RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00954
BRANCH OF SERVICE:  Army	BOARD DATE:  20141118
SEPARATION DATE:  20081112

SUMMARY OF CASE:  The evidence of record indicates this covered individual (CI) was an activated National Guard SPC/E-4 (31B10/Military Police) medically separated for a left shoulder condition.  This shoulder condition could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty or physical fitness standards.  Therefore, the CI was issued a permanent P3/U3 profile and referred for a Medical Evaluation Board (MEB).  The shoulder condition, characterized as “chronic left shoulder pain and weakness” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded one other condition (achalasia, a disorder of the esophagus) as medically unacceptable.  The PEB adjudicated “chronic left (non-dominant) shoulder pain” as unfitting, rated at 10%, referencing the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The IPEB also determined that the remaining condition (achalasia) existed prior to service and was not service aggravate, consequently it was not unfitting, not rated.  The CI made no appeals and was medically separated.  

CI CONTENTION:  “I am still receiving care for my back shoulder and PTSD esophagus” [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.  Likewise, the achalasia (determined to be not unfitting) is also addressed below.  The contended back and PTSD conditions, however, were not identified by the PEB and are therefore not in scope 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 20080619 | VA - (5 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Left Shoulder Pain | 5099-5003 | 10% | Left Shoulder Tendonitis | 5201-5024 | 10% | 20090410
Achalasia | Not Unfitting | Esophagus/Achalasia | 7203-7204 | 30% |
Other x 0 (Not in Scope) | Other x 4 |
Combined:  10% | Combined:  40%
Derived from VA Rating Decision (VARD) closest to separation dated 20090801

ANALYSIS SUMMARY:  The Board acknowledges the CI’s information regarding the significant impairment his service-connected conditions continue to impose, but must emphasize that the Disability Evaluation System has neither the role nor authority to compensate for later severity or complications of conditions that resulted in medical separation, or for service-connected conditions that did not cut short military service.  That role and authority is granted by Congress to the Department of Veterans Affairs, which operates under a different set of laws.  Post-separation evidence is probative to the Board’s recommendations only to the extent it reasonably reflects the unfitting disability at the time of separation.  

Left Shoulder Condition.  In June 2007, the CI suffered an injury to his left shoulder during a firing range training exercise.  Diagnostic X-rays images of the left shoulder were normal but he was diagnoses with a left shoulder acromioclavicular (AC) strain.  Initially the CI did have improvement for his pain with conservative treatment; however, he later reported three episodes of left shoulder instability within a month of his initial injury.  A magnetic resonance imaging (MRI) study in December 2007 revealed mild tendinosis (chronic tendon injury) and degenerative changes of the left shoulder’s AC joint, that was conservatively treated with “steroid and numbing medicine” injection; resulting in only temporary relief.  In January 2008, the CI underwent a left shoulder arthroscopic procedure to repair a torn labrum and to reattach biceps tendons.  Post-operative physical therapy’s documentation reported good range-of-motion (ROM) results and no instability but did state that the CI did have continuous pain.  A repeat MRI (performed 6 months prior to separation) revealed post-surgical changes and tendinosis.

The narrative summary (NARSUM) (prepared approximately 6 months prior to separation), noted post-surgery improvement, nonetheless, the CI was unable to return to full duty status.  He complained of having daily left shoulder pain, which persisted for approximately half the day and each pain episode lasting between 45 to 60 minutes.  The CI also stated that his pain occasionally awakens him from sleep.  The physical examination findings are summarized below.

At the VA Compensation and Pension (C&P) exam (performed 5 months post-separation), the CI reported that he treated his left shoulder pain with Bengay and heating pads and that he did not experience any functional impairment from his left shoulder condition.  The pertinent physical examination findings are summarized in the below chart.  

The goniometric ROM evaluations in evidence the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized below.

Left Shoulder ROM (Degrees) | NARSUM ~6 Mo. Pre-Sep | PT ~4 Mo. Pre-Sep | VA C&P ~5 Mo. Post-Sep
Flexion (180 Normal) | 110 | 150 | 180
Abduction (180) | 160 | 145 | 180
Comments: Right Hand Dominant | Pos. painful motion & tenderness; Decreased strength; Pos. Deluca criteria | Pos. painful motion & tenderness to palpation; Decreased strength; Pos. tests for impingement & AC joint pain | Pos. painful motion; Decreased strength; No instability; Pos. Deluca criteria
§4.71a Rating | 10%* (PEB 10%) | 10% | 10%* (VA 10%)
*IAW VASRD §4.95 Painful Motion

The Board directs attention to its rating recommendation based on the above evidence.  The PEB applied the analogous VASRD code 5099-5003 (degenerative arthritis) and rated at 10%.  The VA applied the combination code of 5201-5024 (tenosynovitis) also rated at 10%.  Rating under 5003, as is code 5024, without compensable ROM limitations, does allow for a 10% rating if limitation of motion is objectively confirmed by satisfactory evidence of painful motion IAW §4.59.  After his rehabilitation, all evidence agrees that he had non-compensable ROM of the left shoulder with adequate documentation of painful motion.  There were no X-ray images in evidence of degenerative arthritis with occasional incapacitating episodes that would allow for a 20% rating under 5003.  Additionally, there was no abnormal movement, instability/dislocation or humeral impairment that would allow for application of specific shoulder codes.  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.

Achalasia Contended Condition.  The Board’s main charge is to assess the fairness of the PEB’s determination that the achalasia condition was not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The achalasia condition was profiled at entrance to the disability evaluation system but was not implicated in the commander’s statement.  It was determined that the achalasia failed retention standards by the MEB; however, the PEB adjudicated that it was not unfitting citing “that the condition existed prior to service and was not aggravated by service”.  The PEB also determined that the condition has not prevented the member’s ability of providing satisfactory service during several extended duty periods and per the CI, this condition did not interfere with his duty nor resulted in weight loss.  All evidence related to the achalasia condition was reviewed by the action officer and considered by the Board.  Although the diagnosis of achalasia was well documented in the service treatment records and the CI had several treatment procedures for that condition, there was no performance based evidence that the achalasia condition significantly interfered with the CI’s duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the achalasia contended condition and so no additional disability rating is recommended.  

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 surmised from the record or PEB ruling in this case that no prerogatives outside the VASRD were exercised.  In the matter of the left shoulder pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended Achalasia condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends no recharacterization of the disability and separation determination

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140219, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			
	           XXXXXXXXXXXXXXXXXX
	           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 XXXXXXXXXXXXXXXXXX AR20150006614 (PD201400954)

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

PD-2014-00954