RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01790
BRANCH OF SERVICE:  Army	BOARD DATE:  20140918
SEPARATION DATE:  20081027

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (68P/Radiology Specialist) medically separated for a right shoulder condition.  The right shoulder condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent U3/S1 profile and referred for a Medical Evaluation Board (MEB).  The right shoulder condition, characterized by the MEB as “recurrent dislocation of the shoulder when not repairable or surgery is contraindicated” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded “adjustment disorder w/anxiety marital problem” as a medically acceptable condition.  The Informal PEB adjudicated “humerus, other impairment of (described as recurrent dislocations of the right dominant shoulder)” as unfitting, rated at 20%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining condition, adjustment disorder with anxiety and marital problems was adjudicated as a condition not constituting a physical disability IAW DODI 1332.38, encl 5.  The CI made no appeals and was medically separated.

CI CONTENTION:  “I am at 50% currently.  I have knee problems in both legs, sever shoulder instability.  PTSD/Depressive Axiety Disorder which affects my work.  Back problems that limit some daily function and impare [sic] feeling.”  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 those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting right humerus/shoulder condition is addressed below.  The conditions adjustment disorder with anxiety and marital problems were also addressed. The contended bilateral knees and back conditions were not identified by the MEB or the PEB, and thus are not within the DoDI 6040.44 defined purview of the Board.  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.

The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected condition continues to burden him; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation.  That role and authority is granted by Congress to the Department of Veterans Affairs (DVA), operating under a different set of laws.  The Board considers DVA evidence proximate to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12-month interval for special consideration to post-separation evidence.  Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation.

RATING COMPARISON:

Service IPEB – Dated 20080919 | VA - (8 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Humerus, Other Impairment | 5202 | 20% | Hyperlaxity of the Right Rotator Cuff with Tendonopathy of all Four Rotator Cuff Muscles and Chronic and Recurrent Inferior Dislocation of the Right Shoulder | 5299-5202 | 20% | 20090701
Adjustment Disorder with Anxiety and Marital Problems | A condition not constituting a physical disability IAW 1332.38 encl 5 | Major Depressive Disorder | 9434 | 10% | 20090702
Other x 0 (Not in Scope) | Other x 6 | 20090701
Rating:  20% | Combined:  50%
Derived from VA Rating Decision (VARD) dated 20090829 (most proximate to date of separation)

ANALYSIS SUMMARY:

Right Humerus Condition.  The narrative summary (NARSUM) recorded the CI had a pre-military history of right shoulder injury with episodes of subluxation, responsive to self-reduction.  However, while in basic training he re-injured the shoulder after falling off a balance beam.  He started noticing painful “popping and grinding” of the right shoulder in November 2006, but did not seek medical attention until May 2007 when his shoulder became unstable during a bear crawl.  The CI reported his shoulder then began dislocating frequently with minimal effort.  Radiographs of the right shoulder dated 14 August 2007 showed “Status-post grade 3 acromioclavicular (AC) joint separation, and widening of the coracoclavicular space also implies injury to coracoclavicular ligament.  Abnormal orientation of the scapula suggests additional injury to its stabilizing structures.”  Orthopedic clinic entry dated 27 August 2007, recorded full range-of-motion (ROM) and minimal tenderness to palpation of the AC joint.  The examiner indicated there was joint instability during the examination.  The CI was referred to physical therapy (PT) for rehabilitation.  The CI was treated for several months with PT, analgesics and anti-inflammatory medications.  Orthopedic clinic note dated 12 February 2008 noted the CI reported recurrent episodes of subluxation.  He had at that time attended PT on three to four occasions and at the last visit he dislocated his shoulder and had not returned to therapy.  In the past the CI was able to reduce the dislocated shoulder, but on this occasion he had to seek care at the emergency room (ER).  The physician ordered a magnetic resonance arthrogram (MRA) and modified PT and discussed surgical options.  The MRA was negative.  At a follow-up orthopedic visit in March 2008, the CI indicated there had not been any additional dislocations or subluxations and he felt 40% to 60% improved.  The examiner recommended several more months of PT before considering surgery.  Full ROM of the right shoulder was recorded in May 2008 during separate PT and orthopedic clinic examinations.  

At the orthopedic visit dated 30 May 2008, the CI reported he did not wish to pursue surgery although he felt his shoulder had become more unstable.  The examiner noted the CI had an altercation with his wife 45 days prior that led to re-injury.  The CI noted symptoms that had once stabilized, had returned.  He reported “catching and grinding” episodes.  Special tests of shoulder instability were positive (hyper laxity of the AC joint).  A June 2008 PT entry, the CI noted he had continued to feel “a lot of instability with ADLs.”  The examiner recorded full ROM of the right shoulder.  There were no further visits to the emergency room related to right shoulder subluxation and no report indicative of significant guarding against full arm movement.  A PT visit dated 10 July 2008 noted right shoulder ROM of 155 degrees of flexion and 158 degrees of abduction.  Pain was noted at 4/10 during the measurements.  The CI indicated he had stopped taking pain medications.  The examiner noted weakness in the shoulder which was opined to be secondary to pain.
At the NARSUM exam dated 15 August 2008, the physician recorded based on orthopedic findings, the CI was deemed not to be a surgical candidate.  The CI’s duties involved lifting and repositioning patients.  Given his shoulder condition, he was not able to perform his duties without risking subluxation.  Physical examination of the right shoulder noted tenderness to palpation of the right AC joint.  ROM was recorded as decreased in the right compared to the left and shoulder function was mildly limited with repeated use, notably secondary to pain.  The examiner noted motor strength was difficult to assess due to the potential of subluxation with application of pressure to the joint.  

At the VA Compensation and Pension exam on 1 July 2009 (approximately 2 months after separation), the CI reported he was working fulltime with special needs children and had lost about 2 weeks of work due to headaches and back pain.  The CI reported in the last 6 months he had to go to the ER on three occasions for reduction; however, he was able to self-reduce the shoulder the other ten times his shoulder dislocated (on average twice a month).  ROM recorded right shoulder flexion and abduction at 180 degrees that decreased to 170 degrees with repetition due to weakness.

The Board directed attention to its rating recommendation based on the above evidence.  Both the PEB and VA assigned a 20% rating to the condition.  The PEB chose to rate the condition under the humerus, other impairment code 5202.  The VA coded the condition analogously 5299-5202.  Applicable diagnostic codes include: 5201 (limitation of arm motion); 5202, (humerus, other impairment), and 5203 (dislocation of clavicle or scapula).  The Board considered the 5201 code for reduced ROM and agreed the reduced ROM was not compensable under any code.  The higher rating of 30% under the code 5202 requires demonstration of frequent episodes of dislocation and guarding of all arm movement, not supported by the record in evidence.  The reported frequency of dislocation in the 6 months prior to separation was on average twice a month.  There were no reports of immobilization of the right arm due to right shoulder pathology.  The Board next considered the code 5203; however, found no benefit since the code does not allow for a rating higher than 20% and code 5202 more descriptively reflects the identified pathology.  Hence, no alternative shoulder code is supported in justification of a rating higher than 20%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded there was insufficient evidence to recommend a change from the PEB’s adjudication of the right shoulder condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the MH condition identified as an adjustment disorder 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 adjustment disorder with anxiety and marital problem condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  All were reviewed and considered by the Board.  There was no performance based evidence from the record that any MH condition significantly interfered with satisfactory duty performance. The adjustment disorder is not a physical disability and is not ratable IAW DoDI 1332.38.  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 adjustment disorder with anxiety and marital problem condition, 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 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 recurrent dislocation of the right shoulder condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended adjustment disorder with anxiety and marital problem 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 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 20140421, 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 AR20150006852 (PD201401790)

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-2014-01790