RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2017-05705
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061123

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an National Guard e6, Small Artillery Repairer, medically separated for “right (dominant) shoulder pain” and “long thoracic nerve palsy,” rated 10% and 0%, respectively, with a combined disability rating of 10%.   

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 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 - 20060818	VARD - 20061218	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder Pain	5099-5003	10%	S/P Rotator Cuff Surgery of Right Shoulder	5299-5203	10%	20060922	
			Status Post for Ruptured Right Biceps Tendon, Muscle Group III	5303	20%	20060922	
Long Thoracic Nerve Palsy	8519	0%	Long Thoracic Nerve Palsy, Right Upper Extremity	8519	10%	20060922	
COMBINED RATING:  10%	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’s right (dominant) shoulder condition began in January 2004, while deployed, with pain starting in the right shoulder and radiating down the arm with intermittent tingling sensation to the fourth and fifth digits.  No trauma or specific injury was reported, and evaluation revealed right scapula winging.  Electromyogram studies showed an isolated involvement of the long thoracic nerve (see below) superimposed on a rotator cuff injury.  Conservative treatment failed, and the first surgical procedure was a repair of the torn rotator cuff and debridement of a non-detached posterior superior glenoid labral tear in June 2004.  He then underwent an arthroscopic capsular release for postoperative adhesive capsulitis of the shoulder and a revision of the rotator cuff repair in September 2004.  During his rehabilitation, he ruptured the proximal long head of the biceps and subsequently underwent a biceps tenodesis (to connect the tendon to the shoulder) in January 2005.  Rehabilitation was complicated by the long thoracic nerve palsy, and at a neurology visit on 28 June 2005, he complained of right hand aching, numbness, and painful dysesthesia (abnormal sensation) which sometimes awoke him from sleep.  He also had some residual discomfort radiating from the hand and wrist up the forearm to the elbow and shoulder.  On examination, the scapula winging had improved compared to the previous year.  He had very minimally diminished rapid alternating movements of the right upper extremity compared to the left, and a slightly diminished biceps and brachioradialis reflex on the right.  A screening needle electrode study revealed some increased polyphasics in the biceps, deltoid, brachioradialis, and infraspinatus, but no acute denervation.  He was found to have a right carpal tunnel syndrome (not in the scope of review).  A mild personage turner syndrome (brachial neuritis) was suspected to have affected his long thoracic nerve and a Gm (1) ganglioside antibody was ordered to check for a multifocal motor neuropathy syndrome, the result of which was not in the STR.  On 16 June 2005, physical therapy documented right shoulder range of motion (ROM) measurements, in degrees, as:  flexion to 170 (normal 180), abduction 160 (normal 180), internal rotation to 70 (normal 90), with pain, and external rotation to 80 (normal 90).  Strength was normal for flexion, 4+/5 for abduction and external rotation, and 4-/5 for internal rotation.  

During the 12 July 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported surgeries on the right shoulder.  Physical examination showed right scapula winging, and ROM measurements, in degrees, revealed:  flexion to 125, extension to 70 (normal 45-60), abduction to 120, adduction to 20 (normal 30-50), internal rotation to 75, and external rotation to 40, with discomfort at endpoints.  The 28 July 2006 MEB NARSUM noted complaints of continued right shoulder pain, and the examiner found slight scapular winging, but no atrophy, edema, or spasm of the upper extremities or paraspinal musculature.  Shoulder ROM measurements were the same as those documented at the MEB examination, and elbow ROM showed extension to 0 degrees and flexion to 135 degrees.  Grip strength was good and reflexes and sensation were intact.  

At the 22 September 2006 VA Compensation and Pension (C&P) examination, 2 months before separation, the CI reported right shoulder pain with loss of strength and lowered endurance including fatigue.  The examiner noted reduced muscle tone of Group III muscles (pectoralis major I (clavicular) and deltoid) with strength graded at 4/5.  There was right bicep tendon damage but no muscle wound/herniation, edema, effusion, weakness, tenderness, redness, heat, or abnormal movement or guarding.  Right shoulder flexion was to 165 degrees, abduction to 110 degrees, external rotation to 60 degrees, and internal rotation to 40 degrees.  Pain occurred at the end of all of the motions, but there was no loss of motion with repetition.  An X-ray showed normal mineralization with the joint spaces well maintained and no soft tissue calcifications, fractures or osseous abnormalities.  

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 pain rated as slight/frequent IAW the US Army Physical Disability Agency pain policy.  The VA also rated the right shoulder condition 10%, but analogously coded 5299-5203 (clavicle or scapula, impairment of), based on the C&P examination, citing limitation by pain after repetitive use.  The VA additionally rated the right biceps tendon condition 20%, coded 5303 (Group III.  Function:  elevation and abduction of arm to level of shoulder), citing loss of power.  The PEB combined the results of the right rotator cuff injury and subsequent surgeries, and the biceps injury and subsequent surgery, as a single unfitting condition coded 5099-5003.  This approach commonly reflected the PEB’s judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The panel’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  It is clear that the various surgical procedures on muscles involved in shoulder motion and stabilization contributed to the disability in this case.  Therefore, panel members agreed that there were not separate conditions which could be reasonably justified as separately unfitting; nor would separate ratings be achievable without violation of VASRD §4.14 (avoidance of pyramiding).

Panel members noted that the VA rated the right biceps condition 20% based on Group III muscle injuries; however, those muscles include the pectoralis major and the deltoid rather than the rotator cuff and biceps which required and underwent surgical repair.  Therefore, the panel agreed that more appropriate codes for rating purposes are 5304 (Group IV.  Function: stabilization of the shoulder against injury in strong movements, holding head of humerus in socket; abduction; outward rotation and inward rotation of arm) and 5305 (Group V. Function:  elbow supination (biceps is a stabilizer of the shoulder joint) and flexion of the elbow).  Since both Group IV and Group V muscles are involved, what would warrant a 10% rating for each IAW VASRD §4.56 (evaluation of muscle disabilities) because of loss of power (although in the absence of trauma), could also provide a 20% rating IAW VASRD §4.55 (principles of combined ratings for muscle injuries), which states:  “For compensable muscle group injuries which are in the same anatomical region but do not act on the same joint, the evaluation for the most severely injured muscle group will be increased by one level and used as the combined evaluation for the affected muscle groups,” since the rotator cuff muscles stabilize shoulder movements.  However, the biceps not only stabilizes the shoulder, but is also involved in flexion of the elbow.  Therefore, two separate joints are involved and the combined evaluation for the affected muscle groups can achieve a rating one level higher.  Therefore, the panel favored a 20% rating using the dual code 5304-5305.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the right shoulder condition, coded 5304-5305.  

Long Thoracic Nerve Palsy.  According to the STR and MEB narrative summary (NARSUM), the CI’s long thoracic nerve palsy began in May 2003 after he felt a pop in the right shoulder while doing pushups.  The palsy did not completely improve and he was unable to perform pushups, prolonged overhead activity, and heavy lifting with the right upper extremity.  The 28 June 2005 neurology evaluation findings were discussed above, and the MEB NARSUM examiner found bilateral deep tendon reflexes at 2/4.  Sensation to light touch and pinprick were intact throughout as was two-point discrimination to the fingertips, and he had good grip strength.

At the VA C&P examination, the CI reported right shoulder pain, and physical findings showed abduction motor weakness most likely related to the long thoracic nerve.  Right shoulder flexion was as noted above, with endpoint pain in all planes but no loss of motion with repetition.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the long thoracic nerve palsy 0%, coded 8519 (long thoracic nerve, paralysis of: mild), citing mild, incomplete paralysis.  The VA rated the long thoracic nerve palsy 10%, coded 8519 (long thoracic nerve, paralysis of: moderate), based on the C&P examination, citing motor weakness of 4/5 in the right upper extremity.  Panel members noted that the long thoracic nerve innervates in the serratus anterior muscle, which is involved in forward and upward rotation as well as elevation of the arm.  However, the rotator cuff muscles are also involved in the same movements.  Shoulder flexion was recorded as normal at all of the documented visits postoperatively, and while internal and external rotation were decreased at the VA examination, it was not delineated which muscles were less than fully functional.  Since the CI underwent two separate rotator cuff surgical procedures, it is more likely than not that the majority of the diminution in ROM related to rotation motions was related to rotator cuff musculature rather than the serratus anterior muscle, especially since there was only slight winging of the scapula, which represented an improvement from a prior examination.  Therefore, the panel majority favored the long thoracic nerve palsy disability to be closer to mild than moderate at the time of separation, thereby warranting a 0% rating rather than a 10% rating.  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 long thoracic nerve palsy.   

BOARD FINDINGS:  In the matter of the right shoulder condition, the panel recommends a disability rating of 20%, coded 5304-5305 IAW VASRD §§4.55, 4.56, and 4.73.  In the matter of the long thoracic nerve palsy and IAW VASRD §4.124a, the panel majority recommends no change in the PEB adjudication.  The single voter for dissent recommends modification to 10% and did not elect to submit a minority opinion.  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, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Shoulder Pain	5304-5305	20%	
Long Thoracic Nerve Palsy	8519	0%	
COMBINED	20%	

The following documentary evidence was considered:

AR20200004346

Dear XXXXXXXXXXXXXXXXXXXXXXXX:

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.