RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03187
BRANCH OF SERVICE:  Army 	Seperation date:  20070703

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-1 (Motor Transport Operator) medically separated for left shoulder pain, rated at 0%.  

CI CONTENTION:  “Please consider all conditions”  

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 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:  

IPEB – Dated 20070621	VA* - Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left (Non-Dominant) Shoulder Pain	5099-5003	0%	Left Shoulder Acromioclavicular Joint Tear (Non-Dominant)	5201	20%	STR	
Other x 0 (Not In Scope)	Other x 0 	
RATING:  0%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20070905 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY: 

Left Shoulder Condition.  The service treatment record (STR) documents that the on 3 March 2007 the CI sustained a left shoulder injury.  During boot camp martial arts training, he was thrown onto his left shoulder.  The 6 March 2007 emergency department clinical impression listed left shoulder strain, and the CI was treated with a nonsteroidal anti-inflammatory drug (NSAID).  The narrative summary (NARSUM), by orthopedic surgery, reported that the right-hand dominant CI fell onto the point of his left shoulder during combatives.  He had immediate pain in the superior aspect of his left shoulder.  The CI did not experience symptom relief with activity modification, extensive physical therapy (PT), or medications (Tylenol, anti-inflammatories).  The CI was not taking any pain medications and described his pain as constant, moderate without activity, and marked with activity.  Pain was exacerbated by PT, and moving his arm, and relieved by not moving his arm.  The physical exam revealed neck range-of-motion (ROM) was full and without pain.  The left shoulder exam showed no prominences and the skin was intact and without tenting.  There was tenderness directly over the acromioclavicular (AC) joint with no tenderness over the greater tuberosity (prominent top of humerus where rotator cuff muscles attach).  The cross-body adduction test (assesses integrity of AC joint) was positive and the sulcus sign (assesses glenohumeral joint inferior instability) was negative.  The Neer and Hawkins tests (assess for subacromial impingement) were equivocal.  Left shoulder ROM measurements were performed with a goniometer and limited by pain.  Active ROM was 130 degrees of forward flexion, 130 degrees of abduction, 75 degrees of external rotation, and internal rotation to the fifth lumbar vertebra (L5).  Rotator cuff strength (5/5) was normal.  The upper extremities were neurovascularly intact.  The left shoulder X-rays were interpreted as “appear normal grossly.”  The diagnosis listed left Grade I acromioclavicular joint separation.  The examiner opined that the CI’s condition was stable, he had received maximal medical care, no further treatment was warranted, and that prognosis for further recovery as a civilian was good.  The 17 July 2007 primary care encounter documented the CI “… presents as walk-in today to get some pain meds to tide him over until can get in for vesting [accession into VA healthcare] and then f/u on the shoulder.…”  He denied pain relief with NSAIDs (ibuprofen, celebrex).  The diagnosis listed shoulder separation and the examiner refilled the hydrocodone (opioid analgesic), and ordered cervical spine and bilateral shoulder X-rays.  The 17 July 2007 X-rays showed a normal cervical spine and no evidence of fracture, dislocation, arthritic change, or other shoulder abnormality.  The 4 August 2007 primary care left shoulder exam revealed tenderness over the AC joint.  It documented, decreased ROM with abduction to only 90 degrees.  On 18 August 2007 the CI presented to the emergency department complaining of 7/10 left shoulder pain that increased with movement.  He reported chronic left AC joint pain since being thrown onto the point of his left shoulder in martial arts training.  The CI stated the left AC joint "pops and clinks and tinks" with movement and the pain was described as “like a rock between my shoulder and shoulder blade."  He reported the pain affected his physical activity, walking, sleep, and feeling of well-being.  The physical exam documented minimal point tenderness at the left AC joint, without subluxation or asymmetry.  The examiner recorded poor effort on left shoulder ROM and strength testing.  The shoulder X-rays of the bilateral AC joints showed no asymmetry or joint widening with weight-bearing.  The CI was treated with intravenous fluids (1 liter normal saline) and intravenous opioids (1mg. morphine).  The diagnosis listed a left grade I AC joint tear.  The 18 August 2007 shoulder X-ray showed no fractures or dislocations, but the left clavicle articulation was irregular with osteoporotic changes.  The CI failed to report for the scheduled 25 August 2007 compensation and pension (C&P) exam.

The Board directed attention to its rating recommendation based on the above evidence.  The Informal PEB rated the left shoulder condition at 0% (VA code 5099-5003; disability rating by analogy-degenerative arthritis).  The PEB cited non-dominant shoulder pain, minimal/occasional pain, pain-limited ROM, good stability, normal imaging, and rated for pain IAW USAPDA pain policy.  The PEB’s rating of 0% analogously to 5003 (degenerative arthritis) does not comport with the VASRD §4.71a stipulation for a 10% rating under 5003 for “2 or more major joints,” the latter without regard to ROM limitation or other factors.  The VA rating decision (VARD), rated the left shoulder at 20% (5201; arm, limitation of motion of:  minor).  The VARD evidence included STR and VA treatment records.  The VARD cited failure to report for the scheduled C&P exam, chronic non-dominant shoulder pain, limited ROM, and a diagnosis of left AC joint tear.  Based upon the NARSUM exam, there was no compensable limitation of motion for consideration under 5201.  The limitation of motion documented in the primary care encounter, one month after separation, was consistent with the 20% rating (at shoulder level [90 degrees]) under 5201.  There was no evidence of scapulohumeral ankylosis to support a rating under 5200, and no evidence of malunion of the humerus, clavicle or scapula, or of dislocation, to support a rating under 5202 or 5203.  The Board assigned more probative value to the NARSUM exam because it documented comprehensive left shoulder ROM measurements with a goniometer.  The Board assigned less probative value to the primary care encounter because it documented an isolated ROM (abduction) measurement without a goniometer specified.  Board members 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 recommends a disability rating of 10% for the left shoulder condition (5299-5201).

BOARD FINDINGS:  As discussed above, PEB reliance on the USAPDA pain policy AR 635-40 DoDI 1332.39 for rating the left shoulder condition was operant in this case and the condition was adjudicated independently of that policy/instruction by this Board.  In the matter of the left shoulder condition, the Board unanimously recommends a disability rating of 10%, coded 5299-5201 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	
Left Shoulder Pain 	5299-5201	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140703, 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), 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXXXXX AR20160004402 (PD201403187)

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 10%
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