RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02829
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20080926

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Recruit, medically separated for “chronic right shoulder pain due to impingement and tendonitis” with a disability rating of 10%.  

CI CONTENTION:  The CI asked the Board to review all of his conditions.  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 - 20080915	VARD - 20090414	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Shoulder Pain Due to Impingement and Tendonitis 	5099-5003	10%	Right Shoulder Sprain, Subacromial Mild Bursitis Impingement without Tear	5019-5201	20%	20081203	
Phase of Life/ Life Circumstance Problems	Cat III	Adjustment Mental Disorder with Anxiety and Depression Associated with… (Shoulder) 	9440	30%	20081203	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Right Shoulder Pain due to Impingement and Tendonitis Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right hand dominant CI injured his right shoulder on 9 February 2008 doing push-ups 4 days after starting his Basic Military Training.  On 22 February 2008, he was placed in the Medical Hold Squadron with plans of completing his rehabilitation and returning to his training.  He was evaluated by orthopedics, and diagnosed with right shoulder impingement with tendonitis of the rotator cuff.  Diagnostic imaging (Magnetic Resonance Imaging (MRI)) showed mild degeneration of the acromioclavicular joint with no evidence of rotator cuff or labral tear.  He was given an injection and ongoing pain led to a failed arthrogram (diagnostic imaging procedure) on 24 June 2008.  

Despite treatment, the right shoulder condition could not be adequately rehabilitated to meet the physical requirements of the CI’s resumption of training and the CI was referred for MEB.  The MEB forwarded “chronic right shoulder pain due to impingement and tendonitis” for PEB adjudication.  

The range of motion (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.  

Right Shoulder ROM
(Degrees)	NARSUM ~2 Mo. Pre-Sep	PT post-MEB ~ 1Mo. Pre-Sep	PT Post-MEB <1 Mo. Pre-Sep	VA ~2 Mo. 
Post-Sep	
Flexion (180 Normal)	165	“wnls”	155/155/154	170	
Abduction (180)	120/120/120		165/168/170	170	
Comments	Pain limited ROM; +impingement signs; tender	Pain; + impingement signs; weakness 4/5; tender	Painful	Pain onset 110 degrees; +DeLuca (see text)	
§4.71a Rating	10%	10%-20%	10%	10%-20%	

At the time of the orthopedics clinic appointment on 2 July 2008, 3 months prior to separation, the CI reported continued right shoulder pain, particularly to the anterior aspect of his shoulder going down to his right arm.  He told the examiner that his physical therapy had been discontinued a month prior due to the fact that he had had no improvement.  The CI had an MRI done that morning to rule out labral pathology.  The examiner noted palpable tenderness along the infra-scapular and suprascapular fossa as well as over the sub-acromial area.  He had painful and limited ROM as charted above.  Neer and Hawkins testing were both positive (tests for impingement).  He had no evidence of instability or ligamentous laxity and strength testing was 5/5 with pain noted, with no breakaway.  There were no motor or sensory deficits noted.  The examiner diagnosed him with “right shoulder impingement with tendonitis noted to the rotator cuff.”  The examiner recommended that the CI reengage in physical therapy but the CI said he was not interested in remaining in the military and preferred to begin the MEB process with hopes of possibly re-entering the military in the future.  There was no MEB history and physical conducted.  The PT examinations in August and September 2008, 1 month prior to separation, documented impingement signs with discomfort on abduction at 80 degrees with ROM reported as normal on the first evaluation and as charted above of the second evaluation.  

At the VA Compensation and Pension (C&P) examination on 3 December 2008, performed 2 months after separation, the CI reported a painful right (dominant) shoulder at 7/10 with activity, lasting only for the period of activity.  He reported that rest alleviated his pain.  There were no complaints of dislocation or instability and no crepitus on motion was recorded.  The CI noted he “avoids using the right hand for everything except writing, lifting more than 5 lbs.”  Physical examination showed some limitation of motion (see ROM chart above).  There was painful motion as well as pain on repeated use.  There was no local tenderness or signs of inflammation.  The MRI done on 2 July 2008 showed mild degenerative joint disease for the acromioclavicular (AC) joint.  The diagnosis was sub-acromial bursitis.  The examiner also noted that there was additional functional loss of the joint stating [DeLuca] “he cannot move it in any direction.”  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5099-5003 code (degenerative arthritis), citing painful motion (flexion 165 degrees and no instability or laxity).  The VA assigned a 20% rating using the 5019-5201 codes (bursitis and arm, limitation of motion) citing limitation of motion at shoulder level for pain from 110 to 170 degrees.  

The VASRD §4.71a (code 5201, arm limitation of motion) threshold for a rating for ROM impairment is “at shoulder level” (approximately 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 the 5202 code (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).  

The Board deliberated if a 20% rating was warranted given the positive impingement signs at the PT exam with “discomfort on movement at shoulder level;” and/or the VA examination indicating painful motion above 110 degrees with repetition and flares additionally limiting the shoulder to “no motion.”  The VASRD ROMs are for active ROM which were all well above shoulder level, while the VA examiner’s indication of additional limitation was not indicated by the examination but based on history which had a lower probative value than the multiple service examinations in evidence.  

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 “phase of life/life circumstance problems” was Category III (conditions that are not separately unfitting and not compensable or ratable).  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 condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  The “phase of life/life circumstance problems” condition was reviewed and considered by the Board.  There was no performance-based evidence from the record that any mental health 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 the “phase of life/life circumstance problems” condition and so no additional disability rating is 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 “phase of life/life circumstances” condition, the Board unanimously recommends no change from the PEB determination as not unfitting/Category III.  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 20140611, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-02829.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings