RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03922
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20081119

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E6, Utility Airplane Repairer, medically separated for left shoulder pain and right shoulder pain, with a combined disability rating of 20%.

CI CONTENTION:  The CI requests consideration of 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 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 - 20080627	VARD - 20090429	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Shoulder Pain…	5099-5003	10%	Residuals, Status Post Labral Debridement, Left Shoulder with Degenerative Changes	5201	20%	20090126	
Chronic Right Shoulder Pain	5099-5003	10%	Residuals, Status Post Arthroscopic Surgery, Right
Shoulder with Degenerative Changes	5201	20%	20090126	
Multiple Environmental Allergies	Not Unfitting	Allergic Rhinitis	6522	0%	20090126	
Bilateral Lateral Epicondylitis and Intermittent Bilateral Carpal Tunnel Symptoms	Not Unfitting	Left Elbow Ulnar Neuropathy with Left Wrist Carpal
Tunnel Syndrome	8511	20%	19920317	
		Right Elbow Ulnar Neuropathy with Right Wrist Carpal
Tunnel Syndrome	8511	20%	19920317	
Intermittent GERD Symptoms	Not Unfitting	No VA Placement	
Xerophthalmus	Not Unfitting	Bilateral Dry Eye Syndrome	6066	NSC	20090126	
Preglaucoma, Elevated Intraocular Pressure	Not Unfitting	Asteroid Hyalosis and  Pterygium Right Eye, Status Post
Pinguecula Excision and Left Eye Nasal Pinguecula	6079	0%	STR	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS:  0%	
ANALYSIS SUMMARY:  

Chronic Left Shoulder Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-handed CI underwent left shoulder surgery in October 2006 for a torn labrum (cartilage disc).  Following surgery on 27 October 2006, further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic bilateral shoulder pain” 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. 

Left Shoulder ROM
(Degrees)	MEB ~7 Mo. Pre-Sep
	VA C&P ~2 Mo. Post-Sep
	
Flexion (180 Normal)	145	160	
Abduction (180)	162	60	
Comments	Crepitus	--	
§4.71a Rating	PEB 10%	 VA 20%	

The MEB examination (recorded on DD Forms 2807 and 2808) dated 9 April 2008, 7 months prior to separation, documented bilateral shoulder pain with abduction, flexion and internal rotation, right greater than left.  The MEB NARSUM evaluation on 24 April 2008 (7 months prior to separation), noted decreased ROM as indicated in the chart above with mild crepitus.  There was no significant tenderness or evidence of instability.  Shoulder dislocations were not reported.  

At the VA Compensation and Pension (C&P) examination on 26 January 2009, performed 2 months after separation, the CI reported problems with lifting and carrying and difficulty reaching but no dislocations.  The examiner noted pain-free limited motion as indicated in the chart above and no additional limitation with repetitive motion.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5003 code (degenerative arthritis), citing “some loss of shoulder motion.”  The VA assigned a 20% rating using the 5201 code (arm, limitation of motion) for abduction limited to 60 degrees based on the VA C&P examination 2 months after separation.  The VASRD §4.71a threshold for a rating for ROM impairment is “at shoulder level” (approximately 90 degrees from the side), and the ROMs in evidence demonstrated motion above this level. There was insufficient limitation of motion to support a rating under 5201, however, Board members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion).  While the VA examination was more proximate to separation, there was no explanation in the record to indicate how or why there was a decrement in the ROM for abduction to 60 degrees in the absence of an inter-current injury, surgery, infection, or inflammatory process and especially with the lack of crepitus, painful motion or other objective findings on examination.  Therefore, after Board members reviewed and discussed the facts in the record, the use of code 5201 based solely on the VA abduction measurement was difficult to support unequivocally.  Furthermore, 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).  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 left shoulder condition.

Chronic Right Shoulder Pain.  According to the STR and the MEB narrative summary (NARSUM), the CI had right shoulder pain initially thought to be related to an impingement syndrome.  After magnetic resonance imaging (MRI) demonstrated a supraspinatus tear and bursitis, right shoulder surgery was performed on 31 July 2007.  Following surgery, further treatment did not result in improvement sufficient to allow unrestricted duty.  A 3 December 2007 MRI showed a probable labral tear, bursitis, and degenerative changes of the acromioclavicular joint.  Orthopedics recommended redoing a subacromial decompression, distal clavicle resection, and labral repair, but the CI opted for an MEB.  The MEB forwarded “chronic bilateral shoulder pain” for PEB adjudication.

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 ~7 Mo. Pre-Sep
	VA C&P ~2 Mo. Post-Sep
	
Flexion (180 Normal)	149	160	
Abduction (180)	104	60	
Comments	Tenderness, crepitus,  and painful motion		
§4.71a Rating	20% (PEB 10%) 	 VA 20%	

The MEB examination (recorded on DD Forms 2807 and 2808) dated 9 April 2008, 7 months prior to separation, showed bilateral shoulder pain with abduction, flexion and internal rotation.  The examiner also noted a decreased ROM of the right shoulder and referenced a physical therapy evaluation, which was not in the case file.  The MEB NARSUM evaluation on 24 April 2008 (7 months prior to separation), documented decreased ROMs as indicated in the chart above.  The CI had a positive Hawkins sign (evidence of painful motion), tenderness, and crepitus.  There was no evidence of instability.  Shoulder dislocations were not reported.  

At the VA Compensation and Pension (C&P) examination on 26 January 2009, performed 2 months after separation, the CI reported problems with lifting and carrying and difficulty reaching but no dislocations.  The examiner noted pain-free limited motion as indicated in the chart above and no additional limitation with repetitive motion.  
 
The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5003 code, citing “some loss of shoulder motion.”  The VA assigned a 20% rating using the 5201 code (arm, limitation of motion) for abduction limited to 60 degrees based on the VA C&P examination 2 months after separation.  The 20% rating for the dominant arm requires motion limited to “at shoulder level” and this was reflected by the NARSUM ROM measurements.  As noted above, the record did not support for the use of the VA measurement for abduction at 60 degrees.  The Board then discussed how the abduction measurement of 104 degrees warrants a 20% rating.  Members noted that the difference between the 104 degrees and the 90 degrees is close enough to fall within the rubric of “at the shoulder level.” There was no fibrous union or nonunion of the humerus to justify a higher rating under the 5202 code (humerus, other impairment of), and no higher rating available under the 5203 code (clavicle or scapula, impairment of).  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 left shoulder condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that allergies, bilateral lateral epicondylitis, GERD (gastroesophageal reflux disease-heartburn) symptoms, xerophthalmus (dry eye), preglaucoma (elevated intraocular pressure), pinguecula (a yellowish, slightly raised thickening of the conjunctiva on the white part of the eye), and intermittent bilateral carpal tunnel symptoms were not unfitting.  None of these conditions were profiled or implicated in the commander’s statement and none were judged to fail retention standards.   There was no performance-based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance at separation.  

Allergies.  In October 2006, the CI was evaluated for a long history of allergic rhinitis and allergic conjunctivitis.  Flonase (fluticasone propionate, a nasal steroid spray) and Claritin (loratadine, an antihistamine) helped, but the CI was concerned about increased intraocular pressure (see below).  The CI received multiple desensitization injections for allergies to tree pollen, grass and cats in 2007.  

Bilateral Epicondylitis. Based on VA examinations in 1992, the CI was diagnosed with bilateral carpal tunnel syndrome and ulnar neuropathy at the elbow level.  Grip strength of the hands was normal and there was no loss of motion of the elbows or wrists.  A note in October 2005 indicated the CI had pain in the right lower arm near the elbow, which had been present for several months and seemed to be aggravated when tying down loads.  The STR had no additional information about the condition.

GERD Symptoms.  A note in June 1989 indicated the CI had mild gastroesophageal reflux without esophagitis.  The service treatment record did not have any additional information related to GERD.

Xerophthalmus, Preglaucoma, and Pinguecula.  A VA C&P examination dated 27 January 2009 indicated the CI had bilateral dry eyes (xerophthalmus) and initially used Restasis (a topical anti-inflammatory medication), but decreased to occasional use.  Tear function was profoundly deficient and he used artificial tears about 10 times a day.  The CI had a history of ocular hypertension with readings apparently as high as 30mm Hg.  Tonometry revealed pressures of 21 and 19mm Hg in the right and left eyes respectively.  A pinguecula (a benign growth) was excised in April 2006 and on examination a non-inflamed nasal pinguecula was present on the left eye.  The CI was advised that he should continue using artificial tears and be seen in follow-up in 1 year or sooner should he develop new or different visual or ocular symptoms.  

Intermittent Bilateral Carpal Tunnel Symptoms.  The STR for the CI’s active duty service from January 2005 through November 2008 did not document any complaints or treatment related to either unilateral or bilateral carpal tunnel symptoms.  However, a 1992 VA rating decision indicated the CI did have symptoms, which were confirmed by electrodiagnostic studies, and that he used wrist splints during that time.

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 determinations for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the left shoulder condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the right shoulder condition, the Board majority recommends a disability rating of 20%, coded 5201, IAW VASRD §4.71a.  The single voter for dissent recommended no change and did not elect to submit a minority opinion.  In the matter of the contended allergies, bilateral lateral epicondylitis, GERD symptoms, xerophthalmus, preglaucoma, pinguecula, and intermittent bilateral carpal tunnel symptoms, 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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation: 

 

CONDITION	VASRD CODE	PERMANENT RATING	
Left Shoulder Pain	5099-5003	10%	
Right Shoulder Pain	5201	20%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140906, 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 (PD201403922)

1.	Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re­ characterize the individual's separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual's original medical separation for disability with severance pay.

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:

a.	  Providing a correction to the individual's separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

b.	Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

c.	Adjusting pay and allowances accordingly.   Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

d.	Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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