RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1200702 SEPARATION DATE: 20031112 BOARD DATE: 20130129 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (63T/Bradley Fighting Vehicle System Mechanic), medically separated for chronic pain left posterior shoulder girdle. The CI first noted neck and shoulder pain in 2001 after lifting duffle bags all night. He was reinjured after a fall and developed chronic left posterior shoulder girdle pain condition. Despite treatment, the CI did not improve adequately to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent U3L3 profile and referred for a Medical Evaluation Board (MEB). The MEB determined the left posterior shoulder girdle myofascial pain and dysfunction to be medically unacceptable and forwarded it to the Physical Evaluation Board (PEB) for adjudication. The MEB forwarded no other conditions to the PEB. The PEB adjudicated the chronic left posterior shoulder girdle pain condition as unfitting, rated 20%, with application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD) and the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals and was medically separated with a 20% disability rating. CI CONTENTION: In Items #3 and 4, the CI entered “See Attachments.” 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 unfitting chronic pain left posterior shoulder girdle condition meets the criteria prescribed in DoDI 6040.44 for Board purview, and is accordingly addressed below. The remaining conditions rated by the VA at separation (lumbosacral strain and chronic daily headaches) and implied on the DD Form 294 are not within the Board’s 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 Army Board for Correction of Military Records. RATING COMPARISON: Service IPEB – Dated 20030806 VA (2 Mos. Pre-Separation) – All Effective Date 20031113 Condition Code Rating Condition Code Rating Exam Chronic pain L shoulder girdle 5099-5003 20% Myofascial pain … strains. 5099-5025 20% 20030924 .No Additional MEB/PEB Entries. 0% X 2 / Not Service-Connected x 0 / Deferred x 1 Combined: 20% Combined: 20% *VARD 20031117 awarded 0% for lumbosacral strain (5237) and chronic daily headache (8199-8100) and deferred and later denied (20040202) the rating of temporomandibular joint dysfunction (9999-9905). ANALYSIS SUMMARY: Chronic pain left posterior shoulder girdle condition. The CI first had upper back and neck pain in 2001 after lifting heavy bags. He responded well to conservative management, but then fell from an M-88 recovery vehicle with recurrence of his symptoms. Conservative management including medications, injections, physical therapy, biofeedback and narcotics failed to resolve his symptoms. His treatment was complicated by narcotic dependence. The Board noted that his initial accession was delayed by a positive urine drug screen for marijuana use and that he had denied use on the history. At a 27 March 2003 physical medicine visit, 8 months prior to separation, he diagnosed with myofascial pain syndrome (MPS) with multiple trigger points present. Two weeks later he was in a motorcycle accident, but had shown no improvement in his symptoms prior to the accident, leading to a U3 profile and referral to MEB. The narrative summary (NARSUM) was dictated 20 May 2003, 6 months prior to separation. The CI reported regional left thoracic paraspinal, interscapular and posterior shoulder girdle pain with multiple tender/trigger points. The pain was aggravated by all activities associated with his MOS. On examination, his sensation, strength and reflexes were normal in both upper extremities. The anterior musculature was well developed compared to the posterior. Trigger points were noted in the muscles of the left posterior shoulder. Overhead motion aggravated his pain. Two signs of non-organic pain were present. It was also noted that “radiological studies have revealed no attributable deformity.” At the MEB examination on 5 June 2003, 5 months prior to separation, the examiner noted no specific findings. On 22 August 2003, a magnetic resonance imaging (MRI) of the cervical spine was normal. The VA Compensation and Pension (C&P) examination was accomplished 24 September 2003, 3 months prior to separation. The CI reported continued pain in the left posterior shoulder and upper back. He was noted to be right dominant and to have a normal posture and gait. The extremities were symmetric on examination and without atrophy or swelling. The range-of-motion was full for the neck and bilaterally for both shoulders. Sensation, strength and reflexes were normal. There was no tenderness. The Board directs attention to its rating recommendation based on the above evidence. The PEB coded the shoulder pain as 5099-5003, analogous to degenerative arthritis, and rated it at 20% using the VASRD and the, since rescinded, USA pain policy. The VA also rated the shoulder condition at 20%, but coded it as 5099-5025, analogous to fibromyalgia. The Board considered both coding options, but determined that neither provided an advantage to the CI. Board precedent is that the PEB code be retained unless a different code provides an advantage to the CI. The Board noted that the examination of the left shoulder was essentially normal other than the presence of trigger points. 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 left posterior shoulder girdle 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 chronic pain left posterior shoulder girdle was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the chronic pain left posterior shoulder girdle 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 pain left posterior shoulder girdle 5099-5003 20% COMBINED 20% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120606, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxx, DAF Acting Director 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 xxxxxxxxxxxxxx, AR20130007510 (PD201200702) 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 xxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)