RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  	CASE:  PD1200788
BRANCH OF SERVICE:  Army	BOARD DATE:  20130529
SEPARATION DATE:  20020409

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (88M10/Motor Vehicle Operator) medically separated for chronic right shoulder, hip, and foot pain complicated with myofascial pain syndrome, as well as chronic pelvic pain possibly secondary to endometriosis with bladder urgency.  CI began experiencing right shoulder, hip, pelvic, and foot pain following a fall over a wall during basic training in 1993.  She underwent three surgeries for her shoulder in 1998, 1999 and 2000.  She received conservative treatments for the hip, pelvis and foot.  The shoulder, hip, pelvis and foot conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was issued a permanent P3, U3, L3 profile and referred for a Medical Evaluation Board (MEB).  The conditions, characterized as “chronic right shoulder pain” and “chronic right hip pain,” “chronic pelvic pain,” and “chronic right foot pain,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  Also addressed by the MEB, and forwarded on the DA Form 3947 for PEB adjudication, were four other conditions (see rating chart below), which were judged to meet retention standards.  The PEB adjudicated the chronic pain conditions as well as the endometriosis, myofascial pain, and sensory urgency of the bladder, as unfitting, coded at 5099-5021 with a combined rating of 10%.  The remaining conditions were determined to be not unfitting.  The CI appealed to the U.S. Army Physical Disability Agency (USAPDA) which affirmed the PEB findings and rating IAW DODIs and AR 635-40.  She was medically separated.

CI CONTENTION:  “Because I had three shoulder surgeries by Army doctor that failed – and his actions led to the end of my career.  I have permanent nerve pain from shoulder, neck, and hand swells and has color changes in it.  Pain, loss of motion – shoulder, bladder pelvic pain from surgerys and I have chronic adhesions disease.  I wish I’d had better health care.  I had carpal tunnel release and my condition got worse.  I had three shoulder surgeries from a young Army doctor.  My conditions are unique and I can’t get with the proper doctors here in Savannah, Georgia.  VA rated me 100% unemployable, rated 90%.  I am confused that I got a 10% rating by a DoD Army board.  Maybe someone can appreciate my situation and see my Army career was taken from me.”

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 combined rating for the unfitting shoulder, hip, pelvis, and foot conditions complicated with myofascial pain syndrome and the bladder urgency and endometriosis conditions are addressed below.  Of the conditions identified and determined to be unfitting by the PEB, members judged that the shoulder, hip, pelvis, foot, and bladder conditions were specified sufficiently in the application to meet the DoDI 6040.44 scope requirements.  The irritable bowel syndrome, adjustment disorder with depressed mood, intermittent hematochezia, and isolated elevation of gamma glutamyl transferase (GGT) conditions were not alluded to in the application and are not judged to have been requested; e.g., they do not satisfy scope requirements.  The carpal tunnel syndrome and neck conditions specified in the application were not identified and adjudicated by the PEB; e.g., they do not satisfy scope requirements.  The above conditions which were excluded from scope, any other conditions intended in request for Board consideration, or any condition or contention outside the Board’s defined scope of review, remain eligible for future consideration by the Board for the Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20011114	VA - (3 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Rt Shldr Pain	5099-5021	10%	Rt Shldr Impingement w/Bursitis s/p Surgical Repair	5201	20%	20020725	
Rt Hip Pain			Bursitis, Rt Hip	5019	10%	20020725	
Rt Foot Pain			Plantar Fasciitis, Rt Foot	5299-5276	0%	20020725	
Pelvic Pain			S/P Hysterectomy w/Lft Ovary Rmvl due to Endometriosis & Chronic Pelvic Pain	7618-7619	30%*	20020725	
Endometriosis							
Bladder Urgency			Interstitial Cystitis	7512	20%	20020725	
Myofascial Pain Syndrome			Myofascial Pain Syndrome	5099-5025	NSC	20020725	
Adjustment Disorder w/Depressed Mood	Not Unfitting	Adjstmt Disorder w/Depressed Mood	9440	10%	20020725	
Irritable Bowel Syndrome	Not Unfitting	Irritable Bowel Syndrome	7319	0%	20020725	
Intermittent Hematochezia	Not Unfitting	Hemorrhoids w/Anal Fissure & Intrmt Hematochezia	7386	0%	20020725	
Isolated Elevation of GGT	Not Unfitting	No VA Entry	
No Additional MEB/PEB Entries	Other x 8	20020725	
Combined:  10%	Combined:  60%	
Derived from VA Rating Decision (VARD) dated 20021003 (most proximate to date of separation [DOS]).   
* Effective 20020501

ANALYSIS SUMMARY:  The PEB combined the right shoulder, hip and foot pain complicated with myofascial pain syndrome conditions as well as pelvic pain possibly secondary to endometriosis with bladder urgency under a single disability rating, coded analogously to 5021 (myosistis).  Although Veterans Affairs Schedule for Rating Disabilities (VASRD) §4.71a permits combined ratings of two or more joints or overlapping conditions to be combined under a single rating, it allows separate ratings for separately compensable joints.  Absent the USAPDA pain policy, (likely applied in this case), non-musculoskeletal system conditions cannot be combined under code 5003 or codes 5013 through 5024.  IAW DoDI 6040.44 the Board must follow suit if the PEB combined adjudication is not compliant with the latter stipulation, provided that each ‘unbundled’ condition can be reasonably justified as separately unfitting in order to remain eligible for service rating.  If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  To that end, the evidence for the right shoulder, right hip, right foot, myofascial pain syndrome and “pelvic pain possibly secondary to endometriosis with bladder urgency” conditions are presented separately; with attendant recommendations regarding separate unfitness, and separate rating if indicated.

Chronic Right Shoulder Pain.  The CI was right hand dominate.  The narrative summary (NARSUM) which was undated notes that the CI had been experiencing right shoulder symptoms for the preceding 7 years since basic training when she had a fall onto her right side.  The symptoms persisted in spite of attempts at treatment with non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy (PT) and steroid injections.  She underwent three operations (early arthroscopic debridement with distal clavicle resection; December 1998 acromioplasty; and November 2000 decompression with re-attachment of the anterior deltoid and rotator cuff repair) on her shoulder and while pain was felt to be improving at the time of the NARSUM, she still had some “routine postoperative shoulder pain.”  At the MEB exam, the examiner stated that her pain and range-of-motion (ROM) limitations prevented her from climbing into and out of trucks and from performing routine maintenance chores required of her MOS as a truck driver.  She was also unable to run, jump or do push-ups secondary to shoulder, hip, and foot pain.  The MEB physical exam noted a well-healed 15 cm longitudinal incision along the anterior aspect of the shoulder.  There was tenderness to palpation (TTP) of the anterior deltoid and the acromion region, with ROM summarized in the chart below.  Diagnosis was chronic right shoulder pain secondary to labral tear vs. impingement syndrome and deltoid tear.  X-rays documented post-surgical changes on the right.  In an addendum to the MEB dated August, 2001 approximately 8 months prior to separation, the physician who performed the last surgery, stated that on his exam done about 11 months prior to separation, the CI had mild impingement and “near full range-of-motion of the right shoulder” and no pain, although she reported “activity-related subacromial bursitis type symptoms with aching.”  The physical exam at the time of the addendum by the orthopedic provider, documented ROM as flexion to 90 degrees, abduction to “265⁰,” internal rotation to 45 degrees, external rotation to 40 degrees (normal 90 degrees).  A PT note dated January 2002, 3 months prior to separation, documents right shoulder abduction to 30 degrees.  At the VA Compensation and Pension (C&P) exam performed 3 months after separation, the CI reported tingling of fingers, pain, swelling of the hands and occasional neck pain.  The CI said that her symptoms were constant, requiring bed rest three times per week and lasting at least 40 minutes.  Pain was being treated with Motrin, heat, Darvocet (narcotic pain medication) as needed, physical therapy and pain management by anesthesia.  ROM of the right shoulder was recorded as flexion to 90 degrees, abduction to 90 degrees, external rotation to 90 degrees and internal rotation to 90 degrees.  Motion was additionally limited by pain.

The goniometric 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.

Right Shoulder ROM
(Degrees)	MEB ~? Mo. Pre-Sep
(UNDATED)	MEB Addendum ~8 mos Pre-Sep (20010802) 	VA C&P ~ 3 Mo. Post-Sep
(20020725) 	
Flexion (180 Normal)	140	90	90	
Abduction (180)	140	“265”*	90	
Comments	Positive impingement sign. TTP.  Pain aggravated by activity.  	Mildly positive impingement findings, subacromial clicking; intermittent pain
*likely “to 65⁰” typo or 165(?) as “265” is not anatomically possible	Limited by pain	
§4.71a Rating	10%	20%	20%	

The Board first considered if the right shoulder condition, having been de-coupled from the combined PEB adjudication, remained unfitting as established above.  Members discussed the possible role played by psychological factors in the pain experienced by the CI.  It was noted that the CI had been treated in a pain management clinic where she was diagnosed with adjustment disorder with depressed mood.  However, in the mental health addendum to the NARSUM, this condition was noted to have occurred “in the context of her chronic pain” and presumably secondary to it.  Subsequent C&P exams diagnosed pain disorder with physiological and psychological factors indicating some psychological overlay along with physiological pain.  The MEB stated the right shoulder condition was medically unacceptable.  Members also noted that although the commander’s statement did not specifically mention and diagnoses or conditions, but referred to the permanent P3/U3/L3 profiles written by orthopedics and internal medicine which detailed the significant duty limitations imposed by the profiled conditions.  The U3 profile was adjudged as specific for the shoulder condition as were the limitations of “no overhead lifting or carrying weight over 5 lbs in right hand, no backpack.”  Member consensus was that the functional limitations in evidence justified the conclusion that the right shoulder condition was integral to the CI’s inability to perform her MOS, was reasonably unfitting, and accordingly a separate rating is recommended for the right shoulder condition.

The Board directs attention to its rating recommendation based on the above evidence.  The VA characterized the condition as right shoulder impingement with bursitis, status post-surgical repair.  The condition was coded as 5201 (limitation of motion of the arm) and rated at 20% citing the fact that ROM was limited by pain with flexion to 90 degrees and abduction to 90 degrees.  There is a disparity between examinations with implications for the Board's rating recommendation.  The Board deliberated the probative value of these conflicting evaluations, and carefully reviewed the entire file for corroborating evidence from the period preceding separation.  The orthopedic NARSUM addendum was considered the exam with the highest probative value and warranted a 20% rating for flexion limited to 90 degrees under code 5201.  The undated NARSUM with greater ROM measurements was considered potential post-surgical honeymoon period, aligned with the orthopedic addendum indicating prior near-full ROM and was offset by the limited PT exam most proximal to separation which documented abduction of only 30 degrees and the VA exam which was also more proximate to separation.  A higher (30%) rating would require limitation of arm motion to midway between side and shoulder level.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 20% for the right shoulder condition.

Chronic Right Hip Pain.  The NARSUM notes that the onset of hip pain corresponded with the fall during Basic Training mentioned above.  Symptoms were aggravated by activities such as prolonged standing and running.  At the MEB exam, the CI reported that prolonged sitting in the truck and vibration of riding on the truck further aggravated both her hip and shoulder pain.  As mentioned above, it was noted that she was unable to run, jump or do push-ups because of her shoulder, hip and foot pain.  The MEB physical exam noted no edema but there was TTP of the greater trochanteric bursa region which elicited referred pain in the right buttock.  Flexion at the hip was recorded as 120 degrees (normal 125 degrees) and external rotation to 45 degrees (normal 45 degrees).  Diagnosis was chronic right hip pain secondary to greater trochanteric bursitis.  At the C&P exam performed 3 months after separation, the CI reported decreased ROM, and continued stiffness, and pain.  Flare-ups were reported to occur four times a week, lasting up to 8 hours.  Examination revealed the following ROM’s:  flexion to 90 degrees, extension to 30 degrees (normal 20 degrees), external rotation to 50 degrees, abduction to 35 degrees (normal 45 degrees) and adduction 25 degrees (normal 45 degrees).  The ROM of the right hip was limited by pain.  Magnetic resonance imaging of the hip with arthrogram performed in April 2000 was normal.  X-rays performed in July 2002 revealed no hip abnormality.

The goniometric 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.

Right Hip (Thigh) ROM
(Degrees)	MEB ~? Mo. Pre-Sep
(UNDATED) 	VA C&P ~ 3 Mo. Post-Sep
(20020725) 	
Flexion (125 Normal)	120	90	
Extension (20)	Not measured	30	
External Rotation (45)	45	50	
Abduction (0-45)	Not measured	35	
Adduction (45)	Not measured	25	
Comment	Very tender to palpation of greater trochanteric bursa region.  Pain referred to right buttock.  Pain with internal rotation	ROM limited by pain	
§4.71a Rating	10%	10%	

The Board first considered if the right hip condition, having been de-coupled from the combined PEB adjudication, remained unfitting as established above.  The potential overlay by psychological factors in this condition was similar to that discussed above.  The MEB stated the right hip condition was medically unacceptable.  The permanent L3 profiles written by orthopedics and internal medicine detailed significant duty limitations imposed by the profiled conditions.  The L3 profile with limitations of “no prolonged standing, no standing in formations, no running, marching, or jumping” were adjudged as relating to the hip and foot conditions with records indicating the hip was the principle contributor of limitations.  Member consensus was that the functional limitations in evidence justified the conclusion that the right hip condition was integral to the CI’s inability to perform her MOS, was reasonably unfitting, and accordingly a separate rating is recommended for the right hip condition.

The Board directs attention to its rating recommendation based on the above evidence.  The VA characterized the condition as bursitis; right hip coded 5019 and rated at 10% citing flexion measured at 90 degrees with pain, but without fatigue, weakness, lack of endurance or incoordination.  The Board noted that painful motion was clearly documented in the C&P exam and that pain with activity was documented in the MEB exam and elsewhere in the Service treatment record.  It concluded that there was ample evidence in the data available to concede VASRD §4.59 (painful motion) and thus a minimal compensable (10%) rating under VASRD 5019 (bursitis).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 10% for the right hip condition.

Chronic Right Foot Pain:  The NARSUM notes that chronic foot pain also began during Basic Training 7 years earlier.  It was diagnosed as plantar fasciitis and in spite of treatment with NSAIDS, PT, stretching, steroid injections and orthotics, the pain remained unrelieved.  At the MEB exam, the CI reported continued foot pain which limited her ability to perform required duties.  The MEB physical exam noted no erythema or edema.  There was TTP of the dorsal midfoot region as well as the proximal plantar fascia.  ROM’s of the ankle, subtallar joint and midfoot were normal.  There was pain on axial loading of the midfoot region, but there was no joint laxity.  Diagnosis was right foot pain secondary to chronic plantar fasciitis and midfoot degeneration, mild.  At the C&P exam performed 3 months after separation, the CI reported pain and stiffness in her right foot.  Standing and walking was reported to lead to pain, weakness, stiffness, swelling and fatigue.  The VA, basing its rating judgment on the C&P exam stated that there was no painful motion on either dorsiflexion or plantar flexion.  The exam also noted limited function for standing and walking because of the plantar pain.  X-rays performed in July 2002 were negative.

The Board directs attention to its rating recommendation based on the above evidence.  The Board first considered if right foot pain, having been de-coupled from the combined PEB adjudication, remained itself unfitting as established above.  Members agreed that, based on the above evidence, there was a questionable basis for arguing that it was separately unfitting as the bulk of the lower extremity duty limitations were attributed to the hip condition discussed above.  The well-established principle for fitness determinations is that they are performance-based.  The Board could not find sufficient evidence in the record that documented any sufficient interference of right foot pain with the performance of duties at the time of separation.  After due deliberation, members agreed that the evidence does not support a conclusion that the functional impairment from right foot pain was integral to the CI’s inability to perform her MOS and, accordingly cannot recommend a separate rating for it.
Chronic Pelvic Pain possibly secondary to Endometriosis with Bladder Urgency.  A gynecology addendum to the NARSUM regarding pelvic pain notes that the CI initially presented with this symptom in 1997 and that after extensive evaluation and work-up, no definite etiology could be found.  In December 1997 a diagnostic laparoscopy was performed which revealed endometriosis and pelvic adhesive disease.  Because of continued pain in spite of treatment with medication, the CI was referred to urology where she was diagnosed with interstitial cystitis.  Treatment of that condition was helpful in controlling bladder pain but pelvic pain recurred.  In order to treat severe endometriosis she underwent a hysterectomy in September 1999.  In January 2002 she underwent left oophorectomy (ovary removal) due to adhesions and endometriosis.  An addendum to the NARSUM from urology states that the CI had been followed in the urology clinic since 1997 because of pelvic pain, urinary urgency and frequency.  She underwent extensive testing and treatment with various medications which did not help the symptoms.  In July 1998, a cystoscopy and hydrodistention was performed under anesthesia, but the procedure only led to temporary improvement in her symptoms of frequency, urgency and pelvic pain.  At the MEB exam, the CI reported continued pelvic pain and bladder problems.  The urologist noted that the patient voided about 8-10 times daily and had no dysuria.  The MEB physical exam and NARSUM addendum documented tenderness in the lower pelvic area.  Diagnosis was chronic pelvic pain and endometriosis, status post multiple surgical procedures.  At the C&P exam performed 3 months after separation, as reported in the subsequent VARD the CI reported that she had urinary incontinence for which she used 2-3 absorbent pads daily but required no appliance nor catheterization.

The Board directs attention to its rating recommendation based on the above evidence.  The Board first considered if the pelvic pain and endometriosis with bladder urgency condition, having been de-coupled from the combined PEB adjudication, remained itself unfitting as established above.  Members agreed that, based on the above evidence, there was a questionable basis for arguing that it was separately unfitting.  The well-established principle for fitness determinations is that they are performance-based.  The Board could not find sufficient evidence in the file that documented sufficient interference with the performance of duties attributable to the pelvic pain and endometriosis with bladder urgency condition at the time of separation.  After due deliberation, members agreed that the evidence does not support a conclusion that the functional impairment from the pelvic pain and endometriosis with bladder urgency condition was integral to the CI’s inability to perform her MOS; and, accordingly cannot recommend a separate rating for it.

Myofascial Pain Syndrome:  The addendum to the NARSUM submitted by rheumatology notes that the CI had been referred about 6 months prior to the NARSUM for right sided generalized pain problems occasionally associated with intermittent blanching and swelling of the right hand.  In addition, she had reported morning stiffness and non-restorative sleep.  The MEB physical exam showed no evidence of synovitis in any peripheral joint, but there were fibromuscular tender points in the upper back, lateral elbow, lateral knee and lateral trochanteric regions.  Diagnosis of myofascial pain syndrome was made and activity modification and simple analgesic therapy along with PT was recommended.  No further rheumatologic evaluation or treatment was thought to be indicated.  At the C&P exam 3 months after separation, the condition was acknowledged, but felt to be not subject to service-connection.

The Board directs attention to its rating recommendation based on the above evidence.  The Board first considered if myofascial pain syndrome, having been de-coupled from the combined PEB adjudication, remained itself unfitting as established above.  Members agreed that, based on the above evidence, there was a questionable basis for arguing that it was separately unfitting.  The well-established principle for fitness determinations is that they are performance-based.  The Board could not find evidence in the commander’s statement or elsewhere in the file that documented any significant interference of myofascial pain with the performance of duties at the time of separation.  Any increase or overlap of this condition with the unfitting shoulder and hip conditions was included in the ratings of those conditions above.  After due deliberation, members agreed that the evidence does not support a conclusion that the myofascial pain condition was separately unfitting; and, accordingly cannot recommend a separate rating for it.

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 DoDI 1332.39 and AR 635-40 for rating shoulder pain, hip pain, foot pain, pelvic pain/endometriosis with bladder urgency and myofascial pain was operant in this case and the conditions were adjudicated independently of that instruction by the Board.  In the matter of the right shoulder pain condition, the Board by a vote of 2:1 recommends a disability rating of 20%, coded 5201 IAW VASRD §4.71a.  The single voter for dissent (who recommended no change in the PEB adjudication) submitted the addended minority opinion.  In the matter of the right hip pain condition, the Board by a vote of 2:1 recommends a disability rating of 10%, coded 5019 IAW VASRD §4.71a.  The single voter for dissent (who recommended no change in the PEB adjudication) submitted the addended minority opinion.  In the matter of the right foot pain, pelvic pain/endometriosis with bladder urgency, and myofascial pain syndrome conditions, the Board unanimously recommends determinations as not separately unfitting.  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; and, that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Right Shoulder Impingement w/Bursitis s/p Surgical Repair	5201	20%	
Bursitis, Right Hip	5019	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20120604, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

	Physical Disability Board of Review

MINORITY OPINION:

The CI was found unfit for seven conditions which were inappropriately bundled together by the PEB as detailed above, and rated a combined 10%.  While I concur with the conclusions of the majority on all but two of those unbundled conditions, I differ with them regarding the separately unfitting determination for the right shoulder and right hip, and the resultant rating(s).  My position is that neither was reasonably justified as separately unfitting, and therefore not eligible for separate ratings.  My conclusions are grounded in the following evidence.

In 1993, apparently while in basic training, the CI sustained a fall injury and landed on her right side, causing low back pain and other symptoms which included right shoulder and right hip pain.  While the record is incomplete, the CI was apparently referred into the Disability Evaluation System (DES) in 1997 for the back pain; the accompanying history and physical notes concurrent complaints of right shoulder and hip pain.  It is unclear what happened as a result of the MEB that apparently transpired in about 1997 or 1998, but, the CI was assigned to the Med Hold Company in May 1998 and that is where she remained until separation in 2002.  A “new” MEB document was prepared in October 2001.  It listed 11 conditions (which did not include the original back pain): seven medically unacceptable (the ones consolidated by the PEB as noted above) and four medically acceptable.  All of the medically unacceptable conditions had existed since 1997 and earlier.  There is no medically unacceptable condition which was not clearly chronic, or which stands out as having in itself cut short the CI’s career.

As regards the right shoulder, the record documents a 7 year history of the condition prior to separation.  Although the CI had undergone three surgical interventions, the most recent was a year prior to separation.  The only clinical entry directly and solely related to the condition within the last 15 months of service was for a pain injection 3 months prior to separation.  The NARSUM documented non-compensable ROM and the orthopedic addendum noted minimal discomfort and a mild positive impingement finding, with residual symptoms of weakness and intermittent pain.  There was a clear error in ROMs on this exam, imparting little probative value to those measurements.  While the VA exam 3 months post-separation did document flexion and abduction at 90 degrees with pain, it also documented that the CI was working as a security guard, which is not indicative of someone with a debilitating shoulder condition.

The right hip condition was similarly longstanding (7 years), without significant functional impairment.  An arthrogram was normal.  Service ROM measurements were normal, and the ROM limitations recorded at the VA exam were non-compensable.  The last clinical entry in the record specific to the hip alone was 9 months prior to separation and noted full ROM.  Although the VA exam noted pain-limited ROM, the post-separation occupational functioning as a security guard again does not connote a debilitating hip condition.

Based on the totality of the evidence, I do not believe either the right shoulder or right hip condition can be reasonably defended as autonomously unfitting.  The evidence proximate to separation does not identify any distinctly unfitting clinical features or performance-based impediments for either condition.  The objective occupational functioning documented in the VA record is not compatible with a conclusion that either of these conditions would have independently interfered with the CI’s ability to do her MOS requirements.  The subjective reporting of the severity of the various symptoms seems discordant with the objective findings, and were arguably influenced by a loss of motivation to continue to serve in the Army.  All of the CI’s various conditions were fully evaluated and reviewed during the course of multiple ongoing disability evaluations over several years, and the DES findings were found to be supported by substantial evidence.  It appears to me that the CI’s chronic “multiple orthopedic complaints” taken together were the reason for her ultimate medical separation, but no single condition would have separately forced a medical separation.

The Board judges the fairness of PEB fitness adjudications based on the fitness consequences of conditions as they existed at the time of separation.  The presence of a diagnosis, in and of itself is not sufficient to render a condition unfitting and ratable.  While DoDI 6040.44 directs the Board to the VASRD as its basis for its rating recommendations, in cases such as this, the Board is bound first by DoD guidance for determining fitness and eligibility for Service rating of any unbundled condition.  The VASRD requirement is applicable after the DES fitness eligibility is established to the Board’s satisfaction; the VASRD does not override decision making with regard to that determination.  I concluded that neither the right shoulder nor right hip condition satisfies the DES requisite for separate rating, specifically that standing alone it rendered the CI “unable to reasonably perform the duties of his or her office, grade, rank, or rating,” quoting DoDI 1332.38 (E3.P3.2.1), which was and still is in effect.  DoDI 6040.44 (E3, 4.d) stipulates that the Board will use “all applicable statutes and any directives in effect at the time of the contested separation” to arrive at its recommendations “to the extent they do not conflict with the VASRD.”  Because the VASRD does not address DES fitness principles, no such conflict exists.

In conclusion, based on all of the evidence I considered, the right shoulder and right hip conditions kept together as a combined condition would have been appropriately rated 10%.  I therefore do not find reasonable justification for recommending a change in the PEB adjudication and strongly believe there is an insufficient DES fitness foundation to support or justify the majority recommendation.

I respectfully urge the Secretary to adopt the minority recommendation that there be no recharacterization of the CI’s disability and separation rating determination.

SFMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(TAPD-ZB), 

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for AR20130015307 (PD201200788)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to recharacterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.  

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:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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						
						         (Army Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA