RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00920
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060421

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Bradley Linebacker Crewman, medically separated for “chronic right shoulder pain…,” with a disability rating of 0%.

CI CONTENTION:  The CI did not submit a contention in the application.  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 - 20060407	VARD - 20060627	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Shoulder Pain ...	5099-5003	0%	Synovitis and Tenosynovitis of the Right Shoulder with Mild Degenerative Changes, Status Post Labral Lesion (Dominant)	5099-5024	10%	20060420	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Right Shoulder Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI suffered an onset of right (dominant) shoulder pain in November 2004.  There were conflicting accounts in the STR as to the circumstances, with the NARSUM describing an atraumatic onset, and outpatient clinical entries describing differing events resulting in injury while deployed to Iraq.  The pain persisted after deployment and the CI underwent arthroscopic surgery in August 2005 (8 months before separation).  There were conflicting accounts of this as well, and the operative report was not in evidence.  The NARSUM described diagnostic arthroscopy without identification of significant pathology; but, there were outpatient post-operative notes that documented debridement of a SLAP (superior labrum anterior and posterior) the ring of cartilage that surrounds the socket of the shoulder joint) lesion.  Magnetic resonance imaging (MRI), both before and after surgery (including an MRI arthrogram 6 months after arthroscopy), consistently described normal findings for the labrum and rotator cuff (no surgical changes reported in post-operative studies).  Regardless of the nature of the arthroscopic intervention, the CI did well afterwards with recovery of near-normal range of motion (ROM) and improving function.  In December 2005 (4 months after the surgery), however, he reported a sudden onset of pain and a “pop” in the shoulder while doing push-ups.  Subsequent STR entries reported continued pain and functional limitations.  The possibility of complex regional pain syndrome (CRPS) was investigated with a nuclear medicine study that was not consistent with the diagnosis and an electrodiagnostic study (NCV/EMG) that was normal.  The above MRI arthrogram suggested synovitis (coracoid) or tenosynovitis (supraspinatus).  

There were multiple formal ROM evaluations documented in the STR after the surgery.  The final two before the above exacerbation recorded forward flexion to 170 degrees (normal 180, 90 for minimum 20%) and abduction to 165 degrees (same parameters).  An entry after the exacerbation, however, documented “he can abduct his right arm past 90 degrees with pain.”  There were multiple STR entries documenting joint stability, but some examiners recorded equivocal signs of impingement.  Further conservative treatment did not result in sufficient improvement to allow unrestricted duty; and, the CI was referred for an MEB which in turn forwarded “right shoulder pain” to the PEB for adjudication.  The NARSUM examination on 14 March 2006 (5 weeks before separation) documented “constant pain and he states that he is unable to at all move or use his arm without pain.”  The physical examination recorded full strength (5/5) in all shoulder girdle groups (including normal grip strength), and did not note any instability or signs of impingement.  The ROM was reported as forward flexion to 165 degrees and abduction to 90 degrees, specifying motion limited by pain.

At the VA Compensation and Pension (C&P) examination on 20 April 2006 (a day before separation) the CI reported continued pain (unquantified) exacerbated particularly with overhead activity.  The physical examination recorded crepitus, no swelling, no “dislocation,” and did not comment on any instability or impingement.  The measured ROM was forward flexion and abduction both to 165 degrees, specifying painful motion.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under code 5099-5003 (analogous to degenerative arthritis), citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy.  The VA rated 10% under code 5099-5024 code (analogous to tenosynovitis, defaulting to criteria of 5003) citing functional loss.  Although the PEB’s 0% rating was compliant with the USAPDA pain policy, members agreed that VASRD §4.59 (painful motion) and/or §4.40 (functional loss) were amply supported in justification of the minimum compensable 10% rating.  Although the NARSUM measurement of abduction to 90 degrees met the criterion for a 20% rating under code 5201 (limitation of motion), members agreed that its probative value was outweighed by the C&P evidence on the eve of separation; the latter also better aligned with the outpatient STR evidence.  There was no ankylosis, fracture (nonunion/malunion) or subluxation/instability that would support a higher rating via any other applicable code available under §4.71a.  After due deliberation, considering all of the evidence and conceding VASRD §4.3 (reasonable doubt), the Board recommended 10% rating for the right shoulder condition, preferring code 5099-5024.

BOARD FINDINGS:  In the matter of the right shoulder condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5024 IAW VASRD §4.71a.  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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Tenosynovitis and Surgical Residuals, Right Shoulder 	5099-5024	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150607, 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 
XXXXXXXXXXXXXXXXXX,  AR20170000752 (PD20100920)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 10% 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
(  ) DVA