RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXX CASE: PD1201067 BRANCH OF SERVICE: ARMY BOARD DATE: 20130410 SEPARATION DATE: 20020212 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (12B/Combat Engineer) medically separated for a chronic thoracic area pain and myofascial pain syndrome (MPS) of upper back and shoulders. The CI experienced bilateral scapula and shoulder pain in 1999 while performing push-ups. He has been seen by the pain management clinic, orthopedics, and physical therapy and modified his activities with no resolution of symptoms. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB). The condition, characterized as two separate conditions of “chronic thoracic spine pain and myofascial pain syndrome,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB (IPEB) adjudicated “chronic thoracic area pain and myofascial pain syndrome of upper back and shoulders” as a single unfitting condition, rated 0%, citing the US Army Physical Disability Agency (USAPDA) pain policy. The CI requested a formal hearing, but waived the request prior to hearing date; he was then medically separated with a 0% disability rating. CI CONTENTION: “Veteran was separated February 12, 2002 by MEB/PEB. He was seen by VA medical staff nurse practitioner Lamphier at Fort Harrison VAMC beginning April 25, 2002 for the disabilities that led to his involuntary discharge. At that time he was awarded 50% rating for the same conditions that led to his disability separation with a 0% rating. Due to the disparity in rating evaluations Veteran requests a review of his file for the purpose of records correction.” SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. Ratings for unfitting conditions will be reviewed in all cases. The unfitting chronic thoracic area pain and MPS of upper back and shoulders condition meets the criteria prescribed in DoDI 6040.44 for Board purview. 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 Board for Correction of Military Records. RATING COMPARISON: Service IPEB – Dated 20011115 VA - (2 Mos. Post-Separation) Condition Code Rating Condition Code Rating Exam Chronic Thoracic Area Pain & Myofascial Pain… 5099-5021- 5003 0% Hypermobility Of Right Shoulder… 5202 30% 20020525 No Additional MEB/PEB Entries Hypermobility Of Left Shoulder… 5202 20% 20020425 Scapulothoracic Pain Syndrome… 5291 10% 20020425 Other x 1 20020425 Combined: 0% Combined: 50% Derived from VA Rating Decision (VARD) dated 20030130 (most proximate to date of separation [DOS]). ANALYSIS SUMMARY: The Disability Evaluation System (DES) is responsible for maintaining a fit and vital fighting force. While the DES considers all of the member's medical conditions, compensation can only be offered for those medical conditions that cut short a member’s career, and then only to the degree of severity present at the time of final disposition. The DES has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation nor for conditions determined to be service-connected by the Department of Veteran Affairs (DVA) but not determined to be unfitting by the PEB. However the DVA, operating under a different set of laws (Title 38, United States Code), is empowered to compensate all service-connected conditions and to periodically re-evaluate said conditions for the purpose of adjusting the Veteran’s disability rating should the degree of impairment vary over time. The Board’s role is confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on severity at the time of separation. Chronic Thoracic Area Pain and Myofascial Pain Syndrome of Upper Back and Shoulders Condition. The CI was first seen for bilateral shoulder pain on 7 March 2000 when he complained of an 8 month history of shoulder pain especially with pushups. He noted that the shoulders came out of place. The range-of-motion (ROM) was normal. He was evaluated in orthopedics and found to have hypermobile shoulders and scapular winging. He was referred for an evaluation for possible Marfans Syndrome, a connective tissue disorder, which was negative. He was again seen in orthopedics on 14 December 2000 and noted to have chronic pain in the thoracic spine and suprascapular area. He was referred to physical therapy (PT) where normal ROM was noted as well as scapular winging. He failed to respond to conservative management and was referred to MEB. The narrative summary (NARSUM) was dictated by an orthopedic surgeon on 5 October 2001, 4 months prior to separation. It noted that despite extensive conservative management, he had continued chronic scapulothoracic pain. On examination, he had “scapular waning” (winging) bilaterally with pushups. Hypermobility at the elbows, wrists, and scapular joints was noted. Strength and sensation were intact. Bilateral shoulder X-rays on 7 March 2000 were noted as being normal as were X- rays of the thoracic spine. His chronic pain was noted as being unacceptable. At the VA Compensation and Pension (C&P) exam performed by a family nurse practitioner on 25 April 2002, a little over 2 months after separation, the CI reported pain precipitated by overhead reaching or heavy lifting. He also noted instability, popping, weakness, and pain/numbness. He stated that he could not lift greater than 10 to 20 pounds, but was working as a janitor and was able to bowl using a 15 pound bowling ball. On examination, his ROM was reduced to 80 bilaterally in abduction and on left flexion. Right flexion was not attempted due to pain. The ROM of the spine was normal. Strength of the upper extremities was reduced at 3-4/5 bilaterally. The examiner noted shoulder dislocation on the left and potential dislocation on the right. Spasm of the muscles about the thoracic spine was absent. The CI was seen in orthopedics at the VA on 23 July 2002, 3 months after the C&P and 5 months after separation, and noted to have some scapular winging with resistance. Subluxation was appreciated both anteriorly and posteriorly. The strength was normal. He was thought to have scapulothoracic pain syndrome and hypermobile shoulders. The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the chronic thoracic area pain and MPS of the upper back and shoulders at 0% using analogous codes for degenerative arthritis (5003) and myositis (5021). The VA rated hypermobility of the right shoulder with recurrent dislocation at 30% and coded it 5202, other impairment of the humerus. It similarly coded the left shoulder, but rated it 20% as it was the non-dominant arm. The scapulothoracic pain syndrome was rated 10% and coded 5291, an old code for limitation of motion of the thoracic spine. The Board considered the significant disparity between the PEB and VA ratings as well as the disparity of the C&P examination compared to the remainder of the record. The Board noted that the VA based the ratings for the right and left shoulders for recurrent dislocations which were documented on the C&P examination. The Board observed that while the C&P examiner, a nurse practitioner diagnosed dislocations, different orthopedic surgeons, both prior to separation and afterwards, noted only hypermobility. The VA orthopedist who examined the CI 5 months after separation also noted subluxation, which is not the same as dislocation, but did not note that reduction was necessary. The Board determined that the record does not support the presence of recurrent dislocations for either shoulder. The hypermobility was not found to be an unfitting condition or medically unacceptable; only the chronic pain was. The PEB adjudicated the pain from the shoulders and thoracic spine as one condition. The Board noted that the X-rays of the shoulders and spine were normal, the ROM normal, and motor examination normal other than on the C&P examination. While hypermobility of the shoulders was noted, it was also present in other joints. The pain was primarily related to activity. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic pain condition. 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 chronic pain of the thoracic spine, upper back and bilateral shoulders was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the chronic thoracic area pain and MPS of upper back and shoulders condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows: UNFITTING CONDITION VASRD CODE RATING Chronic Thoracic Area Pain And Myofascial Pain Syndrome Of Upper Back And Shoulders Condition. 5099-5021- 5003 0% COMBINED 0% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120627, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxxxxxx, DAF Director of Operations Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxxxxxx, AR20130009516 (PD201201067) 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 and hereby deny the individual’s application. This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail. BY ORDER OF THE SECRETARY OF THE ARMY: Encl xxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)