RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02473
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20031103

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Parachute rigger, medically separated for “pain left shoulder, left elbow and left wrist”, with a disability rating of 10%.  

CI CONTENTION:  “Review all conditions.”  The 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 Board 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 determination 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(s) 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 - 20030709	VARD - 20040319	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pain Left Shoulder, Left Elbow and Left Wrist	5099-5003	10%	Status Post Left Shoulder Injury	5299-5203	10%	20040106	
			Status Post Left Wrist Tendonitis with Residual	5099-5024	10%	20040106	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%  	

ANALYSIS SUMMARY:  

Left Shoulder.  The PEB combined the left shoulder, left wrist, and left elbow conditions as a single unfitting condition coded analogously to 5003 (arthritis, degenerative)  and rated 10% with application of the US Army Physical Disability Agency (USAPDA) pain policy and AR 635-40 B24.f.  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 panel 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 panel’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 panel 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 panel 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 left shoulder, left wrist, and left elbow conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-hand dominant CI injured his left shoulder in 1999 during an airborne operation.  The CI underwent a left shoulder arthroscopy and thermal capsular shrinkage in February 2001.  Serial X-rays of the left shoulder were normal.  Magnetic resonance imaging (MRI) of the left shoulder revealed minimal fluid in the subacromial bursa (can be normal finding) and was otherwise unremarkable.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  

The 28 April 2003 MEB NARSUM examination, 6 months prior to separation, noted complaints of postoperative left shoulder pain that persisted despite a full course of rest and physical therapy (PT).  He was taking Naprosyn twice daily for his shoulder symptoms.  Symptoms were exacerbated by push-ups, pull-ups, carrying a rucksack, and performing MOS duties.  The left shoulder examination revealed anterior and lateral tenderness with no signs of instability.  Left shoulder range of motion (ROM) was internal rotation is to the T9 level, forward flexion of 170 (normal 180), and external rotation of 45 degrees (normal 90) degrees.  The examiner recounted the findings of the left shoulder X-rays and MRI.  The diagnosis listed left shoulder instability status post thermal capsular shrinkage with residual bursitis (inflammation of fluid-filled sacs between tissues) and synovitis (synovial membrane inflammation).  At the 6 January 2004 VA compensation and pension (C&P) evaluation, 2 months after separation, the CI reported that left shoulder pain “improved some” following arthroscopy.  Symptoms were exacerbated by throwing, lifting, carrying, and sleeping on his left shoulder.  The left shoulder examination revealed acromion and area below tenderness with no weakness.  Pain-limited left shoulder ROM was forward flexion of 170 degrees (normal 180), abduction of 160 degrees (normal 180), external rotation of 70 degrees (normal 90), and internal rotation of 90 degrees (normal 90).  Repetitive use revealed no fatigue or incoordination.  The diagnosis listed left shoulder injury with impingement syndrome, status post arthroscopy with residuals.

The panel directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the panel must first consider whether the left shoulder condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 10% rating under an analogous 5003 code (arthritis, degenerative) citing left shoulder pain, no post-operative shoulder instability, normal left shoulder radiographs, no ratable limitation of ROM, daily use of anti-inflammatory pain medication, periodic use of Percocet, and rated for moderate and frequent pain.  The VA assigned a 10% rating under an analogous 5203 code (clavicle or scapula, impairment of) based on the VA C&P examination 2 months after separation, citing left shoulder pain, status post arthroscopy, with residuals, ROM, and rated for painful or limited motion of a major joint or group of minor joints.  There was no compensable (at shoulder level [90 degrees] is minimum 20% rating) arm limitation of motion (5201) for consideration under the respective code.  There was no scapulohumeral ankylosis (5200), recurrent dislocation, loss of humeral head, nonunion, fibrous union, or malunion of humerus (5202), or nonunion or malunion of clavicle or scapula (5203) for consideration under the respective codes.  The panel agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  The panel concluded that the evidence did not provide sufficient grounds for recommending separate disability ratings in this case, and that the combined rating of 10%, coded 5099-5003, is a good analogy to both the pathology and disability.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left shoulder, left wrist, and left elbow condition.  

Left Wrist.  According to STR and the MEB NARSUM, the CI’s left wrist condition began in 1999 during an airborne operation when he also injured his left shoulder and elbow.  Radiographs of the left hand were normal. In the MEB NARSUM examination the CI complained of 10 years of left dorsal wrist shooting pain.  Wrist symptoms were exacerbated by driving, picking up children, and activities of daily living.  The left wrist examination revealed extensor digitorum communis tendons tenderness with no signs of carpal instability.  Left wrist ROM was dorsiflexion of 70 degrees (normal 70), palmar flexion of 40 degrees (normal 80), radial deviation of 20 degrees (normal 20), and ulnar deviation of 30 degrees (normal 45).  The Tinel's (percussing carpal tunnel elicits tingling over median nerve distribution) and Phalen's (wrist volar flexion elicits tingling over median nerve distribution) sign were negative.  The examiner recounted the findings of the left hand X-rays.  The diagnosis listed left wrist dorsal extensor tendinopathy (chronic localized tendon thickening).  In the C&P examination, the CI complained of dorsal left wrist pain.  The left wrist examination revealed dorsal extensor digitorum communis tendon tenderness with no weakness or swelling.  Left wrist ROM was dorsiflexion of 70 degrees (normal 70), palmar flexion of 80 degrees (normal 80), radial deviation of 20 degrees (normal 20), and ulnar deviation of 45 degrees (normal 45).  Repetitive use revealed no fatigue or incoordination.  The diagnosis listed left wrist tendonitis with residuals.

The panel directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the panel must first consider whether the left wrist condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 10% rating under an analogous 5003 code (arthritis, degenerative) citing left wrist pain, normal left wrist radiographs, no ratable limitation of ROM, daily use of anti-inflammatory pain medication, periodic use of Percocet, and rated for moderate and frequent pain.  The VA assigned a 10% rating under an analogous 5099-5024 code (tenosynovitis) based on the C&P examination citing left wrist pain, left wrist tendonitis with residuals, ROM, and rated for painful or limited motion of a major joint or group of minor joints.  There was no wrist limitation of motion (5215) for consideration under the respective code.  There was no ulna or radius flail false joint (5210), significant loss of bone substance, marked deformity, nonunion, or malunion (5211 and 5212), impairment of supination or pronation (5213), or wrist ankylosis (5214) for consideration under the respective codes.  The panel agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  The panel concluded that the evidence did not provide sufficient grounds for recommending separate disability ratings in this case, and that the combined rating of 10%, coded 5099-5003, is a good analogy to both the pathology and disability.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left shoulder, left wrist, and left elbow condition.  

Left Elbow.  According to STR and the MEB NARSUM, the CI’s left elbow condition began in 1999 during an airborne operation when he also injured his left shoulder and wrist.  Radiographic studies of the left elbow were normal.  In the MEB NARSUM the CI complained of 10 years of left posterior elbow pain.  Elbow symptoms were exacerbated by lifting.  The left elbow examination revealed olecranon process (proximal ulna bony prominence where triceps tendon inserts) and olecranon bursa tenderness and mild posterior swelling.   Left elbow ROM was flexion of 135 degrees (normal 145) and extension of 0 degrees (normal 0).  The examiner recounted the findings of the left elbow X-rays.  The diagnosis listed left olecranon bursitis.  The VA C&P examination, did not address any elbow complaints.  The PEB assigned a 10% rating under an analogous 5003 code (arthritis, degenerative) citing left elbow pain, no ratable limitation of ROM, daily use of anti-inflammatory pain medication, periodic use of Percocet, and rated for moderate and frequent pain.  The VA did not rate the left elbow.  There was no forearm limitation of flexion (5206), forearm limitation of extension (5207), forearm limited flexion and extension (5208) for consideration under the respective codes.   There was no elbow flail joint (5209), ulna or radius flail false joint (5210), significant loss of bone substance, marked deformity, nonunion, or malunion (5211 and 5212), or impairment of supination or pronation (5213) for consideration under the respective codes.  The panel agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  The panel concluded that the evidence did not provide sufficient grounds for recommending separate disability ratings in this case, and that the combined rating of 10%, coded 5099-5003, is a good analogy to both the pathology and disability.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left shoulder, left wrist, and left elbow condition.  

BOARD FINDINGS:  In the matter of the left shoulder, left wrist, and left elbow conditions and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, 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 20150701, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170013244, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	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,					      
						      					
Enclosure