RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03994
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20051011

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6 (Avenger Crewmember) medically separated for bilateral shoulder pain.  The bilateral shoulder condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  “Chronic bilateral shoulder pain,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “chronic bilateral shoulder pain” as unfitting, rated 10%, with application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.  

CI CONTENTION:  Please consider all conditions.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  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/Naval 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 20050913	VA* - (13 Days Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Shoulder Pain	5099-5003	10%	Residuals of Surgery, Left Shoulder (Non-Dominant)	5299-5203	10%	20050928	
			Residuals of Surgery, Right Shoulder (Dominant)	5299-5203	10%		
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 2	
RATING:  10%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20051110 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:   The PEB combined the bilateral shoulder conditions under a single disability rating, coded analogously to 5003.  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints. The Board must follow suit (IAW DoDI 6040.44) if the PEB combined adjudication is not compliant with the latter stipulation, provided that each “unbundled” condition can be reasonably justified as separately unfitting in order to remain eligible for Service rating.  If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  

Bilateral Shoulder.  The NARSUM noted the CI sustained an injury to his left shoulder around 2000.  The initial injury occurred during physical training with weight lifting and despite conservative treatment and three surgeries his pain had not changed.  Treatment record also documented the history of right shoulder dislocation at the age of 18 and subsequent complaints of recurrent subluxations without frank dislocations.  In 2000, the CI underwent an inferior capsular shift surgery of the left shoulder secondary to unstable shoulder; in 2001 a left Bankart repair was completed and in 2005 he had a third surgery to address a SLAP (superior labrum, anterior to posterior lesion) injury and bicep tenodesis.  The CI underwent arthroscopic Bankart repair of the right shoulder in July 2002.  Since the surgeries of both shoulders, the CI had not had any recurrence of shoulder dislocation; however, continued to have pain.  Orthopedics entry dated 19 July 2005 noted that the CI was on a P3 profile and had been re-classed.  He was advised that further surgical intervention would “most likely not” be beneficial and he indicated a lack of desire to pursue any additional surgery.

At the NARSUM dated 2 August 2005, the CI reported he was not taking any medication and noted that his pain increased with any arm movements, wearing flack vest, and carrying any amount of weight.  His pain did decrease with rest which he described as 5/10 in intensity.  Physical examination was accomplished by orthopedics department on 25 July 2005 and documented normal motor strength, normal sensory exam, and no evidence of vascular compromise.  There were surgical scars noted on both shoulders, and muscle tone and strength were both good bilaterally.  Range of motion (ROM) for the MEB conducted by physical therapy on 8 August 2005 recorded left shoulder flexion to 105 degrees (NL=180),extension to 51 (NL=60),  abduction of 115 degrees, (NL=180), and adduction to 71 (NL=75) compared to right shoulder flexion of 180 degrees, extension to 65, and abduction of 183 degrees.  Pain was solicited during ROM testing of each shoulder, and there was tenderness to palpation of the shoulder joint elements.   He had positive Hawkins and Neers signs bilaterally (tests to evaluate shoulder impingement).  The examiner assessed chronic bilateral shoulder pain and noted the CI’s profile restricted his ability to carry and fire a weapon, carry a load at least 2 miles, construct an individual fighting position; however, he was able to participate in upper body weight training to tolerance.  There was no documentation of shoulder instability during the NARSUM.  

At the VA Compensation and Pension (C&P) examination, approximately 2 weeks before separation, the CI reported pain in both shoulders worse with lifting, ruck sacking, and push-ups, improved with ice, rest, and massage.  He continued with daily pain described as 4/10 in the left shoulder and 3/10 in the right shoulder. There was no report of right or left shoulder dislocation or subluxations.   Physical examination documented tenderness over right and left shoulder joints, and crepitance of the right shoulder, absence of crepitance in the left shoulder, and mild decrease in muscle strength of the left shoulder.  Right shoulder ROM recorded flexion of 180 degrees, compared to 160 degrees on the left, and extension of 30 degrees on the left, and a “+10 degrees on the right with a 10-degree deficit on the left.”  Abduction was not documented.  MRI of the left shoulder in September 2006 documented no significant findings of impingement; the biceps tendon appeared properly located.  There was evidence of arthritis of the glenohumeral joint.  
The Board directed attention to its rating recommendation based on the above evidence.  The PEB chose to rate the condition analogous to 5003 (degenerative arthritis) and under the pain policy, granted 10% for bilateral shoulder pain.  The VA coded the condition analogously under the 5203 code (dislocation of or nonunion of, or impairment of clavicle or scapular) and rated each shoulder separately at 10% for functional loss due to pain.  The NARSUM documented that both the left and right shoulders were painful and interfered with the CI’s ability to perform the duties of a service member.  The VA documented pain in both shoulders, with associated weakness in the left shoulder.  The Board determined that it was appropriate to “unbundle” the shoulders, and consider each shoulder as a separate major joint.  This is consistent with PDBR policy and precedent.  The profile involved restrictions related to right and left shoulders.  Careful review of the treatment record demonstrates that the left shoulder was the focus of treatment in the year prior to separation, and the orthopedic physician appeared to focus on the left shoulder likely due to the 2005 surgery.  The ROM for the MEB demonstrated reduction in the left shoulder and normal measurements in the right shoulder.  The CI reported he was not capable of performing his duties secondary to bilateral shoulder pain, and the NARSUM examiner noted positive signs of impingement evidenced by pain on rotation of the glenohumeral joint, and stated that the CI’s bilateral pain led to restrictions that caused him to not meet retention standards.  The VA examiner recorded pain in the right and left shoulders.  Thereupon, the Board opined, both shoulders were painful, impacted duty performance, and adjudged separately unfitting. At the time of separation from service, both shoulders were painful to motion, but had relatively good ROM.  

The Board considered the 5202 (humerus, other impairment); however, Board members agreed this code was not applicable.  The Board noted that there were no documented episodes of shoulder dislocation, or visits to the emergency room secondary to shoulder instability in the 12 months prior to separation.  Additionally, the record does not support any ratable impairment of the scapula or scapulohumeral joint. Likewise, VARSD code 5201 (arm, limitation of motion) was not applicable since the recorded ROM limitation was not compensable.  However, IAW VASRD §4.71a, when limitation of motion of a specific involved major joint is non-compensable under the appropriate diagnostic code, a rating of 10% is appropriate if there is satisfactory evidence of painful motion.  After due deliberation, and careful consideration of all available evidence, the Board unanimously recommends a separation rating of 10% for chronic, left shoulder pain coded analogously 5003, for painful motion, and a rating of 10% for chronic right shoulder pain coded analogously 5003, for painful motion.  This determination by the Board is IAW VASRD §4.3, §4.14, §4.59, and §4.71a. After deliberation, the Board concluded the record in evidence supported the minimal compensable rating for both the left and right shoulder pain coded 5003, IAW VASRD §4.59.   Considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right shoulder pain condition and 10% for the left shoulder pain condition, for a combined rating of 20%.  

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  As discussed above, PEB reliance on the USAPDA pain policy AR 635-40 DoDI 1332.39 for rating chronic bilateral shoulder pain was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the chronic left shoulder condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the chronic right shoulder condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  

RECOMMENDATION:  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 Left Shoulder Pain	5009-5003	10%	
Chronic Right Shoulder Pain	5009-5003	10%	
RATING (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140915, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander, US Army Physical Disability Agency (AHRC-00), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXX, AR20160004444  (PD201403994)

i. 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 1O, 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