RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01184
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070919

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Human Intelligence Trainee, medically separated for “chronic left shoulder pain,” with a disability rating of 0%.

CI CONTENTION:  Her condition continues to worsen.  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 based upon a 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 – 20070919	VARD – 20080820	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Shoulder Pain	5024	0%	Left Shoulder Injury (Tendonitis)	5201	NSC	20080503	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:

Chronic Left Shoulder Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left shoulder (non-dominate) condition began in August 2006 while in Basic Training, performing overhead arm claps during physical training.  The CI reported feeling a “pop” in the back of her shoulder, but continued exercising.  Radiographic (X-ray) imaging revealed the left shoulder bony structures appeared intact, with no abnormal soft tissue calcifications or destructive lesions.  Orthopedic evaluation on 8 January 2007 diagnosed scapular bursitis and conservative treatment was recommended.  Magnetic resonance imaging performed in March 2007 to further evaluate the scapular bursa was normal.  A fitness for duty evaluation on 23 April 2007 indicated the CI had been unable to participate in any physical training or become military occupational specialty (MOS) qualified and was not fit for duty.  Despite treatment, the left shoulder condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “left rhomboid tendonitis” for PEB adjudication.

During the MEB examination (recorded on DD Forms 2807 and 2808) on 11 May 2007, 4 months prior to separation, the CI reported left posterior shoulder pain due to bursitis.  Physical examination showed full range of motion (ROM), normal strength and “mildly tender to palpation” of the left biceps tendon.  The MEB NARSUM examination on 9 August 2007, 1 month before separation, noted complaints of chronic daily, intermittent left shoulder pain.  The CI reported that she was “very used to it” and could function with the pain.  The physical examination noted the CI was right hand dominant.  There was tenderness with firm nodular muscle mass at upper medial edge of scapular at the trapezius and rhomboid minor insertions.  The ROM showed a flexion and abduction of 180 degrees (normal 180).  There was “no pain on ROM testing.”

At the 3 May 2008 VA Compensation and Pension (C&P) evaluation, performed 8 months after separation, the CI reported constant dull left shoulder pain that became sharp two to three times daily.  She reported she had not sought treatment for the left shoulder since military discharge and took over the counter strength anti-inflammatory medication as needed, which helped the discomfort.  The pain occurred after sitting or standing in one position for long periods of time, but if she kept moving, she was okay.  Physical examination revealed full ROM without painful motion.  Left shoulder examination was normal, except for “pin point tenderness” of the left medial scapular edge mid way down.  There was “no rhomboid muscle mass appreciated” at the examination.  Upper extremity strength, sensation, and reflexes were normal.  Left shoulder X-rays showed no fracture or dislocation.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 0%, coded 5024 (tenosynovitis), citing without loss of motion.  The VA also rated the left shoulder condition 0%, coded 5024, citing no objective evidence of painful or limited motion but injured in service.  The Board agreed there was no limitation of motion of the shoulder to support a rating under diagnostic code 5201 (arm, limitation of motion).  Both MEB and VA C&P examinations did not note findings such as swelling, muscle spasm, satisfactory evidence of painful motion or other evidence of functional loss to support a 10% rating coded according to 5003 rating criteria IAW VASRD §4.59, §4.40 or §4.45.  There was no malunion, deformity, or recurrent dislocation of the humerus to justify a rating under the 5202 code (humerus, other impairment of); and no nonunion or malunion of the clavicle or scapula to warrant any rating under the 5203 code (clavicle or scapula, impairment).  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.  

BOARD FINDINGS:  In the matter of the chronic left shoulder pain 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 re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20141230, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record
SAMR-RB						

MEMORANDUM FOR Commander

08 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170001472 (PD201501184)

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