RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-05230
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20080914

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Automated Logistics Sergeant, medically separated for “left shoulder pain” and “dysthymic disorder” rated 10% each, with a combined disability rating of 20%.   

CI CONTENTION:  “Degradation of 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 - 20080520	VARD - 20081114	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Shoulder Pain	5099-5003	10%	Left Shoulder Strain	5024	10%	20080930	
Dysthymic Disorder	9433	10%	Dysthymic Disorder	9433	10%	STR	
Lumbago	Not Unfitting	Low Back Strain	5237	NSC	20080930	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Left Shoulder Pain (Non-Dominant).  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent an inferior capsular shift in March 1997 and in August 2007 he underwent diagnostic arthroscopy for evaluation of his pain.  The shoulder had remained stable after the first procedure, but the CI had persistent pain.    

During the 4 December 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 9 months prior to separation, the CI reported constant left shoulder pain described as throbbing and stabbing with associated numbness and tingling in the left arm and palm of his hand.  The CI also reported limited range of motion (ROM), weakness and decreased strength which was aggravated by overhead activities, reaching movements, carrying loads and driving.  Physical examination showed tenderness, pain limited ROM and motor strength of 4/5.   

The 25 January 2008 MEB NARSUM examination, 8 months prior to separation, noted complaints of persistent pain.  Physical examination revealed pain to deep palpation anteriorly as well as pain with Neer and Hawkins testing (for shoulder impingement).  There was no swelling, induration, edema, warmth or significant muscle atrophy.  The shoulder showed no signs of instability.  Active ROM after repetition was forward flexion of 150 degrees (normal 180) and abduction of 162 degrees (normal 180) with measurements limited by pain.  

At the 30 September 2008 VA Compensation and Pension (C&P) evaluation, less than 1 month after separation, the CI reported pain, weakness, stiffness, occasional swelling, instability, fatigability and lack of endurance with flare-ups occurring once a month and lasting for 1-2 days.  Physical examination showed no swelling, erythema or disuse atrophy.  Tenderness of the subscapular region was present and the left shoulder was higher than the right.  ROM was 180 degrees forward flexion and 180 degrees abduction with no loss in motion after three repetitions.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the left shoulder condition 10%, coded 5099-5003 (analogous to degenerative arthritis), citing painful limitation of motion.  The VA also rated the left shoulder condition 10%, coded 5024 (tenosynovitis), based on the C&P examination, citing painful or limited motion of a major joint.    

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).  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 condition.

Dysthymic Disorder.  According to the STR and MEB NARSUM mental health (MH) addendum, the CI initially sought MH treatment in 1998-99 and was started on Zoloft which he only took briefly and did not continue MH treatment.  The CI “just recently” sought MH treatment due to issues with his temper.  He was prescribed Wellbutrin and Ambien for sleep.  During the MEB examination the CI reported difficulty sleeping, frequent nightmares and problems with loud noises.   
  
The 13 February 2008 MEB MH NARSUM examination, 7 months prior to separation, the CI reported poor appetite, sleep and energy.  He had not behaved violently but had raised his voice and yelled.  The CI had a girlfriend off and on for the past 2 years and had two marriages.  His mother was his source of emotional support and lived with him during the winter months.  Mental status examination was unremarkable with the exception of depressed mood and affect.  There was no history of visits to the emergency room for MH symptoms or hospitalizations.  Suicidal or homicidal ideation was absent.  The examiner diagnosed dysthymic disorder “manifested by depressed mood for most of the day or more days than not for at least 2 years accompanied by anorexia, insomnia and anergia.”  The examiner stated that “occupationally and socially he will have mild or transient symptoms which decrease his work efficiency and ability to perform occupational tasks during periods of significant stress and will require continuous medication.”
The 5 May 2008 psychiatric memorandum, 4 months before separation, prepared by a different psychiatrist, agreed with the NARSUM examiner’s assessment of the CI, but indicated the CI’s occupational was more consistent with “reduced reliability and productivity and difficulty in establishing and maintaining effective work relationships.”  The author of the memorandum indicated the opinion was based on a review of the NARSUM and commander’s letter.  There was no VA Compensation and Pension (C&P) MH evaluation in evidence. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the dysthymic disorder 10%, coded 9433 (dysthymic disorder), citing mild or transient  symptoms which decreased work efficiency and ability to perform occupational tasks only during periods of significant stress with symptoms controlled by continuous medications.  The VA also rated the dysthymic disorder 10%, coded 9433, based on the STR, citing mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress with symptoms controlled by continuous medications.     

Panel members first agreed that VASRD§ 4.129 was not applicable because the CI’s mental disorder was not the result of a highly stressful event.  The panel next considered the rating recommendation.  There was no emergency room treatment or hospitalizations and the CI only received minimal treatment.  There was no report of panic attacks, problems with concentration, chronic insomnia or legal issues.  The NARSUM examination documented his disorder was mild.  

The commander’s statement, 5 months before separation, documented that the CI attended work every day, maintained an acceptable level of attention and concentration to carry out instructions and completed tasks in a timely manner and related civilly to supervisors and co-workers.  The commander provided no evidence that the CI’s condition had significantly affected his ability to perform the duties of his MOS.  It was noted that the CI had to write down certain things in order to remember them.

Panel members agreed that a 10% rating and no higher was justified for “occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication.  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 dysthymic disorder.  

Contended PEB Condition:  Lumbago.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled, implicated in the commander's statement or judged to fail retention standards.  At the time of the NARSUM examination the CI had not been evaluated for his back pain.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the left shoulder condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the dysthymic disorder, and IAW VASRD §4.130, the panel recommends no change in the PEB adjudication.  In the matter of the contended back condition, the panel agrees that it cannot recommend it for additional disability rating.  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 20170511, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record  

AR20180007373, 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