RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01120
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040101

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Food Service Specialist, medically separated for “right (dominant) shoulder and neck pain” with a disability rating of 0%.  

CI CONTENTION:  The CI contends her condition should have been rated higher.  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 - 20030902	VARD - 20040421	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right (Dominant) Shoulder and Neck Pain	5099- 5003	0%	Chronic Right Shoulder Pain	5299-5203	10%	STR	
			Chronic Cervical Spine Pain	5242	10%	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Right (Dominant) Shoulder and Neck Pain:  The PEB combined the right shoulder, and neck conditions under a single disability rating, coded analogously to 5003 and rated 0% with application of the US Army Physical Disability Agency (PDA) pain policy and AR 635-40 B24.f.  This 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 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 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 right shoulder and neck conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-hand dominant CI injured her right shoulder and neck in Sept 2001 during an airborne parachute jump.  Right shoulder X-rays in January 2002 and June 2003 were normal.  February 2002 magnetic resonance imaging (MRI) of the right shoulder, requested for impingement signs, showed a small amount of fluid in the bursa without evidence of internal derangement or impingement syndrome.  X-rays of the cervical spine in June 2003 showed a normal cervical spine.  

According to the 22 July 2003 MEB NARSUM evaluation, 5 months prior to separation, the CI complained of right shoulder and cervical pain.  Earlier treatments in 2001 were for a right trapezius muscle strain and pain that was determined to be associated with a brachial nerve plexus by Physical Therapy (PT).  Orthopedic consultation did not find a surgical cause for the pain and recommended continuing PT.  The CI underwent a year of treatment by Physical Medicine and Rehabilitation including injections to the upper back, occupational therapy, acupuncture, and osteopathic manipulation.  

Physical examination showed tenderness to the right trapezius and shoulder area with no evidence of shoulder instability.  After repetitive motion, right shoulder flexion was 150 degrees (normal 180) and abduction was 100 degrees (normal 180).  There was painful motion on abduction and elevation.  A Physical Therapy MEB range of motion (ROM) examination done 11 days earlier showed right shoulder flexion at 135 degrees, and abduction was 180 degrees, without mention of painful motion.  The neck examination noted right cervical tenderness, with “extension fully with pain that shoots to the right trapezius, scapula.”  Left rotation was painful, with no pain on right rotation or flexion.  Cervical spine ROM measurements performed by PT on 11 July 2003, (5 months before separation) showed flexion of 40 degrees (normal 45) and combined ROM of 255 degrees (normal 340).  The NARSUM examiner’s diagnosis was myofascial pain syndrome of trapezius, rhomboids, and brachioradialis.  There was no VA examination in evidence proximate to separation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under an analogous 5003 code (arthritis, degenerative), citing the PDA pain policy as noted above.  The VA rated the right shoulder condition 10%, coded using an analogous 5203 code (clavicle or scapula, impairment of), based on the MEB examination finding of painful and limited motion, citing the 10% 5203 criteria.  The VA rated the neck condition 10%, coded 5242 (degenerative arthritis of the spine), based on the MEB examination finding of pain on motion, citing the 10% spine criteria.  

The panel first considered if the neck and/or right shoulder, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The service profile dated 21 May 2003 listed both “chronic shoulder pain” and “chronic neck pain,” and the commander’s statement cited the profile restrictions including no ruck marching, no pushups, no sit-ups, no running, and no airborne operations, as well as indicating that the CI could no longer perform airborne operations, or participate in daily-platoon physical training.  The panel concluded there was not a preponderance of evidence in the service records which overcame the panel’s presumption that the shoulder condition or neck condition was reasonably considered separately unfitting.  The panel then considered its rating recommendation for the unfitting shoulder and unfitting neck conditions at the time of separation.  

Regarding rating the shoulder condition, 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, panel members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion).  There was no malunion or recurrent dislocation of the humerus to justify a rating under the 5202 code (humerus, other impairment of); and no nonunion with loose movement of the clavicle to warrant the next higher 20% rating under the 5203 code (clavicle or scapula, impairment of).  Regarding coding, there were no shoulder joint degenerative changes, however, there was evidence of bursal effusion, with a current diagnosis of myofascial pain syndrome; therefore the panel adjudged that analogous coding to 5021 (myositis) was predominate.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the right shoulder condition, coded 5299-5021.  

Regarding rating the neck condition, a 10% rating, but no higher, was justified for tenderness and painful motion noted documented on the NARSUM or for limitation of flexion (greater than 30 degrees but not greater than 40 degrees) and combined ROM (greater than 170 degrees but not greater than 335 degrees), as reported on the MEB PT examination proximate to separation.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the neck condition, coded 5237 (cervical strain).  

BOARD FINDINGS:  In the matter of the bundled right shoulder and neck pain condition, the panel unanimously recommends that each joint/spine segment be separately adjudicated as follows:  an unfitting right shoulder condition coded 5299-5021 and rated 10%, and an unfitting neck condition, coded 5237 and rated 10%, both IAW VASRD §4.71a.  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 Shoulder Pain	5299-5021	10%	
Chronic Cervical Spine Pain	5237	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160918, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170018654, 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