RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE: pd-2017-00672
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20050728

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E5, Combat Engineer, medically separated for “chronic pain, left shoulder and left leg” with a disability rating of 20%.  

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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.

RATING COMPARISON:

SERVICE PEB - 20050628	VARD - 20070212	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Left Shoulder and Left Leg	5099-5003	20%	Chronic Left Shoulder Pain	5201	20%	20061205	
			Peripheral Neuropathy, Left Shoulder	8715	10%		
			Left Leg Condition	5262	NSC		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:

Left Shoulder and Left Leg.  The PEB combined the left shoulder and left leg conditions under a single disability rating, coded analogously to 5003 (arthritis, degenerative) and rated 20%.  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.  

According to the service treatment records and MEB narrative summary (NARSUM), the right-handed CI underwent left shoulder surgery in January 2004 (distal clavicle resection and coracoclavicular ligament reconstruction).  During that surgery, a left lower leg semitendonosus tendon (hamstring) was harvested to repair the shoulder, causing the CI’s left leg pain condition.  Upper and lower electrodiagnostic studies and neurological evaluations were normal.  Radiographic imaging (MRI) demonstrated susceptibility artifact at the anterior soft tissue of the left shoulder.  

During the 4 November 2004 MEB NARSUM examination, 9 months before separation, the CI reported left shoulder pain status post fixation of the left AC separation and (left) leg pain status after surgery for ligamentous graft that was used to repair the shoulder.  Physical examination showed tenderness in the left shoulder anterior subacromial bursa area.  There was left shoulder crepitus and pain with range of motion (ROM) testing.  ROM was forward flexion to 140 degrees (normal 180) with pain beginning at 70 degrees, and abduction to 180 degrees (normal) with pain beginning at 25 degrees.  The examiner stated that the CI had painful cramping response at the end of ROM in all planes.  

Treatment notes in March 2005 showed a left knee twisting injury.  Subsequent PT and orthopedic notes showed a medial collateral ligament tear with prescription of a hinged brace.  There was continued complaints of decreased flexibility with hamstring pain treatments through separation.  There was slight to minimal knee and ankle weakness noted in PT evaluations.  

During the 5 May 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported left shoulder and left leg pain tingling and numbness of left hand and fingers and left shin area with minimal strength.  Physical examination showed decreased ROM of the left shoulder, and a left knee brace in place.  There was “weakness at the left arm (due to shoulder pathology) and left leg (due to harvesting hamstring transplanted to shoulder).”  The examiner indicated left hand paresthesias due to left shoulder surgery and a cervical disc herniation.  

At the 5 December 2006 VA Compensation and Pension (C&P) evaluation, 16 month after separation, the CI reported constant achy pain, weakness, numbness, and decreased ROM in his left upper extremity.  The CI reported he had to be careful about gripping with his left hand, and had dropped cups and small items many times, unless he used both hands.  He was taking narcotic pain medication and neuroactive medication.  Physical examination of the left shoulder mild weakness (4/5) of the LUE with no muscle wasting or atrophy, and otherwise normal neurologic findings.  ROM was forward flexion to 120 degrees with moderate to severe limitation due to pain, with abduction of 140 degrees with moderate limitation due to pain.  There was increased pain and an additional 10 degree loss in ROM of the left shoulder with repetitive motion.  X-rays showed a small avulsion fracture superior to the acromion and degenerative changes.  

The panel directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB combined and rated the left shoulder and left leg conditions at 20%, coded analogously as 5003 (degenerative arthritis), citing application of the US Army Physical Disability pain policy.  The VA rated the left shoulder condition 20%, coded 5201 (arm, limitation of motion), based on the C&P examination 16 months after separation, citing limitation of arm motion at shoulder level.  The VA also rated left shoulder peripheral neuropathy 10%, coded 8715 (neuralgia, median nerve), citing mild incomplete paralysis of hand movements (attributed to the left shoulder and cervical spine conditions).  The VA did not service-connect the left leg condition, coded 5262 (tibia and fibula, impairment), citing no specific diagnosis provided.  

In this case, both the left shoulder and the left leg conditions were considered to fail retention standards (separately listed on the MEB), were implicated by the NARSUM and by the commander’s statement, and were separately profiled.  Panel members agreed that the evidence reasonably justified that the functional limitations of each condition contributed to the CI’s inability to perform his military duties; each was reasonably unfitting, and accordingly a separate disability rating is recommended for each.  The panel noted that the NARSUM and MEB examinations had the highest probative value for rating at separation.  The VA examination had decreased probative value due to its remoteness (16 months) from separation.  

Regarding separate rating of the left shoulder pain:  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 proximate to separation 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).  

The panel considered if alternative or additional left shoulder pain rating was warranted; however alternatively rating the shoulder pain under other VASRD codes (including neuritis/nerve pain IAW VASRD §4.124a) would not provide any rating higher than 10%, and given that only the left shoulder pain was in scope, there were insufficient additional symptoms for any dual ratings IAW VASRD §4.14 (avoidance of pyramiding).  

Regarding separate rating of the left leg:  The MEB examination showed left leg weakness.  There were treatment notes for left knee ligament strain and hip strain that also noted therapeutic intervention in the hamstring region.  The predominant left leg finding proximate to separation was paresthesias in the surgical area/hamstring area, with no objective evidence showing weakness of the ankle or knee joints.  Electrodiagnostic testing was negative and there were no organic changes documented.  Analogous rating for painful motion or weakness due to guarding (due to pain) of the semitendinosus tendon harvest surgical site was considered as ratable analogous to code 5262 (tibia and fibula, impairment) as slight knee or ankle disability at 10%.  

Alternative analogous rating of the leg pain under VASRD §4.124a (schedule of ratings–neurological conditions and convulsive disorders) would be no higher than 10% (slight to mild 8621-external popliteal nerve).  Separate ratings for each condition at 10%, as described above, would provide no higher rating than that adjudicated by the PEB.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the left shoulder and left leg condition.  

BOARD FINDINGS:  In the matter of the left shoulder and left leg condition 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.  Therefore, the panel recommends 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 20170207 w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20180004732, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	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