RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	 CASE:  PD-2014-02116	
BRANCH OF SERVICE:  Army	 BOARD DATE:  20150714
SEPARATION DATE:  20081127		 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Cavalry Scout) medically separated for a left shoulder condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “left shoulder adhesive capsulitis” and “chronic pain syndrome” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded eight other conditions (see rating chart below) for PEB adjudication.  The Informal PEB adjudicated “left shoulder pain described as adhesive capsulitis” as unfitting, rated 10%, with likely application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined by the PEB to be not unfitting.  The CI made no appeals and was medically separated.  

CI CONTENTION:  “Please consider all conditions.” 

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 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 IPEB – Dated 20081006	VA - (8 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left (Non-Dominant) Shoulder Pain/Chronic Pain Syndrome	5099-5003	10%	Residuals of Adhesive Capsulitis, Left Shoulder	5024	10%	20090716	
Bilateral Patellofemoral Syndrome	Not Unfitting	Patellofemoral Syndrome w/ DJD, Left Knee	5024	0%	20090716	
		Patellofemoral Syndrome w/ DJD, Right Knee	5024	0%	20090716	
Herniated Cervical Disc	Not Unfitting	DDD, Cervical Spine	5243	10%	20090716	
Lumbar Spondylitis	Not Unfitting	Degenerative Joint Disease, Lumbar Spine	5242	0%	20090716	
Post Concussive Syndrome	Not Unfitting	Post-Concussion Headaches	8045-8100	10%	20090716	
TMJ Arthralgia	Not Unfitting	 No VA Entry	
Hypertension	Not Unfitting	Sustained Hypertension	7101	NSC	20090716	
Hyperlipidemia	Not Unfitting	No VA Entry	
Anxiety and Depression	Not Unfitting	TBI Manifested By Depression, Panic Disorder, And Agoraphobia	8045-9413	50%	20090728	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 0 	20090716	
RATING:  10%	RATING:  60%	
Derived from VA Rating Decision (VARD) dated 20100204 (most proximate to date of separation [DOS]).   

ANALYSIS SUMMARY:   

Left Shoulder Pain Condition.  The NARSUM noted this right hand dominant CI injured his left shoulder in October 2006 while on a night training mission.  The CI reported his injury occurred when he stepped in a hole and fell on outstretched arm (FOOSH injury).  He experienced immediate pain, however, did not seek treatment until a month later.  A physical therapy (PT) intake evaluation, dated 21 November 2006, documented the CI’s report of left shoulder pain that was sharp and had an intensity of 4/10, increasing to 7/10 with radiation to the 4th and 5th digits.  The CI noted that despite the pain he was able to continue with training.  Physical examination recorded full active range-of-motion (ROM) without pain, and pain along the course of the bicep tendon and absence of pain over the acromioclavicular joint (ACL).  Radiographs of the left shoulder (November 2006) demonstrated no evidence of arthritis, inflammation or traumatic changes; and normal shoulder.  Magnetic resonance imaging (MRI) of the left shoulder in January 2007 documented no significant abnormalities (normal signal in the rotator cuff, bursa and labra intact, and joint ligaments were intact).  The CI participated in PT and took medication.  His response to treatment was limited.  Orthopedic examination in February 2007 documented full ROM in the left shoulder, and normal strength; however, noted “slight laxity” in both shoulders, left more than right, opined to be secondary to trauma.  He also demonstrated hyper-extension in bilateral elbows.  The physician further noted that the CI had “Marfanoid-like” appearance which may make him prone to laxity. The diagnosis of left subluxation shoulder joint with multidirectional instability was assessed and an aggressive course of strengthening therapy was recommended with the notation that surgery may be imminent.  The CI underwent an uncomplicated left shoulder inferior capsular shift surgery in April 2007 to stabilize the shoulder.  Post-surgery, the CI continued to report some pain in the shoulder and numbness in digits four and five, but was otherwise doing well.  However, In August 2007, he attended a scheduled follow-up visit at the orthopedic clinic with a different physician (his doctor had been deployed since previous visit) who stated that the CI had developed “frozen shoulder.”  The examiner diagnosed adhesive capsulitis of the left shoulder.  The CI returned to aggressive PT and underwent multiple cervical sympathetic blocks with steroid medication (collection of nerve cells in the neck that blocks the sympathetic response to pain located in the face and arm) with limited improvement.  In September 2007 he was transferred to the Warrior Transition Unit (WTU).  In October 2007, electromyogram and nerve conduction studies to evaluate the report of numbness and tingling in the left fingers documented no evidence of cervical radiculopathy, brachial plexopathy, or ulnar neuropathy (normal studies).  He was then given a permanent profile.  

The NARSUM, dated 14 August 2008, documented focused examination of the shoulders that demonstrated normal right shoulder, tenderness to palpation of the left shoulder, no instability, and no evidence of limitation in motion after repetition.  The left shoulder ROM measurements were recorded by PT on 2 April 2008 (7 months prior to separation); flexion was 127 degrees (180) and abduction to 130 degrees (180).  The commander’s statement noted that the CI was not working in his assigned MOS and had been assigned to the WTU.  The commander listed the diagnoses contained in the CI’s profile and the associated physical limitations of the profile, and noted agreement with the physician’s recommendation that the CI not be retained.  

The VA C&P examination conducted approximately 8 months after separation recorded the CI was working in construction and had lost 2 weeks of work over a 12-month period due to neck pain.  The examiner documented normal appearing left shoulder with a normal appearing surgical scar.  ROM forward flexion was documented at 180 degrees (NL), and abduction to 160 (180), with pain at the endpoint of ROM.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 10%, coded analogously 5099-5003 (degenerative arthritis) for limitation of motion.  Likewise, the VA assigned a rating of 10% for limitation of motion, using the 5024 code (tenosynovitis-defaults to 5003).  A 20% rating under the 5003 or the 5024 code requires radiographic evidence of involvement of two or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations; this was not supported by the evidence.  The Board noted the absence of evidence for a compensable rating based on ROM under the 5200 and 5201 codes.  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 left shoulder condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the conditions of bilateral patellofemoral syndrome, herniated cervical disc, lumbar spondylosis, post-concussive syndrome, TMJ arthralgia, hypertension, hyperlipidemia, and anxiety and depression recorded were not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The Board carefully considered the service treatment record including the NARSUM.  Although the NARSUM examiner opined that the conditions of bilateral patellofemoral syndrome, herniated cervical disc, lumbar spondylosis failed retention standards, the record demonstrated absence of specific treatment related to these conditions with the exception of a home exercise recommendation from PT for the knees.  The Board acknowledged that the sympathetic nerve block may have benefitted the neck pain; however, the record clearly demonstrated this procedure was done to address the shoulder pain.  The NARSUM examiner opined that the pain associated with the above conditions “could significantly limit functional ability during flare-ups.”  Board members agreed, although the conditions of bilateral patellofemoral syndrome, herniated cervical disc, and lumbar spondylosis were profiled, the conditions were not judged to fail retention standards.  All ROM measurements documented for the knees, back and neck were normal.  The remaining conditions were not profiled and were not judged to fail retention standards.  Board members concluded there was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  After due deliberation 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:  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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  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 contended bilateral patellofemoral syndrome, herniated cervical disc, lumbar spondylosis, post-concussive syndrome, TMJ arthralgia, hypertension, hyperlipidemia, and anxiety and depression conditions, 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. 

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 20140429, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXX
President	
DoD Physical Disability Board of Review

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 XXXXXXXXXXXXXXX, AR20150013735 (PD201402116)

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:

Encl						     XXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA