RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00896
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080303

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty O3, Field Veterinary Service Officer, medically separated for “complex regional pain syndrome/reflex sympathetic dystrophy right (dominant) shoulder…” with a disability rating of 10%.

CI CONTENTION:  The CI’s shoulder condition continues to worsen and negatively affect daily activities.  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 - 20080410	VARD - 20080212	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Complex Regional Pain Syndrome/Reflex Sympathetic Dystrophy Right (Dominant)
Shoulder	8799-8719	10%	Right Shoulder, Complex Regional Pain Syndrome	5299-5014	10%	20071213	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Complex Regional Pain Syndrome (CRPS).  According to service treatment record and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right hand dominant CI injured her right shoulder during a field training exercise in September 2005.  Despite over 2 years of conservative treatment and extensive physical therapy, to include electric stimulation as well as manipulations, the CI’s symptoms did not sufficiently improve as to allow unrestricted duty.  There was no surgical indication and in August 2007 the CI was issued a P3 physical profile and referred for an MEB.  The MEB forwarded “chronic right shoulder subluxation” and “complex regional pain syndrome/right shoulder” for PEB adjudication.  

CRPS (aka… Reflex Sympathetic Dystrophy [RSD]) is a fairly uncommon, but well recognized, peripheral nerve dysfunction following (often minor) trauma.  It is characterized by hypersensitivity of the involved nerve and results in severe persistent pain out of proportion to that expected from the original injury.  In these cases, there usually are no ancillary or physical examination (PE) findings which are expected to be abnormal and or diagnostic.  Other than the finding of joint hypermobility, this particular case was quite typical and the diagnosis was considered and or corroborated by multiple medical providers.  The CI underwent many specialized imaging and ancillary nerve studies without clear evidence of any alternate biologic etiology.  

At the MEB NARSUM in October 2007, 5 months prior to separation, the examiner noted moderate crepitus with right scapular movement and subluxation of the right shoulder with elevation.  Her PE revealed range of motion (ROM) described as “hypermobile” with supra-normal ranges of flexion and abduction of the right shoulder.  Painful motion was present and her peripheral neurologic exam was normal.  Right scapular winging was present upon shoulder abduction (…indicating dysfunction of an individual muscle attached to the shoulder blade or a nerve that acts upon one of those muscles).  

At the VA Compensation and Pension (C&P) examination in December 2007, performed 3 months before separation, the CI reported daily “sharp pain” that were “…sometimes described as a throbbing pain radiating up into her neck and shoulder.”  Her PE revealed slight atrophy of the right shoulder joint.  Supra-normal ROM with regard to flexion and abduction remained.  There was no comment with regards to the presence of painful motion, but crepitus was present with right shoulder motion.    

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 8719 (neuralgia; long thoracic nerve), citing “moderate, incomplete paralysis.”  The VA also assigned a 10% rating using an analogous 5014 (osteomalacia) code based on the VA C&P examination 3 months prior to separation, citing “crepitus with range of motion.”  Board members first deliberated on the varying coding options presented in this case and concluded that although the electro-diagnostic studies did not specifically identify an abnormal nerve pathology, the well-recognized nerve-related etiology of such symptoms best supported the analogous nerve rating as presented by the PEB.  The dominant extremity under this code can be rated as either moderate (10%) or severe (20%) impairment.  After due deliberation, and considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that the CI’s ability to maintain normal ROM of the shoulder despite the presence of slight atrophy of the adjacent muscles would not support a level of impairment described as “severe”, but rather that of “moderate” at 10%.  

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.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140725, with attachments
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 
XXXXXXXXXXXXXXXXXX, AR20170000838 (PD201500896)

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