RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1100812 SEPARATION DATE: 20071115 BOARD DATE: 20121113 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (13F/Fire Support Specialist), medically separated for a chronic pain, right (dominant) shoulder condition. The CI initially injured the right shoulder in 2003 and was managed conservatively. He reinjured the shoulder and underwent an arthroscopic repair in 2005 with good results. He was able to deploy, but had recurrent pain which lead to a second operation in 2007. Despite rehabilitation, he could not meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was consequently issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded “right shoulder pain, nonspecific” to the Physical Evaluation Board (PEB) as medically unacceptable IAW AR 40-501. No other conditions were submitted by the MEB. The PEB adjudicated the chronic pain, right (dominant) shoulder condition as unfitting, rated 0% analogously to 5003 (arthritis), with application of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals and was medically separated with a 0% disability rating. CI CONTENTION: “I received a medical board for chronic pain right (dominant) shoulder. The medical board should have reviewed the right superior labrum anterior and posterior tear with subacromial bursitis and impingement status post surgical intervention with residual scars.” SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings for unfitting conditions will be reviewed in all cases. The right shoulder condition requested for consideration meets the criteria prescribed in DoDI 6040.44 for Board purview; and is addressed below. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Army Board for Correction of Military Records. RATING COMPARISON: Service IPEB – Dated 20070718 VA (3 Mos. Pre -Separation) – All Effective Date 20071116 Condition Code Rating Condition Code Rating Exam Chronic Pain, R Shoulder 5099-5003 0% Right Superior Labrum Tear…with Residual Scars 5299-5201 30%* 20070823 .No Additional MEB/PEB Entries. Adj Disorder with Anxiety 9499-9440 30% 20070823 Deg Arthritis of the LS Spine 5003-5242 20% 20070823 RPPS 5299-5260 10% 20070823 Right Ankle Strain 5299-5271 10% 20070823 Tinnitus 6260 10% 20070823 0% X 3 / Not Service-Connected x 2 20070823 Combined: 0% Combined: 70% *Decreased to 20% effective 20101001. ANALYSIS SUMMARY: Chronic Pain, Right (Dominant) Shoulder Condition. There were three goniometric range-of- motion (ROM) evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below. Right Shoulder ROM (measurements in degrees) MEB ~6 Mo. Pre-Sep PT ~5 Mo. Pre-Sep VA C&P ~3 Mo. Pre-Sep Flexion (0-180) 150 156, 164, 160 110 Abduction (0-180) 140 135, 145, 143 145 Comments Neg O’Brien; neg drop-arm; neg cross-arm; neg Hawkins; anterior tenderness ROM limited by pain Painful motion; guarding; but no weakness, tenderness, redness; heat; subluxation No additional loss of motion with repetition §4.71a Rating 10% 10% 10% The right hand dominant CI was first seen for right shoulder pain on 26 February 2003. He reported 2 months of pain which had begun after snowboarding. He was managed conservatively with medications and physical therapy with resolution. He was next seen 31 March 2005 for a rotator cuff injury after playing basketball. He did not respond to conservative management. Magnetic resonance imaging (MRI) examination performed on 19 June 2005 showed a labral tear and he had arthroscopic repair of the right superior anterior and posterior labrum. His recovery was good and he was able to deploy on 24 January 2006. He had recurrent pain after load bearing, though, and was found to have a recurrent rotator cuff tear. On 8 February 2007, he underwent a second procedure to repair his shoulder. He did not improve sufficiently to meet his MOS requirements and was issued a U3 profile and referred to MEB. The narrative summary (NARSUM) was dictated on 15 May 2007, 6 months prior to separation by the treating orthopedic surgeon. The CI was noted to be unable to meet either the requirements of his MOS or basic soldiering tasks. He was also unable to throw, lift heavy objects or work over head. He reported slight pain. On examination, he had anterior tenderness over the biceps tendon and anterior deltoid. Specific tests for impingement, acromioclavicular dysfunction and rotator cuff pathology were negative. He was determined to have non-specific right shoulder pain. The ROM is above. At the VA Compensation and Pension (C&P) exam performed on 23 August 2007, 3 months prior to separation, the CI reported weakness, morning stiffness, swelling after use, giving way, lack of endurance and numbness at the surgical sites. He had pain with increased activity and good relief from medications. His impairment was from limited lifting and repetitive motion. The scars were well healed with some hyper-pigmentation, but otherwise unremarkable. Movement was guarded, but there was no edema, effusion, weakness, tenderness, redness, heat or subluxation. The ROM is above. On repetitive motion, there was no additional loss in ROM, but the CI did note pain, weakness, and lack of endurance with pain having the greatest impact. The neurological examination was normal. An X-ray of the right shoulder was normal. He was diagnosed with right labral tear and sub-acromial bursitis and impingement status post (s/p) surgery with residual scars. The Board noted the CI’s contention that the medical board “should have reviewed the right superior labral anterior and posterior test with subacromial bursitis and impingement status post surgical intervention with residual scars.” This statement is, in fact, the C&P examiner’s assessment. The Board noted that the orthopedic surgeon who performed the second operation also dictated the MEB NARSUM and was a member of the MEB. The MEB NARSUM clearly outlines the procedures which the CI underwent. The NARSUM and MEB recommendation to the PEB are reviewed as part of the PEB adjudication. The Board determined that the medical board did perform the review for which the CI contends. The Board directs attention to its rating recommendation based on the above evidence. There is no evidence in the record that the scars interfered with the wear of military uniforms or equipment and the VA examination was unremarkable. There is no basis upon which to determine that the scars were unfitting and thus compensable. The PEB rated the shoulder at 0%, coded 5099-5003, for pain using the USAPDA pain rule. The VA initially rated the shoulder at 30% for a limitation in motion not in evidence on the VA examination or any other examination proximate to separation. The Board determined that the VA examination and the MEB examinations all showed motion above the level of the shoulder. The Board also noted that the VA reduced the rating to 20% after separation using a second C&P examination which actually showed a further reduction in motion. Under code 5201, limitation of motion, motion above the shoulder level rates at 0%. Motion limited to the shoulder level supports a 20% rating. A 30% rating requires motion to be limited to midway between the side and shoulder level. A 10% rating is supported, though, under code 5003, degenerative arthritis, due to limitation of motion which is not otherwise compensable in the presence of objective findings. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right shoulder condition, coded 5099-5003. BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. As discussed above, PEB reliance on the USAPDA pain policy for rating the right shoulder pain was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the right shoulder condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation: UNFITTING CONDITION VASRD CODE RATING Chronic Pain, Right (Dominant) Shoulder 5099-5003 10% COMBINED 10% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20110927, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxx, DAF President Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxxxx, AR20130004942 (PD201100812) 1. I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation to modify the individual’s disability rating 10% without recharacterization of the individual’s separation. This decision is final. 2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum. 3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures. BY ORDER OF THE SECRETARY OF THE ARMY: Encl xxxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)