RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2014-02157
BRANCH OF SERVICE:  Army	BOARD DATE:  20140821
SEPARATION DATE:  20031031

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (27T1P/Avenger System Repair) medically separated for left shoulder condition.  This condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The narrative summary (NARSUM) diagnosed left shoulder pain, posterior capsular irritation; chronic neck pain; low back pain (LBP) and left anterior knee pain.  The MEB forwarded left shoulder pain, posterior capsular irritation to the Physical Evaluation Board (PEB) IAW AR 40-501 as medically disqualifying.  The MEB also identified and forwarded chronic neck pain as not disqualifying and made no comment on the back or knee pain.  The Informal PEB (IPEB) adjudicated left shoulder pain as unfitting and rated it 10%, with probable application of the VA Schedule for Rating Disabilities (VASRD).  The IPEB adjudicated the other conditions as 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 those conditions identified, but not determined to be unfitting by the PEB when specifically requested by the CI.  The ratings for the unfitting left shoulder condition and the contended not unfitting neck pain, LBP and left knee pain conditions are addressed below.  Any other condition or contention not requested in this application, remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20031031	VA* - (2.4 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Shoulder Pain	5099-5003	10%	Residual Injury, Left Shoulder	5003	0%	20030820	
Chronic Neck Pain	Not Unfitting	Degenerative Changes, C Spine	5003	0%	20030820	
Low Back Pain	Not Unfitting	Lower Back Pain	5299	NSC	20030820	
Left Knee Pain	Not Unfitting	Osteoarthritis, Left Knee	5003	10%	20030820	
Other x 0 (Not in Scope)	Other x 1	20030820	
Combined:  10%	Combined:  10%	
*Derived from VA Rating Decision (VARD) dated 20031223 (most proximate to date of separation (DOS))

ANALYSIS SUMMARY: IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on ratable severity at the time of separation.

Left Shoulder Pain.  The service treatment record indicated the CI injured herself after an airborne training operation jump on 30 August 2001.  Her left shoulder gave out subsequently while she was doing push-ups for physical training.  She complained thereafter of chronic left shoulder pain for 2 years localized diffusely to the left shoulder region and to the posterior aspect of her cervical spine, with radiation of the pain intermittently into the left arm.  Shoulder radiographs were normal and a magnetic resonance imaging of the shoulder performed on February 2002 with an arthrogram (to study the joint) showed a possible partial tear of the posterior capsule and possible partial left biceps tendon tear.  She underwent left shoulder arthroscopy under anesthesia on 8 April 2002, which showed posterior instability and a positive sulcus sign (glenohumeral joint-ball and socket instability) but no anterior instability.  No tears were present.  There was no relief from nonsteroidal anti-inflammatory medication, narcotic, steroid injections, physical therapy, pain management or chiropractic treatment, although a muscle relaxer medication (Zanaflex) helped.  Electrodiagnostic studies, which were performed for intermittent numbness of the left arm, were normal.  The commander’s statement dated 25 February 2003 indicated she could not road march, perform airborne operations or participate in daily platoon physical training.  At the MEB medical examination dated 21 February 2003, approximately 8 months prior to separation, the CI reported a very extensive, detailed history of her shoulder injury including the work-up, arthroscopy and multiple treatments.  The CI reported her pain at 6-7/10.  Left shoulder examination revealed generalized tenderness to palpation greatest over the superior rotator cuff area, a positive apprehension test (to check for a possible labrum (cartilage) or anterior instability problem), a full active range-of-motion (ROM), 5/5 strength and an intact distal neurovascular evaluation.  The diagnosis of left shoulder pain-posterior capsular irritation was made.  At the MEB NARSUM examination dated 30 May 2003, approximately 5 months prior to separation, the CI reported constant chronic pain and could not lift significant objects with her left arm or push items although her job required her to lift 50-90 pounds.  The etiology of the shoulder pain was unclear, although she did have tenderness of the left sub-acromial bursa (a fluid filled sac of the shoulder) as well as the biceps tendon.  ROMs for the shoulder are listed in the table below.  The examination was essentially unchanged from the MEB examination in February.  Several temporary physical profiles were issued that included both U3 and L3 categorizations.  A permanent U3 profile was issued for left shoulder pain 30 April 2003 with restrictions of no airborne operations and no running in formation as well as no lifting more than 10 pounds, no ruck marching, no load bearing equipment, no flak vest and no helmet.  At the VA Compensation and Pension (C&P) exam dated 20 August 2003, approximately 2 months prior to separation, the CI reported six parachute jumps.  She felt “that although she [could] do everything, she [was] in constant pain and [had] to watch what [she] did because the more [she exercised] it, the more pain [she had].”  The condition did not interfere with her ordinary lifting or carry or in carrying out her activities of daily living or service functions.  Examination revealed the left shoulder was normal in outline and symmetric in form and function with the right.  There was no muscle atrophy, heat, redness or swelling and no effusion was detected.  Sensation and strength in the upper extremities were within normal limits.  A complete X-ray shoulder series was negative.  The ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Left Shoulder ROM
(Degrees)	NARSUM 
8.4 Mo. Pre-Sep 	PHYSICAL THERAPY
6 Mo. Pre-Sep 	NARSUM 
5.9 Mo. Pre-Sep 	VA C&P 
2.4 Mo. Post-Sep 	
Flexion (180 Normal)	175	175	160	180	
Abduction (180)	175	175	160	180	
Comments			Motor strength 5/5 at the supraspinatus and subscapularis muscles	No restriction or pain on repetition or flare-ups	
§4.71a Rating	0%	0%	0% (PEB 10%)	0% (VA 0%)	
IAW §4.59 (Painful motion)
The Board directs attention to its rating recommendation based on the above evidence.  The IPEB assigned a rating of 10% using the analogous code 5099-5003 for left shoulder pain (IAW AR 635-40) with an arthroscopic diagnosis of posterior capsular irritation and noted the pain was moderate and frequent and the abduction ROM was 175 degrees (N=180).  The VA rated the shoulder pain at 0% disability based on a full ROM without pain and assigned a non-compensable evaluation.  Since the CI’s ROMs on both flexion and abduction were greater than the arm limitation to the shoulder level, a 20% rating using code 5201 (Arm limitation of motion) is not applicable and code 5201 does not have a 10% rating option.  The Board was unable to find a route to a higher rating than the 10% rating adjudicated by the PEB.  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 pain condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that chronic neck pain, LBP and left anterior knee pain 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.

Chronic Neck Pain.  The CI noted associated neck tightness with her left shoulder pain after arthroscopy.  Examination noted the cervical spine was in line with no stepoff or deviation and there was mild tenderness to palpation of the C6-C7 area specifically over the paraspinous muscles.  X-rays demonstrated mild degenerative changes of the c-spine and some straining of the normal lordotic curvature.  The CI was involved in a motor vehicle accident on 11 October 2002, which irritated her neck; she improved with chiropractic treatment.  An X-ray series of the neck performed during the VA C&P process did not demonstrate arthritic changes.  The ROM measurements of the cervical spine were within normal limits without restriction or pain.

Low Back Pain.  The CI noted pain in the lower back in February 2003, which she thought was related to her kidneys, but indicated they “were checked out” and “there was nothing wrong.”  Chiropractic treatment was of benefit.  The NARSUM examination noted tenderness to palpation over the lumbar spine over the muscles, while the VA C&P examination revealed normal curvature of the lumbosacral spine and no paraspinal muscle spasm.  The ROM was within normal limits and occurred without restriction or pain and X-rays were normal.

Left Anterior Knee Pain.  The CI reported knee strain during jump school, but usually carried on despite the pain when it flared up.  The MEB examination noted tenderness to palpation over the patellofemoral tendon (connecting the knee cap and the thigh bone) with a positive retropatellar (behind the knee cap) grind, but negative McMurray’s (test of cartilage defects) and negative laxity.  The ROM was full without pain.  An X-ray performed as part of the VA C&P examination demonstrated minimal osteoarthropathy (arthritis) of the left knee.

The chronic neck pain, low back pain and left anterior knee pain were not specifically profiled or implicated in the commander’s statement.  They were not judged to fail retention standards on the MEB other than the neck pain, but all three were explicitly noted to be “not disqualifying” on the MEB’s DD Form 2808 as well as on the NARSUM dated 30 May 2003.  All of the aforementioned conditions were reviewed by the action officer and considered by the Board.  There was no performance based evidence from the record that any of the 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 the 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 chronic neck pain, low back pain and left anterior knee pain 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 20140514, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			
XXXXXXXXXXXXXXXXX
President
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 XXXXXXXXXXXXXXXXX, AR20150006380 (PD201402157)

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						     XXXXXXXXXXXXXXXXX