RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXX CASE: PD1201367 BRANCH OF SERVICE: ARMY BOARD DATE: 20130424 SEPARATION DATE: 20020221 SUMMARY OF CASE: Data extracted from the available evidence of record reflect that this covered individual (CI) was an active duty SGT/E-5 (13B20/Cannon Crewmember) medically separated for a left (non-dominant) shoulder condition. He initially injured his shoulder in July 2000 while doing physical training (PT) and then re-injured it 2 months later in a motorcycle accident. In January 2001, he was diagnosed with an unfused acromial ossicle (os acromiale) and underwent an open reduction and internal fixation (ORIF). Screws were removed in August 2001 due to hardware-associated discomfort and the condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or to satisfy physical fitness standards. He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB). The left shoulder condition, characterized as “chronic left shoulder pain status post-operative fixation of os acromiale” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501 and no other conditions were submitted by the MEB. The PEB adjudicated the chronic left shoulder pain condition as unfitting, rated 20%. The CI made no appeals, and was medically separated. The CI died of a myocardial infarct on 5 June 2011, and his case was brought to the Board by his widow. CI CONTENTION: “They did surgery on his Broke Shoulder. 6 months later the screws they placed in his shoulder started poking through his skin. They did a second surgery and removed the screws. Then they told him he was unfit for duty. After his surgery his left arm was never right again. He had troubles lifting things. He had pain in it constantly. He had other medical conditions he brought to their Attention, and they told him to go see the V.A. when he got out. The V.A. Rated him from Feb. 2002 to present for those same conditions.” [sic] 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. The rating for the unfitting left shoulder condition is addressed below. No additional conditions were identified by the PEB and therefore any additional conditions inferred in the application are not within the DoDI 6040.44 defined purview of the Board. Any conditions or contentions 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. The Board acknowledges the information regarding the significant impairment with which the CI’s service-connected condition continued to burden him until the time of his death in June 2011, but must emphasize that the Disability Evaluation System (DES) has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation. That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws (Title 38, United States Code). RATING COMPARISON: Service (Admin) IPEB – Dated 20020103 VA - (12 Mos. Post-Separation) Condition Code Rating Condition Code Rating Exam Chronic left shoulder pain 5099-5003 20% Chronic left shoulder pain, s/p operative fixation of os acromiale 5003-5201 20%* STR No Additional MEB/PEB Entries NSC X3 STR Combined: 20% Combined: 40% Derived from VA Rating Decision (VARD) dated 20030225 *VARD 20090326 increased rating for left shoulder to 30% effective 20020222 based on C&P examination 20030225 and treatment records through 2008. ANALYSIS SUMMARY: Chronic Left Shoulder Pain Condition. The right hand dominant CI first injured his left shoulder in July 2000 as he was practicing for his unit’s football competition. He then re-injured it approximately a month later in a fall sustained during a motorcycle accident. He began to experience persistent pain, exacerbated by motion, and was unable to perform push-ups, lift heavy objects, or raise his arm overhead. The CI was seen by orthopedics and diagnosed with os acromiale, or an unfused acromion (a developmental condition). After failed conservative therapy, surgical fixation with bone grafting was carried out in January 2001. Surgical hardware was removed in August 2001 due to persistent pain. Examination in the orthopedic clinic 27 August 2001 recorded flexion of 90 degrees and abduction of 50 degrees. Despite extensive physical therapy and various other attempts at rehabilitation/treatment, the CI’s left shoulder pain did not resolve and he was referred for an MEB. The range-of-motion (ROM) evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below: Left Shoulder ROM (Degrees) MEB ~4 Mo. Pre-Sep (20011102) PT ~2 Mo. Post-Sep (20020422) PM&R ~3 Mo. Post-Sep (20020606) VA C&P ~13 Mo. Post-Sep (20030310) SSA ~16 Mo. Post-Sep (20030625) Flexion (180 Normal) 45 62 85 30 110 Abduction (180) 60 76 85 30 110 Comments Limited by Pain; Tender over Scar; No Instability Limited by Pain Pain at end range Limited by Pain, lack of endurance & weakness §4.71a Rating 20% 20% 20% 20% 10% At the MEB narrative summary (NARSUM) evaluation 2 November 2001, 4 months prior to separation, the CI complained of left shoulder pain and exhibited tenderness to palpation as well as muscle atrophy and weakness in the rotator cuff. There was no evidence of instability. Active flexion was 45 degrees and active abduction was 60 degrees (passive flexion 75, passive abduction 100). Radiographs obtained at the time of the NARSUM examination showed “healing os acromiale [and] no … degenerative joint disease.” A VA physical therapy assessment performed on 22 April 2002, 2 months after separation, documented that the CI had reported ROMs of approximately 90 degrees in December 2001 but worsened since stopping physical therapy. On examination, flexion was 62 degrees and abduction was 76 degrees. Atrophy of musculature was noted. An examination in the physical medicine and rehabilitation (PM&R) clinic on 6 June 2002 reported flexion and abduction of 85 degrees with pain at end range. A magnetic resonance imaging of his left shoulder on 19 August 2002 demonstrated some post-operative changes associated with the acromioplasty, but no tears of the rotator cuff or labrum and no glenohumeral joint pathology. At the VA Compensation and Pension (C&P) examination 10 March 2003, 13 months after separation, the CI reported left shoulder pain and stated that he had been “functionally impaired as he [could not] move properly, bear weight, or sleep on the left side.” The examiner reported tenderness and spasm over the surgical site atrophy of the deltoid muscle. Active flexion was 30 degrees, active abduction was 30 degrees, and active internal rotation and external rotation were also 30 degrees each. The examiner referred to the limitation of motion as unfavorable ankylosis. There were no reported neurovascular abnormalities. Radiographs of the left shoulder performed at that time showed no evidence of bony anklyosis and were essentially unremarkable, excepting the residuals of the surgery at the acromioclavicular joint. Approximately 2 months later at a social security disability evaluation, 25 June 2003, examination of the CI’s left shoulder demonstrated flexion and abduction of 110 degrees. The examiner concluded that there were “no functional impairments except [the CI could not] raise left upper extremity above his head.” The Board directs attention to its separation rating recommendation based on the above evidence. Both the PEB and the VA rated the left shoulder condition 20% citing limitation of motion based on evidence proximate to the date of separation. The Board noted that the CI had multiple examinations bracketing the time of his separation, and his recorded left shoulder ROM fluctuated somewhat during this time, as can be typically expected between various visits and healthcare providers. The MEB NARSUM examination and two examinations in the several months after separation demonstrated the similar functional deficits and ROM consistent with the 20% rating for limitation of arm motion (minor, non-dominant). The Board noted the C&P examination 13 months after separation wherein the examiner termed the worsened limitation of motion unfavorable anklyosis. However there was no objective evidence of ankylosis on imaging examinations and another examination 2 months later documented limitation of motion at the shoulder level. The Board considered the VA’s later determination that the CI’s left shoulder condition warranted a 30% rating however, it saw no indication in treatment records surrounding the time of discharge that the PEB’s assessment of the CI’s disability was incorrect. 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 left shoulder 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. The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. In the matter of the left shoulder condition, 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 Left Shoulder Pain 5099-5003 20% COMBINED 20% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120624, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxxx, DAF Director of Operations Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxxxx, SSN 002-58-5007, AR20130011094 (PD201201367) 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 xxxxxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)