RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04733
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060306

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Administrative Specialist, medically separated for “chronic shoulder pain with distal clavicle excision” and “chronic thoracic facet mediated pain without neurologic deficit,” rated 10% each, with a combined disability rating of 20%. 

CI CONTENTION:  Review requested of the medical evidence with consideration of a new rating.  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 - 20060120	VARD - 20060403	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder Pain…	5099-5003	10%	Residuals Right Shoulder Acromioplasty, with Biceps Tendonitis and Arthritis	5201	30%	STR	
Thoracic Facet Pain…	5299-5242	10%	Thoracic Facet Mediated Pain	5242	40%	STR	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Right Shoulder Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI had a long history of right (dominant) shoulder pain, but his Service entry physical in January 1994 showed no evidence of shoulder impairment.  He reportedly sustained a significant right shoulder injury in a motor vehicle accident in 2000 and then hurt it again doing pushups in January 2003.  Despite undergoing a right distal clavicle excision in December 2003, he continued to have persistent shoulder pain.  An MRI in February 2005 showed evidence of abnormal areas of signal in the rotator cuff tendon, likely representing a chronic partial tear versus tendon changes or tenosynovitis, and humeral head degenerative changes.  

During the 30 August 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, the CI reported shoulder, neck and back pain for which he took oxycodone (opioid), and Mobic (nonsteroidal anti-inflammatory), and Elavil (anti-depressant for sleep) .  He also described injuries and surgeries as reported above.  Physical examination revealed anterior aspect and acromial region tenderness, but no redness or edema.  Motor strength was decreased to 4/5 in all planes, but sensation was intact.   There was evidence of decreased flexion, abduction, extension, internal and external rotation, with pain.  The 31 August 2005 orthopedic range of motion (ROM) measurements revealed flexion to 70 degrees (normal 180) and abduction to 40 degrees (normal 180), with tenderness.  

During the 1 December 2005 MEB addendum examination, 3 months before separation, the CI reported constant pain worsened by any kind of activity or lifting.  The discomfort was mainly located in the anterior aspect of his shoulder.  Physical examination revealed pain-free ROM with “forward flexion abduction up to 85 degrees.”  Rotator cuff strength was 5/5 and equal bilaterally, and provocative maneuvers (Hawkins, Neer, and O’Brien) were all positive for impingement.  There was no objective instability or generalized laxity, and motor and sensory functions were intact.  The condition was noted as stable, but he was unable to perform his duties due to shoulder pain and lack of mobility.  

The 27 February 2006 orthopedic evaluation, 1 week prior to separation, showed tenderness at the right bicipital groove, but no clavicle abnormalities.  Right shoulder ROM tests showed forward flexion to 70 degrees, and abduction to 45 degrees with tenderness.  There was no evidence of instability, dislocation or other abnormalities. 

During the 3 March 2006 VA C&P examination, 3 days prior to separation, the CI reported right shoulder pain that interfered with recreational activities and bathing/sex, but not eating or toileting.  He also had trouble performing motions requiring torque, e.g. opening a jar, and could not do push-ups.  Physical examination showed the right arm “glued” to his side during ambulation, secondary to pain.  There was no muscle atrophy at the deltoid, but there was tenderness through the lateral aspect of the shoulder.  Forward flexion was to 30 degrees and abduction to 20 degrees, with painful motion noted in all planes.  

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 ROM limited by pain and the US Army Physical Disability Agency (USAPDA) pain policy.  The VA rated the right shoulder condition 30%, coded 5201 (limitation of the arm motion), based on the C&P examination, citing limitation of right arm motion midway between side and shoulder level.  Members deliberated over the probative value of the conflicting evaluations, with review of the overall evidence for corroboration.  The MEB addendum cited “forward flexion abduction to 85 degrees,” and it was unclear whether the measurement reflected flexion, abduction or both.  The C&P examination, 3 days prior to separation, cited flexion to 30 degrees and abduction to 20 degrees.  Since these measurements were inconsistent with findings in the rest of the STR, and no explanation was provided for the findings, the panel concluded they were of lesser probative value.  The panel noted the August 2005 and the February 2006 orthopedic examinations had the highest probative value since findings were consistent and the second examination was conducted 1 week prior to separation.  The VASRD §4.71a threshold for rating for ROM impairment under code 5201, is “at shoulder level” (approximately 90 degrees from the side).  A 30% rating for the dominant arm requires motion limited to “midway between side and shoulder level,” and the both orthopedics examinations reflected this degree of limitation.  There was no malunion with marked deformity or frequent episodes of recurrent dislocation of the humerus to justify a higher rating under code 5202 (humerus, other impairment of), and no higher rating available under code 5203 (clavicle or scapula, impairment of).  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the right shoulder condition, coded 5201.  

Thoracic Facet Mediated Pain.  According to the STR and MEB NARSUM, the CI developed facet mediated pain at the cervical and thoracic levels after experiencing a hard helicopter landing in 1994, and being involved in three MVAs.  Conservative treatment did not resolve the pain, but thoracic X-rays and a neck CT scan were normal.  

The 25 August 2005 MEB physical therapy (PT) ROM study, 7 months prior to separation, revealed thoracolumbar flexion to 30 degrees (normal 90), extension to 10 degrees (normal 30), and a  combined ROM of 100 degrees (normal 240), after repetition.  The examiner noted all measurements were pain limited.  During the 30 August 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), the CI reported chronic thoracic and neck pain which radiated to the lumbar spine with activity.  Physical examination of the thoracolumbar spine showed paraspinal tenderness on the right side, and decreased ROM in all planes with pain.  There was mild curvature of the thoracic spine and gait was antalgic.  The commander’s statement on 31 August 2005 noted the CI’s physical condition precluded him from completing office daily tasks.  

The 20 December 2005 MEB NARSUM examination, 3 months before separation, noted complaints of back pain at the T6-T8 levels, just to the right of midline, and exacerbated by prolonged sitting or walking, lifting greater than 15-20 pounds, and sleeping on his right side.  A February 2002 MRI showed mild thoracic dextroscoliosis.  A diagnosis of intermittently severe, chronic moderate thoracic facet mediated pain was rendered.  Physical examination showed kyphocoliosis with minimal dextroscoliosis, full lumbar and cervical ROM, and tenderness on the right at T6-T7, with positive provocative facet thoracic pain. 

During the VA C&P examination, the CI reported daily pain, weakness, stiffness, fatigue and lack of endurance in the thoracic facet area, but denied any associated radiculopathy or required bedrest for incapacitating episodes during the past 12 months.  He was able to walk about half a miles with no unsteadiness, but could not sit for prolonged periods, and had difficulty putting on socks or tying shoes.  The pain was worsened by physical activity and inclement weather, and improved with rest and medication.  He wore a lumbar back support during vigorous physical activity.  The examiner noted the CI walked with an “element of rigidity” and had difficulty looking down as he walked.  There was tenderness through T7-9 on the right, and thoracolumbar flexion was to 20 degrees, with a combined ROM of 130 degrees and painful motion noted in all planes.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the thoracic facet condition 10%, analogously coded 5299-5242 (degenerative arthritis of the spine), citing pain without neurological deficit, ROM limited by pain and positive tenderness IAW with the USAPDA pain policy.  The VA rated the thoracic facet condition 40%, coded 5242, based on the C&P examination, citing thoracolumbar forward flexion of 30 degrees or less.  Again, members deliberated the probative value of the conflicting evaluations, with review of the overall evidence for corroboration.  The C&P examination was more proximal to separation, but findings were inconsistent with the record and there was no explanation for the limited flexion.  The panel thus place greater probative value on the MEB NARSUM examination.  Although full ROM was documented, there were findings of kyphoscoliosis, thereby meeting criteria for a 20% rating.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the thoracic condition, coded 5299-5242.   
BOARD FINDINGS:  In the matter of the right shoulder condition, the panel recommends a disability rating of 30%, coded 5201 IAW VASRD §4.71.  In the matter of the thoracic facet condition, the panel recommends a disability rating of 20%, coded 5299-5242 IAW VASRD §4.71.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Right Shoulder Pain	5201	30%	
Chronic Thoracic Facet Mediated Pain	5299-5242	20%	
COMBINED	40%	

The following documentary evidence was considered:

 [AR NUMBER], XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

I accept the recommendation of the Department of Defense Physical Disability Board of
Review (DoD PDBR) to re-characterize your separation as a disability retirement with the
combined disability rating of 40% effective the date of your medical separation for disability with
severance pay. Enclosed is a copy of the Board’s recommendation and record of proceedings
for your information.
The re-characterization of your separation as a disability retirement will result in an
adjustment to your pay providing retirement pay from the date of your original medical
separation minus the amount of severance pay you were previously paid at separation.
The accepted DoD PDBR recommendation has been forwarded to the Army Physical
Disability Agency for required correction of records and then to the U.S. Defense Finance and
Accounting Service to make the necessary adjustment to your pay and allowances. These
agencies will provide you with official notification by mail as soon as the directed corrections
have been made and will provide information on your retirement benefits. Due to the large
number of cases in process, please be advised that it may be several months before you
receive notification that the corrections are completed and pay adjusted. Inquiry concerning
your correction of records should be addressed to the U.S. Army Physical Disability Agency,
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557.
A copy of this decision has also been provided to the Department of Veterans Affairs
and to the counsel you listed on your application,
.

Enclosure