RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX	CASE: PD-2014-03073 
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20030508

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Infantryman) medically separated for “chronic right shoulder pain,” rated at 0%.  

CI CONTENTION:  The CI requested that the Board review all conditions.  The 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 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 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:  

IPEB – Dated 20030219	VA* - ~7 Months Post-Separation	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Shoulder Pain	5099-5003	0%	S/P Lateral Osteotomy, of Clavicle 	5003-5201	20%	20031124	
Back Pain	Not Unfitting	No VA Placement	
HX Plantar Fasciitis	Not Unfitting		
Other MEB/PEB x 0 (Not In Scope)	Other x 0 	
RATING:  0%	COMBINED RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20031219 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Chronic Right Shoulder Pain.  The service treatment record (STR) had limited primary source material, but a note indicated that on 7 January 2002 the CI injured his right shoulder by carrying a combat load rucksack during a tactical road march, and X-rays revealed a distal clavicle resection and arthritic changes with no change from 2001.  On 31 July 2002, the CI developed pain and numbness in the right shoulder when he rolled on it getting out of bed.  Treatment of the pain consisted of intramuscular Toradol (ketorolac, a nonsteroidal anti-inflammatory drug).  A physical therapy consultation dated 4 September 2002 indicated the CI sustained a clavicle (collar bone) fracture in 1997 secondary to a jump.  In the absence of healing he had a resection of a portion of the clavicle one year later and was discharged in 1999.  However, he re-enlisted in 2001 with a waiver.  Physical examination revealed a well healed incision to the lateral distal clavicle with a positive deformity noting bony exostoses (projections) to the distal end of the clavicle.  Active ranges-of-motion (ROMs) of flexion and abduction were 170 degrees bilaterally; external rotation 90 degrees; internal rotation and inferior Apley (scratch test to T7 normal) on the right to T9 compared to T5 on the left.  Adduction was 50 degrees and extension 70 degrees bilaterally.  Muscle strength was 5/5 and sensation was decreased around the incision.  With an apprehension test there was a loud snap noted on external rotation at the anterior capsule of the shoulder, which caused the CI a lot of his pain and there was increased pain with horizontal abduction.  A home treatment plan to address the tight anterior capsule and pectoralis muscles was agreed upon, but the treatment would not change bony structure, which was opined by the physical therapist to be the underlying problem with ruck marching and in extreme use.

A permanent U3 profile was issued on 10 January 2002 for chronic right shoulder pain with limitations of no push-ups, no pull-ups, no overhead lifting, no wearing a backpack, no lifting greater than 40 pounds, and no marching more than 2 miles.  At the MEB examination, the CI reported on DD Form 2807-1 dated 3 September 2002 that his collar bone had pain since surgery, his right shoulder sometimes became numb and swelled when he slept on it, and lifting with the right arm caused a lot of pain.  The MEB physical examiner noted on DD Form 2808 dated 5 November 2002 tenderness to palpation over the surgical scar of the right acromioclavicular (AC) joint region.

The MEB narrative summary (NARSUM) dated 17 September 2002 noted the CI initially complained of right shoulder pain secondary to a fall in basic training in October 1996 and subsequently underwent a distal clavicle resection and a Weaver-Dunn reconstruction with a Bosworth screw (for treatment of a severely  separated shoulder) in June 1998.  Postoperative weakness resulted in his discharge.  After returning to active duty, he had sick call visits for persistent shoulder pain secondary to heavy lifting and ruck marching.  The examiner incorporated the ROM measurements performed by the physical therapist 13 days earlier.  Because of continued right shoulder pain made worse with overhead lifting or pulling, the CI was unable to perform his MOS as an infantryman.  The commander’s statement dated 12 November 2002 indicated the CI was unable to perform normal physical activities for his MOS and there has been a marked decline in his physical performance since the injury.

At the VA Compensation and Pension (C&P) examination dated 24 November 2003, performed 7 months after separation, the CI reported he suffered from chronic right shoulder pain since 1998 status post AC separation and surgery.  Examination revealed the shoulder joint's general appearance was abnormal on the right side with findings of a surgical scar over AC area, 8cm by 1cm, hyperpigmented, but otherwise unremarkable.  ROM measurements revealed right flexion was 120 degrees with pain at 90 degrees; abduction was 120 degrees with pain at 90 degrees; external rotation was 90 degrees with pain at 80 degrees; and internal rotation was 90 degrees with pain at 90 degrees.  The ROMs were additionally limited by pain, but the ROMs were not additionally limited by fatigue, weakness, lack of endurance and incoordination.  The CI was not receiving any treatment for the condition and functional impairment was limited to lifting and sleeping on his side.  Although he was working as a ward clerk, time lost from work was uncertain.

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.

Right Shoulder ROM
(Degrees)	MEB ~8 Mo. Pre-Sep
	VA C&P ~7 Mo. Post-Sep
	
Flexion (180 Normal)	170	120	
Abduction (180)	170	120	
Comments	Pain increased on horizontal abduction	ROMs limited by pain	
§4.71a Rating	 PEB 0%	VA 20%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating using code 5099-5003 (degenerative arthritis) for chronic right shoulder pain (moderate-intermittent).  The VA assigned a 20% rating using code 5003-5201 (arm limitation of motion) for chronic right shoulder pain S/P AC separation and S/P lateral osteotomy of clavicle.  The Board sought a route for a higher rating and first considered a rating of 10% using code 5099-5003 based upon a noncompensable ROM at the MEB examination, and painful motion of abduction, while use of the analogous code 5299-5203 (clavicle impairment) offers a 10% rating as well in the absence of loose movement.  The Board then considered a higher rating based on the VA examination findings post-separation, but within 12 months of separation, although the ROM of 120 degrees is greater than the shoulder level (90 degrees) needed for a 20% rating.  However, the examiner also reported painful motion.  VASRD §4.3 (Benefit of doubt) would suggest favor a 20% rating for the CI; however, the record was silent on the disparity and decrement of ROMs between the MEB examination 8 months prior to separation and the VA examination 7 months post-separation.  The Board members discussed the probative value of each examination and noted the CI was working as a ward clerk post-separation.  There was insufficient evidence to support a rating higher than 20% with the reported ROMs or to warrant the use of a separate nerve code even with the CI’s report of occasional numbness.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the chronic right shoulder pain condition.  

Contended PEB Conditions-Hx Plantar Fasciitis and Back Pain.  The Board’s main charge is to assess the fairness of the PEB’s determination that the history of plantar fasciitis and back pain were 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 history of plantar fasciitis and back pain were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  Other than the CI’s noting at the MEB examination that his “combat boots beginning to give me discomfort and corns,” there was no explicit mention in the STR about either of the conditions.  The aforementioned was reviewed and considered by the Board.   There was no performance based evidence from the record that either 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 either the history of plantar fasciitis or back pain conditions; therefore, no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the chronic right shoulder pain condition, the Board unanimously recommends a disability rating of 20% coded 5003-5021 IAW VASRD §4.71a.  In the matter of the contended Hx plantar fasciitis and back 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.  

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	
Chronic Right Shoulder Pain	5003-5021	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140627, with attachments
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 XXXXXXXXXXXXXXXXXXXX, AR20160005017 (PD201403073)

1. I have reviewed the enclosed Department of Defense Physical Disability Board of
Review (000 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
( ) OVA