RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03643
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080626

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E2, medically separated for “right shoulder pain secondary to snapping scapula syndrome” with a disability rating of 10%.  

CI CONTENTION:  “My shoulder (RT side) is getting worse.  It now binds and pops a lot (lots of pain) (falls asleep a lot).”  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 - 20080509	VARD - 20080922	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder Pain… 	5099-5003	10%	Right Shoulder Degenerative Joint Disease	5014	10%	20080724	
Right Hip Pain Following Femur Fracture	5299-5255	 --%*					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	
*PEB determined the condition was not in the line of duty and did not rate.

ANALYSIS SUMMARY:  

Right Shoulder Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s right (dominant) shoulder condition began in April 2006 after another soldier fell on his shoulder during basic training.  At a primary care visit in February 2007, he complained of constant throbbing pain, but right shoulder X-ray and neuroimaging over the next few months was negative.  His pain persisted and he was given a profile and referred to physical therapy (PT).  Orthopedic evaluation on 7 June 2007 rendered a diagnosis of periscapular pain possibly due to a snapping scapula.  At a follow-up visit, the provider noted the CI was not compliant with PT and could voluntarily snap his scapula.  He had tenderness along the medial border of the scapula, but negative impingement signs and normal strength.  A contrast tomography (CT) scan was negative.

The CI had a motorcycle accident on 1 September 2007 and suffered a fracture of the right shoulder acromion and glenoid neck (as well as the right femur).  The accident was determined to be “not in the line of duty.”

At a primary care visit on 18 October 2007, the CI complained of continued daily pain and difficulty lifting objects over his head, but reported no loss of grip strength.  He was reevaluated in orthopedics on 23 January 2008, and X-rays showed a small, well-healed and non-displaced fracture through the base of the glenoid.  The examiner assessed possible acromioclavicular (AC) arthrosis, impingement, and a snapping scapula with some myofascial pain; and opined that progression of the pain and symptoms might require right shoulder arthroscopy.  

During the 7 May 2008 MEB NARSUM examination, 2 months prior to separation, the CI reported constant pain and that he could not lift or carry greater than 10 pounds, perform activities of daily living (ADLs), or accomplish the Army fitness test.  He had undergone extensive PT and missed multiple duty days, and was taking a narcotic daily for pain with some relief.  Physical examination showed tenderness and decreased, painful abduction and forward flexion.  Right shoulder strength was 4/5 and decreased in abduction at the deltoid, biceps and triceps; the other muscle groups were 5/5 and symmetric with the left.  The provider referred to a PT range of motion (ROM) evaluation from 3 March 2008 which showed average active flexion after three measurements to 118 degrees (normal 180) and abduction to 117 degrees (normal 180).  The ROM study showed that limitation of motion was due to pain and repeated flexion produced tremors and pain with tingling over the third, fourth and fifth fingers.  Repeated abduction caused “popping” and “binding” in the shoulder, and painful internal and external rotation produced weakness after repetition.  The NARSUM examiner diagnosed right shoulder pain/snapping scapular syndrome, and opined that the increased symptoms did not “translate into further decrement” in the ROM and that to say they could be “translated into additional functional limitations” would be “speculation.” 

At the 24 July 2008 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported intermittent pain rated at 3-7/10 and aggravated by weather changes and lifting weight above the shoulder.  He also complained of popping and grinding sounds, and took pain medication daily which seemed to help, as did cold packs and stretching.  He denied dislocation but suspected subluxation.  He was able to perform ADLs, but had difficulty raising his right arm above his shoulder when dressing.  He also reported the shoulder condition slowed his pace of work as a locator for a boring machine and limited his ability to snowmobile more than once a week.  Physical examination of the shoulders showed symmetry with no signs of swelling, masses, deformity or atrophy.  There was tenderness over the sub-acromion process and “objective evidence of weakness, crepitation, guarding of movement and painful motion as evidenced by facial grimace,” but no swelling, instability or abnormal movement.  Right shoulder ROM showed flexion to 120 degrees and abduction to 105 degrees.  After repetition, pain further limited flexion to 110 degrees and abduction to 100 degrees, but there were no additional limitations due to fatigue, weakness, or lack of endurance.  The examiner annotated shoulder strength as 5/5 bilaterally.  Diagnostic imaging revealed “very mild degenerative change” of the right AC joint.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder condition 10%, analogously coded 5099-5003 (arthritis, degenerative), citing shoulder weakness as a residual of a humeral fracture in the motorcycle accident and preceded by shoulder pain, with limited and painful ROM.  The VA rated the right shoulder condition 10%, coded 5010 (arthritis, due to trauma, substantiated by x-ray findings), based on the STR or C&P examinations, citing limited, painful motion.  Members noted that the VASRD §4.71a threshold for rating ROM impairment (code 5201, arm limitation of motion) is “at shoulder level” (approximately 90 degrees from the side), and ROM testing demonstrated motion above this level.  However, the panel agreed that the MEB and C&P examinations justified a 10% rating for painful motion with application of VASRD §4.59 (painful motion).  There was no malunion or recurrent dislocation of the humerus to justify a rating under code 5202, and no nonunion with loose movement of the clavicle to warrant the next higher 20% rating under code 5203.  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 right shoulder condition.  

BOARD FINDINGS:   In the matter of the right shoulder pain condition and IAW VASRD §4.71a, the panel 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 20170514, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180010036, 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