RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03283
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20090729

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Radar Repairer, medically separated for “right (dominant) shoulder periarticular pathology” and “lumbosacral strain described as lumbago,” rated at 10% and 10%, respectively, with a combined disability rating of 20%.  

CI CONTENTION:     The applicant contends that there were conditions not adjudicated in their application.  The applicant’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 based upon a 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 - 20090518	VARD - 20090828	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder Pathology ... Rotator Cuff Tear	5099-5003	10%	Tendon Tear, Right Shoulder	5299-5203	10%	20080909	
Lumbosacral Strain 	5237	10%	Sprain, Thoracolumbar Spine	5239-5237	10%		
Duane's Syndrome, Left Eye	EPTS and Not Unfitting 	Strabismus Of The Left Eye With Amblyopia/Esotropia	6099-6092	NSC		
Strabismic Amblyopia, Left Eye						
Right Elbow Pain ... Ulnar Nerve Transposition	Not Unfitting	Surgical Residuals, Ulnar ... Neuropathy, Right Elbow	8516	0%		
		Scar, Right Elbow	7805	0%		
Glaucoma, Both Eyes		Glaucoma, Both Eyes	6013	10%		
Adjustment Disorder with Mixed Anxiety and Depressed Mood	Ineligible IAW DoDI 1338.32	Major Depression 	9413	30%		
Chronic Neck Pain	Not Unfitting	Spondylosis, Cervical Spine 	5299-5239	10%		
Obstructive Sleep Apnea		No VA Claim or Rating		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Right Shoulder Injury.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI suffered an atraumatic onset of right (dominant) shoulder pain during basic training in 2007.  The pain persisted with conservative treatment and magnetic resonance imaging (MRI) demonstrated a rotator cuff tear (full thickness, supraspinatus); but, after consultation with orthopedics, surgery was deferred and the condition was added to the MEB in process for other conditions.  The MEB forwarded “right shoulder pain status post rotator cuff tear” to the PEB.  The STR clinical entries documented non-specifically decreased range of motion (ROM) and mild impingement, with no indication of ratable (as defined below) ROM limitation; and, the outpatient STR evidence was consistent with the NARSUM findings presented below.  

At the VA Compensation and Pension (C&P) examination on 9 September 2008, performed 10 months before separation, the CI complained of constant pain rated 7/10 rendering him “unable to perform overhead duties or lift anything heavy.”  The physical examination did not record specific joint findings, but provided ROM measurements of forward flexion to 125 degrees (normal 180, 90 for minimum 20%) and abduction to 85 degrees (same parameters), specifying painful motion.

At the NARSUM examination on 20 April 2009 (3 months prior to separation) the CI complained of constant pain averaging 6/10 limiting “overhead work or any type of lifting.”  The physical examination recorded the absence of tenderness or instability, some “mildly positive” impingement signs, and 5/5 arm strength with a normal grip.  Measured ROM was forward flexion to 145 degrees and abduction to 135 degrees, specifying painful motion.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the analogous code 5099-5003 (arthritis degenerative) which was compliant with VASRD §4.71a criteria for the ROM and ratable findings.  The VA assigned a 10% rating under the analogous code 5299-5203 (clavicle or scapula, impairment of); and, referenced the C&P forward flexion measurement, but not the abduction of 85 degrees (a 20% criterion).  The Board considered whether a 20% rating could be recommended based on this finding, but members agreed that the probative value was insufficient given the conflicting STR and NARSUM evidence (the latter significantly closer to separation).  There was no ankylosis, fracture (nonunion/malunion) or instability that would support a higher rating under any other joint code.  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 of the right shoulder condition.

Lumbosacral Strain.  The CI experienced an onset of low back pain after sit-ups in September 2008.  The pain persisted with intermittent complaints of right lower extremity (RLE) subjective weakness with foot numbness (non-dermatomal).  There were multiple STR entries documenting normal neurological findings (5/5 strength, intact sensation, symmetric reflexes) with no evidence the contrary.  An MRI demonstrated a “tiny” disc protrusion (L4/5, no neural impingement).  Multiple entries documented grossly normal ROM, with only one examiner noting non-specifically reduced ROM.  There was STR confirmation of normal gait and spinal contour, with no exceptions, and there was no documentation of incapacitating episodes.  Surgery was not recommended; conservative treatment did not result in improvement sufficient to allow unrestricted duty; and, the CI was referred for MEB which in turn forwarded “lumbago” to the PEB.  

The 10-month pre-separation VA C&P examination documented constant pain rated 6/10 without radicular complaints, rendering the CI “unable to lift heavy objects or bend over for long periods of time.”  The physical examination recorded a normal gait, the absence of tenderness or spasm, and normal neurological findings (motor, sensory, reflexes).  Measured ROM was flexion to 80 degrees (normal 90) and combined ROM of 195 degrees (normal 240), specifying painful motion.

The 3-month pre-separation NARSUM examination documented constant pain rated 5/10 “triggered by lifting,” with intermittent RLE radiation and “tingling of the right foot upon prolonged standing.”  The physical examination recorded a normal gait and spinal contour, the absence of tenderness or spasm, and “no radicular signs” with normal neurological findings (motor, sensory, reflexes).  Measured ROM was flexion to 90 degrees and combined ROM of 230 degrees, specifying painful motion. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 10% rating under code 5237 (lumbosacral strain) cited the criterion of combined ROM, and was compliant with §4.71a criteria for the ROM and ratable findings.  The VA rated 10% analogously under the same code citing the C&P ROM and findings.  There was no ROM evidence supporting a rating higher than 10%, no evidence for abnormal gait or contour to support a 20% rating, and no documentation of incapacitating episodes which would provide for a higher rating under that formula.  The Board considered whether additional rating could be recommended under a nerve code for the RLE radicular symptoms, but members agreed that neither the functional link to fitness requisite for rating nor the presence of a VASRD ratable deficit were supported by the 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 of the lumbar spine condition.    

Contended PEB Conditions: Duane’s syndrome and strabismic amblyopia of the left eye, open-angle glaucoma of both eyes, right elbow pain status-post ulnar nerve transposition, chronic neck pain, and obstructive sleep apnea (OSA). The Board’s main charge is to assess the fairness of the PEB’s fitness and rating eligibility determinations for those conditions.  Adjustment disorder is not a compensable or ratable condition.

Eye Conditions.  Duane’s syndrome and strabismic amblyopia are closely related congenital abnormalities with muscle control of eye tracking.  The CI received a waiver for strabismus upon entry into the military.  Treatment with temporary patching, then corrective lenses, began in basic training.  There were ophthalmology entries in the STR reflecting continuing surveillance and a stable course.  Glaucoma (elevated intraocular pressure [IOP]) was diagnosed in 2007, treated with drops (Xalatan), and was stable with normal IOP measurements throughout the balance of service.  An ophthalmology addendum (30 May 2009, 3 months prior to separation) recorded corrected visual acuity of 20/20 right and 20/25 left, and normal bilateral IOP.  The examiner opined that all of the conditions were stable, with the strabismus conditions failing retention standards and the glaucoma meeting standards.  The CI was issued an E3 profile for Duane’s syndrome early in service, and the strabismic amblyopia or glaucoma conditions were not listed on the permanent profile.  The commander’s performance statement addressed “medical issues” without providing functional evidence specific to individual conditions.  The MEB forwarded the strabismus conditions as existing prior to service (EPTS) without service aggravation.  The PEB’s DA Form 199 decision stated, “These are congenital/developmental conditions and as such have been present for long periods of time and do not interfere with the performance of his duties.”  Members agreed that there was no performance-based evidence that challenged the PEB’s fitness conclusion, with no evidence of any worsening of the strabismus conditions over the period of service; and, further agreed that the evidence supports the MEB conclusion that they were EPTS without service aggravation, thereby not eligible for rating even if conceded as unfitting.   Members also agreed that, based on the evidence, the glaucoma was well controlled without any significant functional impact on performance in support of a conclusion that it was unfitting. 
Right Elbow Condition.  The CI was diagnosed with an entrapment neuropathy of the ulnar nerve at the right elbow in early 2008 and underwent corrective surgery (nerve transposition) on 5 June 2008 (14 months prior to separation).  He suffered persistent pain and intermittent paresthesias with subjective weakness, but all neurologic examinations after surgical recovery documented normal (most specifying 5/5) strength without objective sensory deficits.  The condition was profiled U2 until it was upgraded to U3 on the permanent profile (no explanation in evidence).  The pre-separation C&P examination noted “weakness at the elbow when carrying items” as the only functional limitation, and the NARSUM noted interference with lifting and push-ups.  The NARSUM examiner, however, judged that the condition met retention standards.  The commander’s statement (as above) was non-contributory.  Members agreed that, although the documented functional limitations could arguably impact MOS requirements, there was not a preponderance of performance-based evidence that the right elbow condition would have in itself prohibited further military service.  

Chronic Neck Pain and OSA.  The NARSUM documented chronic neck pain since childhood attributed to head positioning in correction of the strabismus.  The CI was diagnosed with OSA in October 2008, improved with a continuous positive airway pressure device, and was issued a P2 profile.  There is no STR evidence for any significant clinical acuity for either condition and both were judged to meet retention standards by the MEB.  Members agreed that there was no basis in evidence for an argument that either of these conditions was unfitting.

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 (or DoDI 1338.32 eligibility) determinations for any of the above conditions; thus, they are not eligible for Service rating.

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 lumbar strain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended Duane’s syndrome and strabismic amblyopia of the left eye, the Board unanimously recommends no change from the PEB determinations as not unfitting; and concurs with the opinion that they existed prior to service and were not permanently aggravated by service.  In the matter of the contended adjustment disorder with mixed anxiety and depressed mood, the Board unanimously agrees that the diagnosis of record is not eligible for service rating IAW DoDI 1338.32 (Enclosure 5); and, this notwithstanding, agrees that it was not unfitting.  In the matter of the contended glaucoma, right elbow ulnar neuropathy, cervical, and obstructive sleep apnea 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, 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 20140714, 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), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX AR20160014199 (PD201403283)

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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA