RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00327
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20071013

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Military Police, medically separated for “chronic upper back-shoulder pain” with a disability rating of 0%.  

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 - 20070717	VARD - 20141211	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Upper Back-Shoulder Pain	5009-5003	0%	Thoracic Outlet Syndrome, Right Upper Extremity	8512	20%	20141015	
			Snapping Scapula Syndrome, Right Shoulder	5201-5019	10%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Right Upper Back-Shoulder Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-hand dominant CI underwent right shoulder surgery (partial scapula resection) in November 2003 for snapping scapular syndrome.  Despite treatment, the “chronic right upper back-shoulder pain” condition could not be adequately rehabilitated and his condition was deemed as not amenable to further surgical treatment.  

At the 20 February 2007 orthopedic clinic appointment, 8 months prior to separation, the CI reported neck pain, similar back pain and increased numbness and tingling in his right hand as prior to his operation.  He had problems with lifting, firing his weapon, push-ups and running.  Physical examination showed slight winging of the right inferior scapula.  Surgical scars were well healed.  There was no shoulder tenderness, swelling, effusion, or instability.  Right shoulder range of motion (ROM) was normal with pain on motion, at the medial edge of the scapula.  There was no decreased sensation, decreased motor strength, or muscle atrophy of the right arm.  Reflexes were normal.  There was no pain on motion of the neck.  Radiographic studies showed a normal right shoulder without evidence of significant degenerative, inflammatory, or traumatic change.  Neuro-diagnostic studies (EMG/NCV) performed on 23 February were normal, with the caveat that it did “not rule out long thoracic or dorsal scapular nerve lesions resulting of the winging of the scapula.”  

During the 11 April 2007 MEB examination (recorded on DD Forms 2807-1 and 2808) 6 months prior to separation, the CI reported constant right scapular pain, impaired use of the right arm, with numbness and tingling in the right arm and hand.  He had been wearing a brace to assist with the scapular pain for the previous 4 months.  Physical examination showed full shoulder ROM with decreased muscle strength of the right trapezius compared to the left.  

The 11 June 2007 MEB NARSUM examination, 4 months prior to separation, noted complaints of problems with lifting heavy objects, firing a weapon or performing push-ups and running.  Physical examination showed full right shoulder ROM without pain or signs of scapular winging.  There was tenderness to palpation of the scapula with palpable defect compared to the left side.  Strength was decreased (4/5 versus normal 5/5) compared to the left side and neurovascular evaluation was equal bilaterally without deficit.  The physician’s assessment indicated significant limitation of physical activity (functional loss) and “limitation in the maximum carrying weight of 10 pounds to the right upper extremity.”  The diagnosis was chronic right upper back pain secondary to scapular dysfunction with occasional radiculopathy.  

There was no VA Compensation and Pension (C&P) evaluation in evidence proximate to separation.  The C&P examination, 7 years after separation, showed right thoracic outlet syndrome (markedly positive Adson’s test) and right snapping scapula syndrome with painful motion (see rating comparison chart above).  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the “chronic right upper back-shoulder pain” condition 0%, coded 5099-5003 (analogous to arthritis, degenerative), citing the US Army Physical Disability Agency pain policy.  The VA rated the right upper extremity condition 20%, coded 8512, (lower radicular group nerves, partial paralysis) and 10%, coded 5201-5019 (arm limitation of motion – bursitis) ; based on the C&P examination 7 years after separation, citing thoracic outlet syndrome symptoms and painful motion respectively.  The panel adjudged that there was decreased probative value of the C&P examination due to its remoteness from separation, and that the STR had the highest probative value for rating at separation.  There was no limitation of motion of the shoulder to support a rating under diagnostic code 5201 (arm, limitation of motion).  Although the MEB examination did not note satisfactory objective evidence of painful motion, there was sufficient reasonable doubt to support a 10% rating IAW VASRD §4.59 and §4.45.  There was no other evidence for higher rating under VASRD §4.71a (musculoskeletal system).  However, there was significant evidence of right upper extremity functional loss (IAW §4.40) and the STR documented weakness (4/5 abduction and flexion) of the right shoulder with complaints of paresthesias of the arm including pain.  The panel therefore considered potential alternative rating under the schedule of ratings for muscle (VASRD §4.73 – surgery and weakness) or peripheral nerve (VASRD §4.124a – weakness and paresthesias) disability coding.  

The panel deliberated if the CI’s disability picture at separation was best represented by a 20% 8512 rating for mild incomplete paralysis of the lower radicular group (includes weakness and pain), or by a slight (0%) or moderate (20%) muscle injury rating under Group III (5303) coding.  The normal neuro-diagnostic testing specifically did not exclude long thoracic or dorsal scapular nerve lesions which may be associated with shoulder pain, radiculopathy, and weakness; and analogous peripheral nerve rating best described the CI’s disability picture at separation.  There was no separate upper back (thoracic spine) disability for separate rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 20% for the “chronic right upper back-shoulder pain” condition, coded 8599-8512.  

BOARD FINDINGS:  In the matter of the “chronic right upper back-shoulder pain” condition, the panel majority recommends a disability rating of 20%, coded 8599-8512 IAW VASRD §4.124a.  The single voter for dissent recommended modification to 10% and did not elect to submit a minority opinion.  There are no other conditions within the panel’s scope of review for consideration.  

The panel 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 Upper Back-Shoulder Pain	8599-8512	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160520, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170016857, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	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