” was assigned for the facet involving memory, attention, concentration, executive function.  

The PEB rated cognitive disorder, according to the updated TBI rating rules that became effective 20081023, 1 month prior to separation.  The Board reviewed the table entitled “Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified” containing Facets of TBI related to cognitive impairment and subjective symptoms.  It provides criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, label “total.” The criterion for rating TBI residuals is: “Assign a 100-percent evaluation if “total” is the level of evaluation for one or more facets.  If no facet is evaluated as “total,” assign the overall percentage evaluation based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent.”  The NARSUM examination noted he was able to multi-task and make executive decisions and the C&P examination noted he showed normal the MSE showed normal attention, memory, recall and concentration.  The commander noted he had done an excellent job as Training Room Officer. The Board members agreed that the impairments most closely approximated the “1” or 10% level under the TBI rating criteria.  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 TBI condition.  

BOARD FINDINGS:  

In the matter of the left shoulder pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the TBI condition and IAW VASRD §4.124, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  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 20140221, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 
XXXXXXXXXXXXXXXXXXXXX AR20160010963 (PD201400951)

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