RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	 CASE:  PD-2013-02313
BRANCH OF SERVICE:  Army	 BOARD DATE:  20140731
SEPARATION DATE:  20030423

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (91B20/Medical Specialist) medically separated for Sjogren’s syndrome and right shoulder pain.  The condition 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/E2 profile and referred for a Medical Evaluation Board (MEB).  The MEB forwarded the Sjogren’s syndrome and right shoulder pain conditions as medically unacceptable to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The informal PEB adjudicated “Sjogren’s syndrome and right shoulder pain” as unfitting, rated 20% and 0%, citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy and Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.  

CI CONTENTION:  “My VA rating was higher than 20%.”  

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 ratings for the unfitting Sjogren’s syndrome and right shoulder pain conditions are addressed below and no additional conditions are within the DoDI 6040.44 defined purview of the Board.  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 20021230 | VA - (4 Months Prio to Separation and based on Service Treatment Records (STR))
Condition | Code | Rating | Condition | Code | Rating | Exam
Sjogren’s Syndrome | 5099-5002 | 20% | Sjogrens Syndrome, Multi Joint | 5099-5002 | 40% | 20021219
Right Shoulder Pain | 5099-5003 | 0% | Tendinitis Right Should, Post Decompression Capsular | 5099-5024 | 10% | 20021219
| | | Thoracic Outlet Syndrome, Right (claimed as nerve damage right shoulder | 8599-8515 | 10% | 20021219
No Other Items In Scope | Other x 2 (Not in Scope) | 20021219
Combined:  20% | Combined:  60%
Derived from VA Rating Decision (VARD) dated 20030305 (most proximate to date of separation [DOS]).   

ANALYSIS SUMMARY:  

Sjogren’s Syndrome Condition.  The narrative summary (NARSUM) notes that the CI was evaluated in approximately 1998 by a rheumatologist for multiple joint pains associated with dry eyes and mouth.  Several blood markers for rheumatologic diseases were positive, but no definitive diagnosis was rendered at the time and she was treated with non-steroidal anti-inflammatory medications.  Notes in the service treatment record (STR) indicated that the CI continued to have multiple joint arthralgias especially of the, neck, shoulder, wrists, hands and feet.  Her primary care provider initiated an MEB for myofascial pain syndrome in September 2002 and referred her to rheumatology for diagnostic clarification.  Electromyography/Nerve conduction studies (EMG) of the right upper extremity (RUE) dated 8 June 2002, noted no changes of the ulnar nerve (composed of C7-8 nerve fibers) at the wrist.  The impression was C7-8 nerve deficit without muscle involvement and questioned a radiculopathy or possible nerve damage at the level of the brachial plexus (nerve trunk from spine to UE) and recommended further evaluation.  Magnetic resonance imaging (MRI) of the C-spine in June 2002 was normal, with no evidence of a radiculopathy.  At the rheumatology consult on 22 October 2002, the CI reported discomfort of her elbows, wrists, fingers, ankles and feet, with morning stiffness.  She reported having sleep difficulties with dry eyes and mouth.  The examiner noted the CI was able to perform her duties as a physical therapy (PT) technician, but was unable to carry a backpack, fire a weapon, do pushups or complete physical fitness testing.  On the rheumatology examination there were small ulcerations in the mouth, all joints of both upper and lower extremities had full range of motion (ROM) and no tender points were noted, and full examination was otherwise normal.  Tests for dry eyes (Schirmer’s test) were positive bilaterally and the rheumatologist diagnosed Sjogren’s syndrome (autoimmune disorder with dry eyes, mouth, joint pains, can involve organs).  The CI was started on hydroxychloroquine (specific drug therapy for Sjogren’s syndrome) with some improvement in her symptoms.  Notes in the STR proximate to separation indicated the CI’s condition was stable, with no evidence of incapacitating episodes in the previous 12 months.

At the MEB examination dated 31 October 2002, 6 months before separation, the CI reported pain in her shoulders, elbows, wrists, hands, and knees.  The MEB NARSUM cited the DD Form 2808, Report of Medical Examination for the MEB, which noted decreased shoulder ROM with localized mild shoulder weakness and no evidence of acute or chronic joint inflammation.  Physical therapy RUE ROM for the MEB noted decreased, painful ROM of the right shoulder and normal wrist and finger ROM.  The examiner indicated that the CI was currently medically stable 

At the VA Compensation and Pension (C&P) examination performed on 19 December 2002, 4 months prior to separation, the CI reported intermittent joint pains with flare-ups of the elbows, fingers, and feet, and dry eyes and mouth with sores in her mouth.  The CI reported less pain since on hydroxychloroquine.  On examination the CI was noted to be right hand dominant, with normal posture and gait.  Examination of the head, eyes, ears, nose and throat was normal except for dry eyes and mouth and an ulceration of the tongue.  Neurological evaluation of the bilateral upper and lower extremities noted normal strength, sensation and reflexes, with normal vascular status.  Musculoskeletal examination noted no swelling, redness or deformity of any joints and full ROM of the elbows wrists, fingers and toes noted.  The examination was otherwise normal except of the RUE as noted below in the discussion of the right shoulder condition.

VA outpatient treatment notes after separation indicated that the CI experienced some waxing and waning of the joint symptoms without abnormalities on examination.  There was some medication adjustment that continued after separation in response and joint symptoms increased when her anti-inflammatory medication was temporarily stopped due to side effects.  

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the Sjogren’s syndrome with arthralgias 20%, coded as 5099-5002 (analogous to rheumatoid arthritis for Sjogren's syndrome) and noted that the CI was stable on medications.  The VA coded it as 5099-5002 also, but rated at 40%.  The evidence in the record supports the CI had chronic joint arthralgias associated with dry eyes and mouth that responded well to treatment for Sjogren’s syndrome, without documented incapacitating episodes.  Proximate to separation the CI’s condition was indicated to be stable by multiple examiners in the STR, including the MEB NARSUM examiner.  At the pre-separation VA C&P examination the CI reported ongoing subjective joint symptoms of discomfort, with possible flare-ups of some joints, but examination of all joints was unremarkable.  (except the right shoulder, addressed separately by the Board).  At post-separation outpatient treatment visits within a year of separation the CI continued to have chronic joint symptoms with no objective change noted in the normal joint examinations.  The Board first discussed whether the Sjogren’s syndrome should be rated as a single active systemic illness analogous to rheumatoid arthritis, coded 5099-5002 as the PEB and VA did or if a higher evaluation was achieved rating on the chronic residuals separately, also permitted by 5002.  The evidence in the records available supported only the right shoulder as potentially meeting a separately compensable evaluation, already a separately unfitting condition, but no other joints had evidence to support ratable impairment that would achieve a compensable rating IAW VASRD rating guidelines.  Therefore, the Board agreed that the Sjogren’s syndrome was appropriately rated analogously with 5002.  The Board agreed that the CI’s disability due to the Sjogren’s syndrome most closely met the 20% rating criteria of 5002, specified as “one or two exacerbations a year in a well-established diagnosis,” but did not meet the next higher evaluation of 40%, reflective of symptoms producing definite impairment supported by objective findings or three or more incapacitating exacerbations a year.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board unanimously concluded that there was insufficient cause to recommend a change in the PEB adjudication for the Sjogren’s syndrome condition.  

Right Shoulder Pain Condition.  The NARSUM notes that the CI had a history of multidirectional instability of both shoulders and eventually developed painful right shoulder impingement at about the same time she was being evaluated for multiple joint pains, and RUE symptoms of paresthesias to the right 5th finger.  The CI underwent right shoulder decompression surgery 31 January 2000.  At the surgery it was felt that the significant instability was also an aggravating factor and the shoulder was both stabilized (capsular shrinkage) and decompressed.  Following the surgery the shoulder was stable, but the CI continued to report pain.  At a primary care visit on 6 May 2002 she reported the RUE paresthesias were present before her shoulder surgery and were less after, but not resolved.  The CI reported that the orthopedic surgeon had diagnosed thoracic outlet syndrome (TOS).  On examination there was full neck ROM with normal strength and reflexes, normal strength except mild decreased strength (4/5) of an isolated rotator cuff muscle.  RUE sensation was normal except after positive TOS provocation testing, which reproduced the right hand weakness and tingling in the C7-8 distribution.  Right upper extremity EMG noted no muscle abnormalities and the radiologist suggested possible nerve impairment at the level of the brachial plexus or a radiculopathy.  Cervical spine films and MRI were normal and did not indicate a radiculopathy.

At the MEB examination on 31 October 2002, 6 months before separation, the CI reported right shoulder pain.  The MEB NARSUM cited the DD Form 2808, Report of Medical Examination, for the MEB which noted decreased shoulder ROM with localized mild localized weakness and no evidence of acute or chronic joint inflammation.  Physical therapy limited RUE ROM for the MEB was shoulder flexion of 155° (normal 180°) and abduction of 172° (normal 180°) with normal wrist and finger ROM.  The MEB examiner indicated that the right shoulder pain was stable.

At the VA Compensation and Pension (C&P) examination dated 19 December 2002, 4 months prior to separation, the CI reported right shoulder pain that began without specific injury in 1996.  Following shoulder surgery in 2000 the CI reported intermittent pain aggravated by activity.  The CI also reported a long history of recurrent RUE symptoms that preceded the right shoulder surgery of dull aching that radiated to the 4th and 5th fingers and weakness of the hand that had been diagnosed as TOS.  On the examination the neck exam was normal, with normal sensation and reflexes of the bilateral UE with full muscle strength, including of both hands.  The CI was noted to have more difficulty maintaining a circle with her right fifth finger and her thumb, but all other fingers were the same as the left.  Testing for nerve compression at the wrist was negative and the examiner indicated that the CI had a “positive thoracic outlet syndrome result” but also noted that two EMGs were normal.  There was full ROM of the elbow, wrist and all fingers and toes noted.  There was no shoulder crepitus noted and ROM in degrees of the shoulder was flexion of 150 ° and abduction of 140° with pain noted and mildly decreased ROM of the wrist.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated right shoulder pain 0%, coded 5099-5003 and cited the USAPDA Pain Policy.  The VA rated right shoulder tendinitis 10%, coded 5099-5024 (analogous to tenosynovitis) and also rated right TOS 10%, coded as 8599-8515 (analogous to mild incomplete paralysis of the median nerve).  The evidence in record supports that the CI had residual right shoulder pain and mildly decreased shoulder ROM following surgery in 2000.  The Board noted that the decreased shoulder ROM noted did not meet a compensable rating under 5201 for loss of ROM alone, with the threshold rating of 10% being specified as arm motion limited to “shoulder level” and Board practice when rating with 5201 has considered 90°of abduction or flexion “shoulder level”.  The Board discussed that the shoulder condition would meet the 10% rating coded as 5201 IAW §4.59 for painful motion, but that the disability due to the shoulder pain was subsumed in the rating for the Sjogren’s syndrome noted above and could not be rated twice under two different diagnoses IAW §4.14 (Avoidance of pyramiding).  The Board reviewed to see if a compensable evaluation was achieved with any other applicable VASRD code but there was no evidence of shoulder instability, dislocations, persistent or recurrent rotator cuff injury, nonunion, malunion, or ankylosis to achieve a compensable rating with criteria of 5252 criteria (humerus impairment), 5203 (clavicle or scapula impairment) or 5200 (shoulder ankylosis).  The Board considered if the TOS condition was a separately unfitting condition at the time of separation but the TOS was not forwarded by the MEB or adjudicated by the PEB; it was not profiled, implicated in the commander’s statement or judged to fail retention standards.  There was no performance based evidence from the record that the reported mild RUE symptoms and minimal objective findings attributed to the TOS condition (5th finger weakness with otherwise normal hand strength, and sensory changes noted only with provocative testing) were disabling or interfered with satisfactory duty performance.  Therefore, the Board unanimously agreed that it could not recommend any higher or additional disability rating for the TOS condition.  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 right 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.  As discussed above, PEB reliance on the USAPDA pain policy DoDI 1332.39 for rating the right shoulder pain condition was operant in this case and the condition was adjudicated independently of that policy/instruction by the Board.  In the matter of the Sjogren’s syndrome and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the right shoulder pain 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.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131028, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

		
XXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXX, AR20150002584 (PD201302313)

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						     XXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA

PD-2013-02313