RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00764
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061013

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Military Policeman, medically separated for “chronic right shoulder pain” with a disability rating of 20%.

CI CONTENTION:  “Review 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 based on 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 - 20060808	VARD - 20070906	
Condition	Code	Rating	Condition	Code	Rating	Exam	

Chronic Right Shoulder Pain
	5099-5003	20%	S/P Failed Reconstructive Surgery, Right Scapula and Right Shoulder	5201	30%	20070326	
			Paralysis, Long Thoracic Muscle	8519	30%		
Laryngeal Dyskinesis	Not Unfitting	Laryngeal Dyskinesia	6520	0%		
Headaches		Migraine Headaches	8100	10%		
Low Back Pain		Degenerative Disc Disease	5242	20%		
Right Hand Paresthesia		Paresthesias and Neuralgia, Right Wrist	8715	10%		
Hearing Loss, Left		Bilateral Hearing Loss	6100	NSC	20070404	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:  

Right Shoulder Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had a long history of right shoulder pain due to an injury in 1997.  Multiple notes in the STR indicated the CI was left hand dominant using the left hand to eat and write, but an equal number indicated she was ambidextrous, using her right arm for all other activities.  In 2003 a retention physical noted the CI had a several year history of right shoulder pain diagnosed as tendonitis and the physical exam noted slightly limited range of motion (ROM).  Over several years the CI developed progressive loss of strength and orthopedic evaluation in 2005 noted scapular winging.  According to the NARSUM, electrodiagnostic studies (EMG/NCV) in January 2005, 21 months prior to separation, were consistent with long thoracic nerve palsy (cause of scapular winging).  Despite extensive physical therapy the scapular pain continued and the CI underwent surgery in September 2005 for stabilization of right medial scapular dyskinesia (abnormal scapular position/motion).  Following surgery the CI reported persistent shoulder and scapular pain, decreased ROM and numbness of the right upper extremity.  The MEB forwarded “right shoulder pain with scapular dyskinesis, pain is moderate and constant” 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 NARSUM~5 Mo. Pre-Sep
	MEB 2808 ~ 3 Mo. Pre-Sep
	Ortho ~2 Mo. Pre-Sep
	VA C&P ~5 Mo. Post-Sep
	
Flexion (180 Normal)	110	110	100	90	
Abduction (180)	110	90	100	90	
Comments	Mild Scapular Dyskinesis	
Right Scapular Winging	No erythema or ecchymosis; significant scapular hypermobility	Severe winging of the scapula; pain on movement	
§4.71a Rating	10% (PEB 20%)	10% (PEB 20%)	10%- 20% (PEB 20%)	20%	

The MEB NARSUM examination on 4 May 2006, 5 months prior to separation, noted complaints of persistent right shoulder pain and weakness, without complaints of instability, subluxation or dislocation.  Physical examination showed abnormality of posture, limited ability to retract the scapula actively and weakness of shoulder external rotation and flexion.  Shoulder ROM was as noted in the chart above.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated 13 July 2006, 3 months prior to separation, physical examination showed shoulder ROM as noted in the chart above.  Repeat EMG/NCV studies on 19 July 2006, 3 months prior to separation, were normal, with no evidence of long thoracic nerve neuropathy, peripheral neuropathy, cervical radiculopathy or brachial plexopathy.  At an orthopedic follow-up visit on 14 August 2006, 2 months before separation, the CI reported use of a scapular stabilization brace and ongoing PT.  She reported significant pain with shoulder ROM above 90 degrees.  The physical examination noted well healed surgical incisions.  There was no asymmetry or rotator cuff muscle atrophy noted.  With the scapula stabilized, shoulder ROM was as recorded in the chart above.  Significant scapular hypermobility with ROM was noted.  There was pain with ROM.  The impression was improving scapular function after surgery with significant shoulder joint symptoms.  A repeat MRI was ordered but no report was noted in record.  

At the 26 March 2007 VA Compensation and Pension (C&P) evaluation, performed 5 months after separation, the CI reported stiffness, pain, and weakness in her right shoulder, without giving way, locking or fatigability,.  She had daily scapular pain aggravated by lifting “above 45 degrees from the shoulder.”  She denied dislocations or recurrent subluxations.  She was not using any device or brace and took anti-inflammatory medication daily which was helpful in high doses.  Physical exam noted the CI was ambidextrous and showed generalized atrophy of the right shoulder girdle, palpable spasms in the shoulder girdle, and significant 50% winging of the scapula on inspection.  Shoulder ROM was as recorded in the chart above with painful motion noted.  There was no additional limitation of motion with repetitive use.  Right shoulder X-rays were normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder condition 20%, coded 5099-5003 (Arthritis, degenerative), citing the US Army Physical Disability Agency pain policy.  The VA rated the right shoulder condition 30% coded 5201 (Arm, limitation of motion of), citing limitation of motion and also provided a 30% rating coded 8519 (Paralysis of long thoracic nerve, citing complete paralysis whenever the arm cannot be raised above shoulder level and there is a winged scapula deformity), based on the C&P examination.  

The PEB rated the shoulder pain with scapular dyskinesis 20% and therefore the Board reviewed to see if a higher rating was supported with any applicable VASRD code.  There was evidence of limited arm motion at shoulder level to support a 20% rating for the dominant upper extremity, coded 5201 (limitation of arm motion).  There was not evidence of limited arm motion midway between side and shoulder level for the next higher rating.  Although the CI reported pain with use midway between the side and shoulder level, her shoulder ROM was documented to be above that on all examinations.  There was evidence of a winged scapula with difficulty raising the arm due to pain, but there was not evidence to support “complete inability to raise the arm above shoulder level” noted for the next higher rating based on “paralysis of the long thoracic nerve.”  There was evidence of some motion above shoulder level at the MEB NARSUM, MEB DD Form 2808, and orthopedic examinations before separation and repeat EMG/NCS in July 2006 was normal.  Under code 8519, the VASRD notes that rating under 8519 is not to be combined with a rating under 5201, therefore the CI’s disability due to the shoulder condition can be coded and rated with either code, but cannot be provided two ratings utilizing both codes.  Although the Board arrived at a 20% rating under a different coding and rating approach IAW VASRD rating criteria, the PEB’s reliance on the USAPDA pain policy was not detrimental to arriving at the highest rating, therefore no change to the PEB code or adjudication is recommended.  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 with scapular dyskinesis condition. 

Contended PEB Conditions:  Headaches, Low Back Pain, Right Hand Paresthesia, Laryngeal Dyskinesis and Hearing Loss.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  

Headaches, Low Back Pain, Right Hand Paresthesia.  None of the conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  

Laryngeal Dyskinesis and Hearing Loss.  The laryngeal dyskinesis was given a P2 profile and the HL was given an H2 profile.  A profile designation of “2” indicates a condition which requires some physical limitations, but is not in all cases disqualifying for continue military service.  The PEB Form 199 noted they did not require “significant physical profile restrictions.”  Neither condition was implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the chronic right shoulder pain with scapular dyskinesis condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended headaches, low back pain, right hand paresthesia, laryngeal dyskinesis and hearing loss 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 recommends 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 20150603, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170005107, XXXXXXXXXXXXXXXXXX. 

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,