RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01339
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051120

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

CI CONTENTION:  “Review all conditions.”  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel's scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the panel for Correction of Military Records.  Furthermore, the panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’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 panel 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 panel 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 - 20051013	VARD - 20081022	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Shoulder Pain	5024	0%	Tendonitis Biceps and Rotator Cuff Right Shoulder	5099-5024	NSC	STR	
			Tendonitis Biceps and Rotator Cuff Left Shoulder	5099-5024	NSC	STR	
Left Knee Pain	Not Unfitting	No VA Placement	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:  

Chronic Bilateral Shoulder Pain.  The PEB combined the right and left shoulder conditions as a single unfitting condition coded 5024 (tenosynovitis) and rated 0%.  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The Board also noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the right and left shoulder conditions is presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-hand dominant CI first complained of right shoulder pain in December 2004 after doing push-ups, while in Basic Training.  He first complained of left shoulder pain in May 2005 without specific injury.  Shoulder radiographic (X-rays) studies were normal and magnetic resonance imaging scans of both shoulders were consistent with supraspinatus tendonitis.  

A physical therapy evaluation on 18 August 2005 noted tenderness to palpation of both shoulders with full range of motion (ROM) and “with only minor pain at end ROM.”  The CI had been evaluated for fitness for duty (FFD) in the end of July 2005.  At the FFD evaluation the bilateral shoulder examination was normal and it was noted the CI was on a temporary 2 profile from orthopedics at the time.  The CI was referred to a senior profile officer and evaluated again on 22 August 2005 for FFD, ROM measurements were reported as normal.  The CI was unable to perform the required number of push-ups due to pain and a permanent P2 profile was initiated.  A permanent U3 profile dated 29 August 2005 listed chronic bilateral shoulder pain and indicated a MEB was initiated.  The MEB forwarded “chronic bilateral shoulder pain/biceps and supraspinatus tendonitis” for PEB adjudication.  

The commander’s memorandum, dated 6 September 2005, 3 months prior to separation, indicated that the CI’s bilateral shoulder tendonitis made him “incapable of reasonable performing his” military specialty and “from effectively conducting operations in a tactical or strategic environment.”  

The 12 September 2005 occupational therapy (OT) ROM study, 2 months prior to separation, noted pain with push-ups, carrying activities, lifting activities, especially overhead lifting activities.  On examination the right shoulder ROM showed flexion of 170 degrees (normal 180 degrees) and abduction of 160 degrees (normal 180 degrees).  Left shoulder ROM showed flexion of 170 degrees and abduction of 170 degrees.  There was crepitus in the right shoulder with both shoulder abduction and shoulder flexion.  The examination was silent in regards to painful motion in either shoulder with ROM testing. 

According to the MEB NARSUM evaluation on 16 September 2005, 2 months prior to separation, the CI complained of shoulder pain aggravated by lifting greater than 20 pounds; carrying heavy loads on his back; or standing at parade rest.  Shoulder dislocations were not reported.  The examiner indicated that the CI had been unable to finish his military specialty training due to his bilateral shoulder conditions.  The examiner also indicated that the CI’s bilateral shoulder pain precluded him from performing the events of the physical fitness test and from conducting combat marches or digging fighting positions.  Physical examination showed no tenderness or swelling and normal muscle strength.  Shoulder ROM was the same as noted at the OT ROM study.  
  
The MEB examination (recorded on DD Forms 2807 and 2808) dated 19 September 2005, 2 months prior to separation, revealed a normal upper extremity evaluation with “grossly normal” bilateral shoulder ROM.  At the 4 October 2005 orthopedic clinic appointment, 2 months prior to separation, the CI complained of right shoulder pain only.  The examiner recorded that there was no pain, clicking sensation, or catching during movement in the right shoulder joint.  However the right shoulder joint felt unstable occasionally while wearing a heavy pack.  On examination the right shoulder was tender to palpation.  There was no swelling of the right shoulder joint.  Active abduction and flexion were both normal and there was no pain elicited with ROM testing.  The examination did not address the left shoulder.

The Board first considered if the right and left shoulder conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The bilateral shoulder condition was permanently profiled with physical limitations equally applicable to both shoulders and the commander’s statement implicated both shoulders as impairing the CI’s duty performance.  The NARSUM indicated that the CI failed retention standards due to bilateral shoulder pain.  The Board concluded that there was not a preponderance of evidence of the service records that overcame the Board’s presumption that the bundled right and left shoulder conditions were each reasonably considered separately unfitting and accordingly separate disability ratings for each shoulder are recommended.  The Board then considered its rating recommendation for the unfitting shoulder conditions at the time of separation.  

The PEB rated the bilateral shoulder pain condition 0%, coded 5024 (tenosynovitis).  The VA Rating Decision in 2008 did not service-connect either shoulder based on the CI’s failure to attend the scheduled VA C&P examination in October 2008, citing no evidence that a condition that either occurred in or was caused by service currently existed.  The VASRD §4.71a threshold for rating for ROM impairment (code 5201, arm limitation of motion) is “at shoulder level” (approximately 90 degrees from the side), and the examinations in evidence demonstrated motion above this level.  Although there was insufficient limitation of motion to support a rating under the 5201 code, Board members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion), for the right shoulder, coded 5024.  The OT ROM evaluation for the MEB noted crepitus of only the right shoulder with ROM and the CI was evaluated for right shoulder pain at the October 2005 orthopedic examination with no mention of left shoulder pain or examination of the left shoulder.  Given the lack of objective findings of the left shoulder at the OT MEB, MEB DD 2808, MEB NARSUM, and orthopedic examinations proximate to separation, the Board concluded that there was not satisfactory evidence of painful motion or functional loss of the left shoulder at separation and therefore no more than a 0% rating was supported coded as 5024.  

There was no evidence of ankylosis, impairment of the humerus, clavicle or scapula of either shoulder to warrant rating under the applicable codes (5200, 5202, and 5203).  There was therefore no higher rating available for the right or left shoulder with any applicable VASRD code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt).  The Board recommends a disability rating as follows: an unfitting right shoulder condition, rated 10% and an unfitting left shoulder condition rated 0%, both coded 5024.  

Contended Condition:  Left Knee Pain.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that the condition 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 the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the chronic bilateral shoulder pain condition, the Board unanimously recommends a disability rating as follows: an unfitting right shoulder rated 10% and an unfitting left shoulder rated 0%, both coded 5024.  In the matter of the contended left knee condition, 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 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	
Chronic Right Shoulder Pain	5024	10%	
Chronic Left Shoulder Pain	5024	0%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150615, w/attachments
Exhibit B.  Service Treatment Record

AR20170005991, XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure