RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	      CASE:  PD-2014-01474
BRANCH OF SERVICE:  Army                                                                   SEPARATION DATE:  20061002

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Signal Support Systems Specialist, medically separated for “right shoulder pain…” with a disability rating of 0%. 

CI CONTENTION:  “At the time of separation there were far more injuries than were evaluated.  All injuries were combat related and related to one another.”  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 –20060818	VARD - 20080123	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder Pain	5003	0%	Right Acromioclavicular Joint Sprain with Joint Instability	5203	0%	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Right Shoulder Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right shoulder condition began approximately 14 months prior to referral for MEB.  The CI injured his right shoulder in a motorcycle accident.  Serial diagnostic imaging (X-rays) showed a right acromioclavicular joint (ACJ) dislocation.  A subsequent magnetic resonance imaging (MRI) showed inflammatory changes in the ACJ and underlying muscle.  A physical therapy (PT) right shoulder exam revealed global tenderness with a highly tender ACJ.  The Hawkin’s (assesses impingement of rotator cuff, supraspinatus, and subacromial bursa), O’Brien’s (assesses glenoid labrum and ACJ) and ACJ shear (assesses abnormal ACJ movement) tests were positive.  Range of motion (ROM) was full and pain free.  At an orthopedic surgery evaluation, the right hand dominant CI complained of a year of right shoulder pain following his ACJ separation.  Symptoms did not resolve with use of a sling and ROM and rotator cuff strengthening with PT.  He reported the shoulder felt unstable and weak but denied clicking, catching, and radicular (nerve root irritation or injury) arm pain or numbness.  The right shoulder exam revealed muscle atrophy and shoulder elevation compared to the left.  There was tenderness over the ACJ and anterior deltoid.  There was no swelling, erythema (redness) or warmth.  There was no Codman sign (assesses for of the supraspinatus tendon rupture) and the apprehension test (assesses anterior and posterior shoulder instability) was negative.  Abduction active ROM was normal and flexion was painful in last 10 degrees of arc.  The assessment listed right ACJ sprain with evidence of subacromial bursitis (inflammation of fluid filled sacs between tissues).  The examiner performed a subacromial bursa injection with a corticosteroid (Kenalog) with good effect.  A right shoulder X-ray showed ACJ separation.  

A sports medicine right shoulder exam revealed ACJ tenderness, pain with motion, and no swelling.  The Hawkin’s and Neer’s (assesses impingement of the rotator cuff, primarily the supraspinatus) tests were positive.  Active ROM revealed forward flexion was comparable to the left and abduction was limited by 20-30 degrees as compared to the left.  Strength and sensation were normal.  The assessment listed ACJ separation with failed steroid injection and PT.  The examiner opined that a possible source of shoulder impingement might be spur formation under the acromion noted on MRI.  The orthopedic surgery consultation for the MEB, recounted the initial motorcycle injury.  The CI complained of constant severe right shoulder pain and pain at rest, which awakened him from sleep.  Pain worsened during deployment and was exacerbated by shoulder elevation, cross-body adduction, load bearing, lifting, pushing, pulling, and firing weapons.  The CI experienced short-lived pain relief from an ACJ steroid injection.  He did not enjoy significant improvement with conservative management which included activity modification, PT, and anti-inflammatory medications.  The focused right shoulder exam revealed prominence of the clavicle with a “piano key-type motion” to depression and anterior/posterior instability.  There was tenderness at the ACJ and along the distal clavicle.  There was crepitation (grating sensation or sound) with ROM.  Motion was significantly limited in abduction and forward elevation secondary to pain.  Rotator cuff muscle function, and distal sensory function, were intact.  The examiner recounted the findings of the X-rays and MRI which showed a complete (Grade III) ACJ separation and significant degenerative changes.  The diagnosis listed right Grade III ACJ separation with resultant ACJ arthritis.  

The report of medical exam for the MEB (DD FORM 2808) right shoulder exam revealed a prominent clavicle and ACJ tenderness with no erythema or edema.  There was pain with ROM and significant limitation of motion with abduction of 90 (180 normal) degrees.  Repetitive (X3) active ROM was measured by PT for the MEB.  Right shoulder abduction was 60/64/63 (180) degrees.  In the 22 June 2006 NARSUM, 3 months before separation, the CI complained of ongoing right shoulder pain and instability with several minor recurrent injuries.  He failed conservative management and orthopedic surgery deemed he was not a surgical candidate.  The right shoulder exam revealed a prominent distal clavicle with focal ACJ tenderness.  There was anteroposterior instability of the clavicle and painful crepitus with motion.  The ROM was significantly limited in abduction and forward elevation secondary to pain.  The rotator cuff appeared to be intact on strength testing and there were no distal sensory or neuromuscular deficits.  The examiner cited the ROM measurements by PT for the MEB and the X-ray and MRI findings.  The diagnosis listed right shoulder Grade III ACJ separation with resultant ACJ traumatic osteoarthritis and subacromial bursitis.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under the 5003 code (degenerative arthritis), citing right shoulder pain, initial motorcycle accident, subsequent minor injuries while deployed to Afghanistan, clavicle tenderness, pain limiting ROM, and radiographs consistent with arthritic changes.  The VA documented the CI missed 2 scheduled VA Compensation and Pension (C&P) exams and assigned a 0% rating under code 5203 (clavicle or scapula, impairment of) based on the STR and VA treatment reports.  Based upon the PT, orthopedic surgery, and sports medicine exams, there was no compensable limitation of motion (at shoulder level [90 degrees] is minimum 20% rating) for consideration under code 5201.  The medical exam for the MEB (DD Form 2808) ROM values, and the PT for MEB ROM values, were consistent with the 20% rating under code 5201.  There was clavicle or scapula nonunion with movement to support a 20% rating under code 5203.  There was no scapulohumeral ankylosis for consideration under 5200, and no humerus loss of head, nonunion, fibrous union, malunion, or dislocation for consideration under 5202.  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 recommended a disability rating of 20% for the left shoulder condition.  

BOARD FINDINGS. In the matter of the right shoulder condition, the Board unanimously recommends a disability rating of 20%, coded 5203 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 his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Right Shoulder Pain	5203 	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140323, 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 AR20160008329 (PD201401474)

1. 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,
accept the Board's recommendation to modify the individual's disability rating to 20%
without re-characterization of the individual's separation. This decision is final.

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.

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:

CF:
( ) DoD PDBR
( ) DVA