RECORD OF PROCEEDINGS

PHYSICAL DISABILITY BOARD OF REVIEW

NAME: BRANCH OF SERVICE: AIR FORCE

CASE NUMBER: PD0900466 BOARD DATE: 20100609

SEPARATION DATE: 20060909

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SUMMARY OF CASE: This covered individual (CI) was a Technical Sergeant Medical Services Technician medically separated from the Air Force in 2006 after 6 years 10 months of service. The medical basis for the separation was Left Shoulder Pain. The CI was referred to the Physical Evaluation Board (PEB), found unfit for the condition determined unfit for continued military service and separated at 20% combined disability using the Veterans Affairs Schedule for Ratings Disabilities (VASRD) and applicable Air Force and Department of Defense regulations.

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CI CONTENTION: The CI states: “VA rated left shoulder condition at 40%. VA also rated Mental Health condition to shoulder injury-30%.”

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RATING COMPARISON:

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ANALYSIS SUMMARY:

Left Shoulder Pain: The CI was mobilized in April 2003 and experienced left shoulder pain while working as an Aeromedical Evacuation Technician at Scott AFB. In February 2004 he deployed to Iraq and had significant pain in his left shoulder. He returned from Iraq in April 2004 and was referred to orthopedics. He was diagnosed with left shoulder impingement and received a steroid injection. A Magnetic Resonance Imaging (MRI) was done and it revealed a left rotator cuff tear. He eventually required two surgeries. In the fall of 2004 he underwent arthroscopic acromioplasty and in January 2005 he underwent an open revision of the acromioplasty and rotator cuff repair. A second MRI between the two surgeries also revealed a rotator cuff tear. In April 2006 an Informal PEB (IPEB) determined he was unfit with a 10% rating for 5399-5304 Left Shoulder Pain; Status-post Acromioplasty. He appealed this decision and a Formal PEB (FPEB) determined he was unfit at 20%. He appealed this decision and his case was reviewed by the Air Force Personnel Council (AFPC). The AFPC determined that the preponderance of medical evidence supported the Formal PEB determinations.

Multiple range-of-motion (ROM) examinations are present in the record dated from approximately one month after the second surgery to two months after the CI separated from the Reserves in September 2006. Exams by VA Compensation and Pension (C&P) and unit flight surgeon from 20060310 and 20060602 respectively show extremely limited ROM and support a 40% rating. The VA exam was completed as part of the CI’s request for increased disability rating. The examination by the flight surgeon was not requested by the PEB and was not part of the official PEB process but was submitted by the CI as evidence for a higher rating. The military exam of 20060217 cited by AFPC would rate 20% using either 5399-5304 or 5201. Exams completed both before and after the 40% disability level exams show disability at the 20% level. It appears the limitations increased during the time of the IPEB, FPEB, and AFPC reviews but then decreased two months after separation from the Reserves. From VA medical history (MH) notes, CI had depression and stress related to PEB process and this could have contributed to temporarily increased symptoms. The temporarily increased symptoms could also be secondary to an intervening event as suggested by the AFPC but there is no reported history of further injury or insult and CI was reportedly not working.

CI appears to have a consistently limited ROM of the left shoulder at 90 degrees of flexion and abduction with intermittent periods of more pronounced limitations. However, the exam closest to the date of separation in Sept 2006 is the VA new patient H&P (history and physical) done in November 2006. This exam shows flexion and abduction limited to shoulder height or 90 degrees. This exam is also the most recent exam.

The 5201 code appears to be more accurate. However, a 20% rating is warranted under either 5201 or 5399-5304 and changing the code would not provide any advantage to the CI.

Depression: The CI had no duty restrictions related to this diagnosis and his profile was S1. There is no evidence this condition interfered with satisfactory performance of any required duties. He filed a VA claim for this condition in December 2005 and his last active duty period ended 20041112. There is no evidence of any mental health diagnosis prior to this time and no Line of Duty investigation was done to determine whether this condition was incurred in the line of duty. The condition was not unfitting or may or may not have been related to military service.

The VA considered this condition to be service connected only as a condition related to the service connected disability of shoulder impingement syndrome, not as independently service connected.

Other Conditions Not in Disability Evaluation System (DES) package: Tinnitus; Perforated Right Eardrum; and Septoplasty Status Post Recurrent Sinusitis and Deviated Septum.

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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 Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. After careful consideration of all available information the Board unanimously determined that the CI’s shoulder condition is most appropriately rated at 20% under either VASRD 5399-5304 or 5201. The VA C&P of 20060310 is the only examination in the record that includes a complete ROM examination done with a goniometer and more weight is applied to the results of this examination than to any other individual examination. This examination documents the left shoulder was limited by pain to 30 degrees of flexion and 25 degrees of abduction. However, the preponderance of medical evidence documents a much greater ROM both before and after that examination. The preponderance of evidence supports flexion and abduction of the dominant shoulder limited to 90 degrees by pain and this warrants a 20% rating under either VASRD code.

The Board also considered Depressive Disorder and unanimously determined this condition did not interfere with satisfactory performance of any required duties. Additionally no line of duty investigation was completed for this condition and the Board found no evidence that this condition was incurred in the line of duty. Therefore no disability rating is applied to this condition. The other diagnoses rated by the VA (Tinnitus, Perforated Right Eardrum, and Septoplasty Status Post Recurrent Sinusitis and Deviated Septum) were not mentioned in the Disability Evaluation System package and are therefore outside the scope of the Board. The CI retains the right to request his service Board of Correction for Military Records (BCMR) to consider adding these conditions as unfitting.

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RECOMMENDATION: The Board therefore recommends that there be no recharacterization of the CI’s disability and separation determination.

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The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20090728, w/atchs.

Exhibit B. Service Treatment Record.

Exhibit C. Department of Veterans' Affairs Treatment Record.

Deputy Director

Physical Disability Board of Review

SAF/MRB

1535 Command Drive, Suite E-302

Andrews AFB, MD 20762-7002

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2009-00466.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate. Accordingly, the Board recommended no recharacterization or modification of your separation with severance pay.

I have carefully reviewed the evidence of record and the recommendation of the Board. I concur with that finding and their conclusion that re-characterization of your separation is not warranted. Accordingly, I accept their recommendation that your application be denied.

Sincerely

Director

Air Force Review Boards Agency

Attachment:

Record of Proceedings

cc:

SAF/MRBR