RECORD OF PROCEEDINGS

PHYSICAL DISABILITY BOARD OF REVIEW

NAME: BRANCH OF SERVICE: army

CASE NUMBER: PD0900150 Separation date: 20040124

BOARD DATE: 20090901

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SUMMARY OF CASE: This covered individual (CI) was a Staff Sergeant (SSG/E-6) medically separated from the Army National Guard in 2004 after approximately 18 years of service. The medical basis for the separation was "Chronic pain, right shoulder, due to acromioclavicular arthrosis and rotator cuff tendinopathy, rated as light/intermittent." The injury started gradually, beginning in September 2002 during physical training in Afghanistan and the CI was initially diagnosed and treated for rotator cuff syndrome. On 20030620 Orthopedics changed the diagnosis to "right rotator cuff tendinopathy and A-C (acromioclavicular) joint arthrosis." The CI declined offered surgery which was not considered unreasonable. The CI was referred to the PEB, found unfit and separated at 0% disability.

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CI CONTENTION: "I was not properly rehabilitated. I was not able to return to my civilian career. Still have pains as a result of the injury."

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RATING COMPARISON:

Chronic Pain, Right Shoulder due to acromioclavicular arthrosis and rotator cuff tendinopathy. Rated as light/intermittent. The CI's shoulder issue started gradually in Sept 2002, during physical training exercises in Afghanistan and there is an LOD in the records. The CI was seen and treated by a physician downrange with a diagnosis of rotator cuff syndrome. The CI was placed on a temporary profile and completed his deployment. He had physical therapy and on 20030516 Orthopedics diagnosed right shoulder A-C joint arthrosis with follow-up confirming no obvious rotator cuff tear. Intra-articular steroids resulted in only temporary relief. Orthopedics added a diagnosis of right rotator cuff tendinopathy in addition to the A-C joint arthrosis. Per the NARSUM, the CI was given the options of changing jobs or undergoing arthroscopy with subacromial decompression, distal clavicle excision, and rotator cuff evaluation. The soldier opted to avoid this surgery which was deemed not unreasonable. The CI was not able to perform in his regular MOS, and was referred to the Medical Evaluation Board.

Military exam demonstrated tenderness in the right acromial clavicular junction with some pain on full abduction of the right upper extremity (RUE). Range of motion on 20030721 showed right shoulder flexion 160˚ (180 normal), extension 35˚, abduction 170˚ (180), adduction 53˚, internal rotation 55˚ (90), external rotation 90˚ (90); On neurological, no motor or sensory deficit of the extremities. Right shoulder X-rays with outlet views showed mild degenerative joint disease changes in the A-C joint.

VA examination, dated 20040812 demonstrated a history of discomfort in the right shoulder because of repetitive lifting and difficult to raise his shoulder over his head at one point, although, now he indicates this motion has returned. He reports discomfort with extreme motion and on repetitively raising his right hand over his head. Right shoulder is stable and nontender. Normal range of motion, with flexion and abduction from 1˚ to 180˚ (normal = 0 to 180); internal and external rotation to 90˚ (normal = 0 to 90); extension to 50˚. Ranges of motion are the same actively, passively, repetitively and against resistance. Motion is not limited by pain, weakness, fatigue, or lack of endurance on repetition. X-rays of the right shoulder - normal. Addendum note reveals arthritis shown in MRI in 2002. The VA rated the CI from 20030324 at 10%, 5010, for painful or limited motion of a major joint or group of minor joints and on reevaluation kept the 10% level, but changed coding to 5201-5010 as there was minor decreased range of motion at examination of 20040812.

Either the military or VA exams demonstrate painful motion. The military exam and post-discharge exams show ROM less than the VA normal limits for the right shoulder. The PEB specifically referenced the Army pain rule in their disability description. Absent the pain rule, the right shoulder should be rated at 10% IAW §4.59 Painful motion.

Bilateral Patellofemoral (Knee) Syndrome. This was not contended by the CI. The CI had undergone a Medical Duty Review Board for this condition and was found fit for return to duty with permanent profile in 19990624. The NARSUM addressed the condition in the review of systems as "knee pains on and off with swelling at times for 12 years. He had a P2 profile for this since May 2002. This was previously diagnosed as patellofemoral syndrome." Exam demonstrated no joint swelling; no tenderness; no limitations of joint movements. There is no indication in the records that this condition significantly worsened or that it produced duty limiting disability. This condition did not rise to the level of being unfitting at the time of PEB or discharge.

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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 PDBR to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. The Board unanimously voted that the right shoulder should be rated at 10% IAW §4.59 Painful motion and that no other condition should be added as unfitting. ________________________________________________________________

RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows effective as of the date of the CI’s prior medical separation.

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The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20090211, w/atchs.

Exhibit B. Service Treatment Record.

Exhibit C. Department of Veterans' Affairs Treatment Record.