RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-02476
BRANCH OF SERVICE:  Army  	BOARD DATE:  20150722
SEPARATION DATE:  20090401

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Cavalry Scout) medically separated for a left shoulder condition.  The left shoulder condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty; however, his profile authorized an alternate aerobic event to satisfy physical fitness standards.  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  “Severe left shoulder impingement, s/p [status post] arthroscopic resection of AC joint and tendinosis/partial tear of rotator cuff,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded five other conditions meeting retention standards (left knee arthralgia; adjustment disorder/generalized anxiety disorder/insomnia; lumbosacral strain w/episodic pain; pes planus, asymptomatic; and, right tympanic membrane mild scarring with normal auditory examination) for PEB adjudication.  The Informal PEB adjudicated left (non-dominant) shoulder pain as unfitting rated 20%, with likely application Veterans Affairs Schedule for Rating Disabilities (VASRD).  The adjustment disorder/generalized anxiety disorder/insomnia condition was considered by the PEB and found to be not compensable, although it may be administratively unfitting.  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.  

CI CONTENTION:  He was given a higher rating for his condition by the VA.  His complete submission is at Exhibit A. 

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:  

IPEB – Dated 20090212 | VA* - (<1 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Left (Non-Dominant) Shoulder Pain… | 5299-5202 | 20% | Left Shoulder Posttraumatic Acromioclavicular Separation… | 5210-5303 | 30% | 20090410
Other MEB/PEB Conditions x 5 (Not In Scope) | Other x 6
RATING:  20% | COMBINED RATING:  60%
*Derived from VA Rating Decision (VARD) dated 20090618 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Left (Non-Dominant) Shoulder.  The right dominant CI sustained a superficial gunshot wound (GSW) to the left shoulder on 8 March 2007.  The metal fragments were not removable secondary to size and he was released back to his unit after treatment.  He then reinjured it weight lifting and after a fall.  He noted continued pain with activity despite physical therapy (PT) when seen in orthopedics 11 months later on 20 February 2008.  He was thought to have damage to the acromioclavicular joint (ACJ – the fibrous connection between the shoulder and collar bone) secondary to the GSW and surgery was recommended.  On 2 May 2008, one metal fragment was removed and the end of the collar bone (clavicle) was removed.  Despite rehabilitation, he continued to have pain.  An MRI on 5 October 2008 showed changes at the ACJ consistent with the surgery and/or ACJ Grade II separation, with partial tear of the coracoclavicular ligament (from the shoulder blade to the collar bone), severe subacromial bursitis (inflammation of a tissue sac which reduces friction from a tendon) as well as damage to the rotator cuff (muscles which move the shoulder).  This was consistent with his examination.  A trial of steroid injections were unsuccessful and additional surgery was not recommended.  The CI then requested a MEB because he could not meet duty requirements.  In orthopedics on 4 November 2008, he reported pain with lifting over 20 pounds or throwing.  He denied locking or dislocation.  On examination, his strength was normal, but signs of impingement were present.  Instability was not noted.  He was tender over the ACJ.  On range-of-motion (ROM) measurement in PT, he was noted to guard movement in all planes and to have limited strength at 4/5.  The ROM was limited by pain.  

The narrative summary was dated 15 December 2008, just over 3 months prior to separation.  The CI reported that he was severely handicapped and overhead activities were limited.  He appeared in discomfort and guarded his left upper extremity throughout the examination.  Motion was painful and limited.  Popping was heard with movement (consistent with cartilage damage, impingement, or a rotator cuff tear).  Strength was reduced; however, his grip was normal.  Instability was noted with overhead movement; this had not been recorded by the orthopedic surgeon.  The ACJ was tender; muscle atrophy was not recorded.  

At the VA Compensation and Pension (C&P) examination performed 9 days after separation on 10 April 2009, the CI reported a constant popping sensation with movement and pain.  He did not use a sling and had no limitations in daily activities other than when using both hands.  The ROM was limited, but he was able to move past pain.  The ROM decreased with repetition and these values are charted below.  The examiner estimated that the ROM during a flare and with repetition to be 10 degrees greater than that actually measured.  Muscle atrophy was absent.  

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.

Left Shoulder ROM
(Degrees)

PT ~5 Mo. Pre-Sep

PT ~4 Mo. Pre-Sep

VA C&P ~9 Days. Post-Sep

Flexion (180 Normal) | 85 | 85 | 80
Abduction (180) | 80 | 80 | 80
Comments | 6 months post op | 7 months post op | 11 months post op
§4.71a Rating | 20% | 20% | 20%

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the shoulder at 20%, coded 5299-5202 (analogous to other impairment of the humerus).  The VA rated the shoulder at 30%, coded 5201-5303 (limitation of motion of the arm and impairment of Group III muscles).  The examiner noted “…In consideration of the X-ray findings, the overall disability picture demonstrates a level of functional impairment that more closely approximates that which is contemplated in the 30 percent evaluation criteria directive that an open comminuted fracture with muscle or tendon damage will be rated as a severe injury of the muscle group involved.”  The Board did not concur with the assessment of the VA rater.  The GSW was superficial and the CI was released to duty.  He apparently did well until the re-injury from weight-lifting and the fall.  The involvement of the subacromial bursa and rotator cuff on MRI is consistent with the findings of limited and painful motion, especially overhead movement.  Moreover, the Board noted that the signs and symptoms for a severe level of muscle injury under VASRD §4.56 (evaluation of muscle disabilities) were not present.  This level of disability is not expected from a superficial GSW.  A severe injury involves a shattering or open comminuted fracture; prolonged infection or sloughing of soft tissue; and intermuscular binding and scarring.  Objective findings include depressed and adherent scars with wide damage to muscle in the missile path.  Muscles swell and harden abnormally to contraction.  A severe loss of function is present.  Atrophy is present as well as scar adherence to underlying bone with loss of overlying muscle.  These findings were not evident.  The Board considered the coding options applicable to the shoulder.  Absent a ROM limited to 25 degrees from the side, instability, a frozen shoulder, locking, or severe muscle loss (as described above), the Board found no route to a rating higher than the 20% adjudicated by the PEB.  The VA rater’s coding options were more accurate, but provide no rating advantage to the CI and are therefore not recommended.  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 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 and IAW VASRD §4.56, 4.71a, and 4.73, 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 re-characterization of the CI’s disability and separation determination. 

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131115, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX
President
DoD 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 XXXXXXXXXXXXXXX, AR20150013253 (PD201302476)

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

PD-2013-02476