RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01142
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041101

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Infantryman, medically separated for “right shoulder pain,” with a disability rating of 10%.

CI CONTENTION:  He was given a higher rating for his conditions by the VA.  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 – 20040928	VARD - 20060816	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder Pain	5024	10%	S/P Labral Tear Right Shoulder	5201	20%	20050525	
Myofascial Neck Pain	Not Unfitting	Degenerative Disc Disease, Cervical Spine	5243	20%	20050525	
Low Back Pain	Not Unfitting*	Lumbosacral Strain	5237	20%	20050525	
Migraine Headaches	Not Unfitting	Migraine Headaches	8100	10%	20050525	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Right Shoulder Pain.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right shoulder (dominant) pain began in February 2002 after a motor vehicle accident where he was rear-ended while stopped at a light.  In July 2002, the CI underwent a right shoulder arthroscopy with debridement and capsular shift.  At the Physical Medicine appointment on 30 August 2004, 2 months prior to separation, the examiner noted painful limited motion, normal motor strength, and no obvious atrophy.  Empty can (assesses supraspinatus muscle and tendon of rotator cuff) testing was 4+/5 and sulcus (assesses glenohumeral joint inferior instability) testing was negative.  An electroneuromyographic study study done the same day was considered normal without evidence of a right suprascapular or long thoracic neuropathy (peripheral nerve irritation or injury).  There was no evidence of cervical radiculopathy (nerve root irritation or injury) involving the right upper extremity.  Following surgery, further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “right shoulder, chronic tendonopathy” for PEB adjudication.  

The MEB NARSUM examiner, on 15 September 2004 (a month prior to separation), noted tenderness to pressure around the lateral deltoid muscle, without warmth or swelling.  There was decreased bulk of the right supraspinatus muscle and decreased sensation along the tricep muscle down into the ulnar forearm into the hand, consistent with lower brachial plexus (complex network of nerves) sensory dysfunction.  Motor strength was -5/5.  Right shoulder range of motion (ROM) was flexion 150 (normal 180) degrees and abduction 120 (normal 180) degrees.  

At the VA Compensation and Pension (C&P) examination in May 2005, performed 7 months after separation, the CI reported decreased discomfort of his right shoulder since surgery, but had difficulty with lifting above shoulder level.  Physical exam showed no heat, swelling or redness.  On examination the right shoulder ROM was flexion 150 (normal 180) and abduction 110 (normal 180).  Muscle strength and sensory examinations were normal.  There was no guarding of arm movements and scars were well healed. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under code 5024 (tenosynovitis), citing a 20-30 degree loss of flexion and abduction.  The VA assigned a 20% rating using code 5201 (arm, limitation of motion of) based on the VA C&P examination 7 months after separation, citing limitation of motion at shoulder level with weight in his right hand.  The VASRD §4.71a (code 5201) threshold for a rating for ROM impairment is “at shoulder level” (90 degrees from the side), and the ROM in evidence demonstrated motion above this level.  Although there was insufficient limitation of motion to support a rating under 5201, Board members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion).  There was no malunion or recurrent dislocation of the humerus to justify a rating under code 5202 (humerus, other impairment of); and no nonunion with loose movement of the clavicle to warrant the next higher 20% rating under the 5203 code (clavicle or scapula, impairment of).  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 Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that myofascial neck pain and migraine headaches were not unfitting.  Additionally, the NARSUM listed recurrent low back pain as an additional diagnosis but the condition was not referred to the MEB or adjudicated by the PEB; the Board judged this was likely an erroneous omission and that the low back pain should be assumed to constitute a de facto PEB determination that the condition was not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The myofascial neck pain, migraine headaches, and recurrent low back pain were not profiled and were not judged to fail retention standards.  However, the commander’s statement noted the CI “cannot perform his duties without severe shoulder and neck pain, and headaches, along with some mid and low back pain.  His back and neck began to hurt after extensive time standing, and the shoulder, neck and headaches set in after any strenuous work.”  The commander’s statement referenced “profiled six times,” but the STR contained no profiles (temporary or permanent) for the neck, back or headaches.  

Myofascial Neck Pain.  This condition was noted on the NARSUM to meet retention standards.  Cervical X-rays in May 2005, 7 months after separation, noted mild, early degenerative disc disease of C6-7.  On examination in August 2004, approximately 2 months before separation, tenderness was noted, but without spasm or deformity.  The ROM was recorded as flexion of 55 (45) and a combined of 265 (340) degrees.  The VA C&P examination completed in May 2005 noted full ROM, normal lordotic (anterior spine curvature) curvature with tenderness.  There were no complaints of painful motion, weakness, impaired endurance, incoordination or instability.  The CI was employed.

Migraine Headaches.  This condition was noted on the NARSUM simply stating “he has been treated for migraines.” No medication for migraines was recorded.  One STR note from August 2003 stated “having headaches.” Otherwise the record was silent regarding this condition.  At the VA C&P examination completed in May 2005, 7 months after separation, the CI reported headaches once every two months and he treated the headaches by lying down.  He took no medication for this problem.

Recurrent Low Back Pain.  This condition was noted on the NARSUM to meet retention standards.  Lumbar X-rays completed in May 2005, 7 months after separation, were reported as normal except for mild levoscoliosis (abnormal left lateral spine curvature).  On examination in August 2004, approximately 2 months before separation, there was minimal tenderness and no spasm.  The ROM was recorded as flexion of 75 (normal 90) and a combined of 210 (normal 240) degrees.  The VA C&P examination completed in May 2005 noted a ROM of flexion of 85 (normal 90) and a combined of 235 (normal 240) degrees.  Normal lordotic curvature with mild tenderness was noted.  With repeated anterior flexion, there was no additional loss of ROM, pain on ROM, instability incoordination or fatigability.  

All contended conditions were reviewed and considered by the Board.  The NARSUM examiner and MEB considered all of the above conditions to meet retention standards.  While the commander’s statement identified these conditions as impediments to duty performance, none were permanently profiled.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

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 myofascial neck pain, migraine headache conditions and recurrent low back pain, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 20140218, 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

28 JUL 2016

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXX, AR20160008283 (PD201401142)

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