RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03580		
BRANCH OF SERVICE:  Army	Separation Date:  20091009

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Cannon Crewmember, medically separated for “chronic right shoulder pain status post SLAP [superior labral anterior to posterior tear repair],” with a disability rating of 10%. 

CI CONTENTION:   The CI requests the Board consider all 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 - 20090804	VARD - 20090918	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder (Dominant)	5099-5003	10%	Post-Operative Supraspinatus Tendon Tear with Residual Paresthesia, Right Shoulder s/p Repair	5201	10%	20090918	
			Scar, Right Shoulder	5201-7805	0%	20090918	
Bilateral Hearing Loss	Not Unfitting	Left Ear Hearing Loss	6100	0%	20090917	
		Right Ear Hearing Loss	6100	NSC	20090917	
Migraine Headaches	Not Unfitting	Migraine Headache Syndrome	8100	30%	20090918	
OSA	Not Unfitting	OSA	6847	50%	20090918	
ITTP in Remission	Not Unfitting	ITTP	7705	0%	20090918	
Adjustment Disorder	Not Unfitting	Anxiety Disorder	9400	0%	20091003	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Right Shoulder Condition.  The CI initially injured his right shoulder in March 2007.  He had a shoulder separation followed by a dislocation.  Between March 2007 and August 2008, the CI had eight shoulder dislocations.  Despite extensive physical therapy (PT) and activity modification, the shoulder symptoms persisted.  The CI underwent an arthroscopic SLAP repair in August 2008.  The CI did well with his post-operative healing until he reinjured his shoulder in November 2008.  His shoulder remained stable; however, the pain increased pain and severely limited his activity tolerance.  He was treated with PT, narcotic pain medications, periodic immobilization, TENS, ice, and physical profiling.  There was improvement in the range of motion (ROM); however, the pain, limited ability to perform overhead movements and difficulty lifting persisted.  He reinjured his right shoulder in March and June 2009.  An MRI with arthrogram done 15 April 2009 showed a surface tear in the supraspinatus tendon without muscle retraction or atrophy.  A right shoulder X-ray series done on the same day showed no misalignment or significant degenerative, inflammatory or traumatic changes.  The Medical Evaluation Board (MEB) narrative summary (NARSUM) examination, approximately 3 months prior to separation, documented reports of constant, aching anterior right shoulder pain with intermittent sharp twinges.  He had pain flares with lifting and overhead motion.  The baseline pain was rated at 4/10 and with flares rated at 8/10.  The MEB NARSUM physical examination findings are summarized in the chart below.  

The VA Compensation and Pension (C&P) examination, 22 days prior to separation, documented that the CI had intermittent sharp pain rated at 8/10 with normal daily activity.  He had difficulty with working overhead and could not do any push-ups, throwing, or lifting greater than 10 to 20 pounds.  There were two goniometric ROM evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.  

Right Shoulder ROM
(Degrees)	MEB ~3 Mo. Pre-Sep	VA C&P 22 Days  Pre-Sep	
Flexion (180 Normal)	160,161,165	170	
Abduction (180)	140,145,140	180	
Comments
Right Hand Dominant	Painful motion; Tenderness to palpation (TTP) anterior port scar; strength, sensation, reflexes nml	TTP; reflexes nml	
§4.71a Rating	10%	                          10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the right shoulder condition as 5099-5003 (analogous to arthritis, degenerative [hypertrophic or osteoarthritis]), rated 10%.  The VA coded the post-operative supraspinatus tendon tear with residual paresthesia, right shoulder s/p repair condition as 5201 (arm, limitation of motion of), rated 10%.  The 11 January 2010 VARD noted that the rating was based on functional limitation of the shoulder due to pain.  The Board considered whether the evidence supported a rating higher than 10%.  Service and VA treatment records evidenced shoulder pain with all activities.  All examinations met the 10% criteria rating with application of VASRD of §4.59 painful motion.  There was no evidence of arm limitation of motion at shoulder level or occasional incapacitating exacerbations for a higher rating.  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 pain condition.  

Contended PEB Conditions.  The contended conditions adjudicated as not unfitting by the PEB were bilateral sensoneural hearing loss, migraine headache syndrome, obstructive sleep apnea (OSA), idiopathic thrombocytopenia purpura (ITTP) in remission and adjustment disorder.  The Board’s first charge with respect to these conditions is an assessment of the appropriateness of the PEB’s fitness determinations.    

Bilateral Sensoneural Hearing Loss.  The Military entrance evaluation in 1998 indicated a mild hearing loss.  The CI was diagnosed with a bilateral hearing loss in 2000.  An audiology examination in November 2001 demonstrated mild to moderate asymmetric hearing loss.  An air conduction hearing threshold test in June 2006 demonstrated that hearing tests were within normal limits.  On the Filtered Speech Test (SPRINT) the CI scored a 62% (38% of all Soldiers with H-2 profiles in the Army will score higher).  The MEB Audiology examination approximately 5 months prior to separation documented normal hearing in the right ear and moderate to severe hearing loss in the left.  The CI was wearing bilateral hearing aids.  He was put on an H2 profile with additional restrictions of no exposure to noise in excess of 85dBa or weapon firing without the use of properly fitted hearing protection.  The Audiologist performed the CNC test which demonstrated right ear excellent word recognition and fair to poor word recognition in the left.  The VA C&P Audiology examination noted that the CI had right ear normal hearing with a mild sensorineural hearing loss at 1500 to 2000Hz and left ear moderate to severe sensorineural hearing loss above 1000Hz.  He reported tinnitus which began in 2000.  The CNC word recognition testing demonstrated a right ear score of 98% at 60dB HL and left ear score of 94% at 75dB HL and 96% Db HL.  The otoscope examination revealed clear ear canals and intact tympanic membranes bilaterally.  Tympanometry was normal bilaterally.  The audiology hearing thresholds and speech discrimination results are summarized in the chart below.  

HEARING	EXAM	MEB  ~5 Mo. Pre Sep	VA C&P 22 days Pre-Sep	
LEFT EAR	Average Hearing Loss	
No data	 51 dB	
	Speech Discrimination		94%	
	Table VI / VIa		 / I	
	Comments	Mod to severe at 1.5-4 kHz sloping upward to mild at 6kHZ; poor word recognition	
Normal hearing loss	
RIGHT EAR	Average Hearing  Loss	
No data
	18.75 dB	
	Speech Discrimination 		94%	
	Table VI / VIa		 III increased to IV /  I	
	Comments	normal	Normal hearing loss	
§4.85 RATING	Table VII	PEB Not Unfitting	0% right/ 0% left	
(Average hearing loss is the sum of pure tone thresholds at 1000, 2000, 3000, and 4000 Hz divided by four)

The Board considered whether the preponderance of evidence supported that the bilateral hearing loss condition was unfitting.  The Board noted that the condition was profiled H2 and the commander’s statement documented that if the CI were to continue in his present occupational specialty, it would further damage his hearing.  The Board also noted that the PEB and an impartial review determined that the hearing loss condition met retention standards.  There was no performance based evidence from the record that the bilateral hearing loss condition 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 bilateral hearing loss. Therefore, an additional disability rating is not recommended.

Migraine Headache Syndrome.  Treatment records evidence that the CI initially presented with a 3 day history of headache in December 1999.  He was diagnosed with a tension headache and treated conservatively.  The records were silent for headache until a hospitalization for ITTP in January 2006 documented that CI had a severe headache that was treated with morphine and Phenergan intravenously. A review of the medication profile revealed a prescription for migraine headache medication in September 2006.  At an evaluation for OSA in November 2008 the CI reported dull, tension type headaches that occurred intermittently on waking in the morning.  The VA C&P examination 22 days prior to separation documented that the CI reported that the headaches started in 2006 and involved the entire head. He was sensitive to noise (phonophobia), light (photophobia) and had associated nausea and vomiting.  He was treated with a migraine specific medication.  He reported that his headache could last for 1 day, that he usually had headaches five times per month and that he missed 2-3 days of work per month due to the headaches. The VA coded the migraine headaches as 8100, rated 30% (with characteristic prostrating attacks occurring on an average once a month over last several months).  The migraine headache condition was reviewed and considered by the Board.  The migraine condition was not permanently profiled or implicated in the commander’s statement and was not judged to fail retention standards.  There was no performance based evidence from the record that the migraine headache condition 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 migraine headache contended condition and so no additional disability rating is recommended.

OSA.  The CI had a long history of snoring, excessive daytime sleepiness, waking up choking or gasping for air, witnessed apnea, waking to the sound of his own snoring, extreme fatigue, morning headaches, weight gain, poor judgment, poor concentration and restless sleep.  In 2008, he was hospitalized for pharyngitis and the nursing staff witnessed sleep apnea.  He reported that he took daytime naps, excessive sleepiness in all sedentary situations, prone to falling asleep at stoplights and on waiting for entry to the gate on Post.  The CI’s score on the Epworth Sleepiness Scale was 22/24 points which indicated severe daytime sleepiness.  A Split Night Polysonogram done 11 November 2008 demonstrated severe sleep apnea syndrome which was eliminated with CPAP.  The examiner recommended a CPAP machine for use at night.  The VA C&P examination 22 days prior to separation documented that the CI was being treated with a CPAP machine which helped.  The VA coded the OSA condition as 6847 (Sleep Apnea), rated 50%.  The OSA condition was reviewed and considered by the Board.  The CI was profiled P2 and the OSA was considered to be medically acceptable.  The commander’s statement did not implicate OSA as a condition interfering with the CI’s ability to perform his duties.  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 OSA condition, so no additional disability rating is recommended.

ITTP.  The CI was hospitalized in  January 2006  with symptoms of cervical lymphadenopathy, red spots on and beneath his tongue (petechiae) left lower quadrant abdominal tenderness, petechiae on both arms, lower abdomen and both legs and a mass in the left groin.  The labs showed thrombocytopenia (low platelet count).  He underwent two platelet transfusions with poor response.  He underwent a biopsy and a CT of the head, abdomen and pelvis. The abdominal CT scan showed an enlarged spleen and enlarged inguinal lymph nodes.  He was diagnosed with ITTP and started on medications.  The thrombocytopenia got progressively worse and he underwent removal of his spleen in March 2006. THE NARSUM stated the ITTP was in remission and the condition was not profiled.  The VA C&P examination 22 days prior to separation documented that the CI was in remission and required no current treatment.  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 ITTP condition and, therefore, no additional disability rating can be recommended.

Adjustment Disorder.  Adjustment disorder is a condition not constituting a physical disability.

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 bilateral sensorineural hearing loss, migraine headache, ITTP, and adjustment disorder conditions, the Board unanimously recommends no change from the PEB determinations of 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 20140728 w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXX, AR20160008662 (PD01403580)

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