RECORD OF PROCEEDINGS
                     PHYSICAL DISABILITY BOARD OF REVIEW

NAME:            BRANCH OF SERVICE:  air force
CASE  NUMBER:   PD1000719                                 SEPARATION   DATE:
20050706
BOARD DATE:  20111028


SUMMARY OF CASE:  Data extracted  from  the  available  evidence  of  record
reflects that this covered individual (CI) was an  Air  National  Guard  Air
Reserve  Technician,  MSgt/E-7  (1A2/Loadmaster),  medically  separated  for
right (dominant) shoulder pain associated with partial  rotator  cuff  tear,
acromio-clavicular arthritis and  chronic  impingement,  moderately  severe.
He injured his right shoulder after performing loadmaster duties in Iraq  in
2003.  His treatment included  medications,  physical  therapy,  subacromial
and  nerve  root  injections,  and  three  arthroscopic  surgeries,  without
significant improvement.  He did not respond  adequately  to  treatment  and
was unable to perform within his Air Force Specialty (AFS) or meet  physical
fitness standards.  He was issued a  U4  profile  and  underwent  a  Medical
Evaluation Board (MEB).  Right (dominant) shoulder  pain  was  forwarded  to
the Physical Evaluation Board (PEB) as medically unacceptable  IAW  AFI  48-
123.  One other condition, as identified in  the  rating  chart  below,  was
forwarded on the MEB submission as a medically  acceptable  condition.   The
Informal  PEB  (IPEB)  adjudicated  the  right  (dominant)   shoulder   pain
associated with partial rotator cuff tear, acromio-clavicular arthritis  and
chronic impingement,  moderately  severe,  as  unfitting,  rated  20%,  with
application  of   the   Veterans’   Administration   Schedule   for   Rating
Disabilities (VASRD).  The CI appealed for a formal PEB but  later  withdrew
his appeal, and was medically separated with a 20% disability rating.


CI  CONTENTION:   “Please  see  attached  DAV  memorandum  and  DVA   rating
decisions.”  A contention  for  the  inclusion  his  VA  conditions  in  the
separation rating is implied.  All service conditions are  reviewed  by  the
Board for their potential contribution to its rating recommendations.


RATING COMPARISON:

|Service IPEB – Dated 20050504    |VA (8 Mo. Pre-Separation) – All       |
|                                 |Effective Date 20050707               |
|Condition                        |Code                          |Rating |
|Combined:  20%                   |Combined:  30%*                       |


*Right shoulder, 5010-5203  increased  to  20%  (effective  20070412),  100%
(20090626-20091001), 30% (20091119), 100% (20100313-20101001) with  combined
70% from 20101001; Cervical spine, 5242 increased to 20% effective 20070412





ANALYSIS SUMMARY:

Right  Shoulder  Condition:   The  record  indicates  the   CI   had   three
arthroscopic surgical procedures prior to separation.  The first  (September
2003) was a debridement of the rotator cuff and  subacromial  decompression.
Despite post-operative physical therapy there was minimal improvement.   The
second (November 2003) surgery included a labral debridement,  rotator  cuff
debridement, synovectomy, partial thickness rotator  cuff  repair,  revision
of prior subacromial decompression, and distal clavicle resection.   The  CI
did not regain full range of  motion,  and  a  third  surgery  (April  2004)
consisted  of  extensive  glenohumeral  debridement,  another  revision   of
subacromial   decompression   with   resection   of    extensive    fibrosis
(subacromial, subdeltoid, subcoracoid, subclavicular, AC interval),  partial
coracoplasty, debridement and repair intratendinous rotator cuff  tear,  and
introduction of a pain pump catheter.

There were three shoulder evaluations in evidence proximate to separation
which the Board weighed in arriving at its rating recommendation.  All
three of these exams are summarized in the chart below.

|Goniometric ROM –|VA C&P ~ 8 Mo.   |MEB (w/          |Ortho ~ 2 Mo.  |
|Right Shoulder   |Pre-Sep          |attachments) ~ 7 |Pre-Sep        |
|                 |                 |& 8 Mo. Pre-Sep  |               |
|Flexion (0-180)  |100⁰             |“Significant     |“Decreased by  |
|                 |                 |decrease of ROM  |pain”          |
|                 |                 |secondary to     |               |
|                 |                 |pain”            |               |
|Abduction (0-180)|110⁰             |                 |               |
|Ext Rotation     |78⁰              |                 |               |
|Int Rotation     |64⁰              |                 |               |
|Comment:  Third  |Pain limited     |Pain limited     |Scapular droop;|
|surgery          |motion;          |motion, TTP,     |abnormal       |
|15 Mo. Pre-Sep   |appearance       |atrophy, (ortho -|scapular       |
|                 |normal; not      |weakness and     |rhythm; TTP;   |
|                 |additionally     |numbness in C6 & |“exquisitely   |
|                 |limited by       |C7, numbness in  |painful”       |
|                 |fatigue,         |ulnar n, +       |impingement    |
|                 |weakness, lack of|Tinel’s at       |tests,         |
|                 |endurance or     |elbow),          |O’Brien’s, &   |
|                 |incoordination;  |(neurosurg –     |Jobe’s tests;  |
|                 |neuro normal     |entire hand numb)|weak 4+/5      |
|                 |                 |                 |abduction & ext|
|                 |                 |                 |rotation       |
|§4.71a Rating    |10% (VA 10%)     |≥10%             |≥10%           |
|(musculoskeletal)|                 |                 |               |
|§4.73 Rating     |0%               |PEB 20%          |10, 20, or 30% |
|(muscle)         |                 |                 |(5304)         |
|§4.124a rating   |0%               |20% or 40% (8511)|20% or 40%     |
|(nerve)          |                 |                 |(8511)         |

The VA exam, eight months pre-separation,  documented  pain-limited  motion.
Neurological evaluation  was  normal.   Radiographs  revealed  evidenced  of
previous osteotomy of the clavicle and a normal glenohumeral joint.  The  VA
diagnosed degenerative joint disease (DJD) of the shoulder, rated 10%.   The
NARSUM, seven months pre-separation, did not  contain  its  own  examination
report; rather, it included clinical  exam  information  from  two  attached
consults; one from orthopedic surgery from earlier the same month,  and  one
from neurosurgery from the prior month.   The  neurosurgical  exam  noted  a
“significant decrease of range of motion  in  his  right  arm  secondary  to
pain, both active and passive range of motion.”  The orthopedic  exam  noted
pain limited motion, and also reported  atrophy  (location  not  specified).
Both exams also noted neurological deficits in the hand.  The NARSUM  stated
the orthopedic consult reported weakness and  numbness  in  the  C6  and  C7
distribution, although that was not substantiated in the source  (orthopedic
addendum) or elsewhere in the record.  Intermittent numbness in  the  entire
right hand was well documented.  The orthopedic addendum noted  numbness  in
the ulnar nerve (C8 and T1) region, positive Tinel’s sign at the elbow,  and
decreased sensation in the index finger and  thumb  which  was  less  severe
than the ulnar side and was postulated to be due to carpal  tunnel  syndrome
or to a cervical (C6) radiculopathy.   The  neurosurgical  consult  reported
reduced sensation in the entire right hand, including all fingers,  but  did
not  describe  any  motor  deficits.   Nerve  conduction  studies  confirmed
entrapment of the ulnar nerve at the elbow.   Radiographs  showed  DJD  with
subacromial  osteophytes,  and  two  MRIs  confirmed  the  DJD,  showed  the
osteophytes to be impinging on the supraspinatus muscle, and  also  revealed
rotator cuff tendon tears (full-thickness  supraspinatus,  partial-thickness
infraspinatus), and a possible avulsion of the anterior glenoid labrum.

An orthopedic exam two months prior to separation  (three  weeks  after  the
PEB) reported shoulder ROM “decreased by pain,” and  noted  scapular  droop,
abnormal scapular rhythm, and widespread tenderness.  Tests for  impingement
(Neer’s, Hawkins’, Coracoid),  for  acromioclavicular  or  labral  pathology
(O’Brien’s) and for anterior instability  (Jobe’s  apprehension  test)  were
all “exquisitely painful.”  Abduction and external rotation  were  weak,  at
4+/5.   Radiographs  revealed  heterotopic  bone  in  the  acromioclavicular
interval and exostosis on the greater tuberosity and biceps  tendon  groove.
The examiner believed  neck  surgery  should  be  considered  again  by  the
neurosurgeon, and that one additional shoulder surgery would be  appropriate
(after neck surgery).  The examiner also noted that he  had  spoken  to  the
neurosurgeon, who  indicated  the  CI  experienced  significant  improvement
(although transient)  in  neck  pain  and  ROM  with  selective  nerve  root
injections, and that he believed the shoulder condition was likely the  CI’s
primary problem, but that the cervical and shoulder pathology had  caused  a
chronic droop in his shoulder causing some brachial neuritis.

It is obvious that there is a clear disparity between  the  VA  and  Service
examinations, with  very  significant  implications  regarding  the  Board's
rating recommendation.  The Board thus carefully deliberated  its  probative
value assignment to these conflicting evaluations,  and  carefully  reviewed
the Service file for corroborating evidence in the 12-month period prior  to
separation.  The VA exam did not provide the kind of detailed  muscular  and
neurological evaluations included in  the  Service  records;  it  apparently
used a “joint template,” focusing primarily on ROM  impairment.   Thus,  the
highest  probative  value  is  attributed  to  the   Service   examinations,
corroborated by the Service treatment record.  The PEB  rated  the  shoulder
condition as a muscle injury IAW §4.73, while the VA  used  §4.71a  to  rate
the condition for impairment  of  the  clavicle  or  scapula.   The  CI  had
multiple  diagnoses  and  disability  associated  with  his  right  shoulder
including:   rotator   cuff   impingement;   rotator   cuff   tendon   tear;
acromioclavicular  osteoarthritis;  labral  tear;  impingement,  subacromial
outlet   pain;   and   sensory   deficit   and/or   neuritis   related    to
brachiitis/ulnar compression  and/or  cervical  outlet.   The  contributions
from  all  diagnoses  to  the  CI’s  total  right  shoulder  impairment  are
considered in the rating by this Board.  All records  indicate  the  CI  was
right hand dominant.

The Board discussed the separate impairments  related  to  muscles  (rotator
cuff  tendon   tears,   weakness),   bones   (distal   clavicle   resection,
coracoplasy, osteophytes, exostosis), and nerves (entrapment  neuropathy  at
elbow and possibly at carpal tunnel or brachial plexus;  cervical  radicular
pain), and noted that the CI’s overall shoulder impairment was greater  than
the rating provided with ROM limitation or painful motion alone.  The  Board
also  noted  the  significant  impairment  described  in   the   commander’s
statement, with inability to “write with his hand or drive his car  and  has
missed approximately 300 days of work this year because of his  disability.”
 The Board considered separate ratings for muscle impairment under  5301  or
5304, with additional rating for bone impairment with painful  motion  under
5003/5010 and/or 5201, but judged a single rating  under  muscle  impairment
to be superior, with the caveat that it should reflect the total  disability
picture, including impairment caused by non-muscle pathology (i.e., bone  or
nerve).  IAW §4.56 (Evaluation of  muscle  disabilities),  the  CI’s  muscle
impairment met many of the descriptions under both “moderately  severe”  and
“severe” categories.  He clearly had a “record of  consistent  complaint  of
cardinal signs and  symptoms  of  muscle  disability  [per  para  (c)],  and
“evidence  of  inability  to  keep  up  with  work  requirements.”    Strict
interpretation of history  and  findings  favored  a  rating  of  moderately
severe, with atrophy compared with sound side, and “tests  of  strength  and
endurance  compared  with  sound  side  demonstrate  positive  evidence   of
impairment.”  Although  it  is  possible  that  impairments  from  the  neck
condition, neurological  deficits  in  the  right  upper  extremity,  and/or
painful  scars,  were  overshadowed  by   the   shoulder   condition,   that
possibility  is  unduly  speculative  as  the  basis  for  a  Board  fitness
recommendation, and there was not sufficient evidence to support  separately
unfitting  recommendations  for  those  conditions  by  the  Board.    These
conditions likely contributed  to  the  CI’s  overall  shoulder  impairment,
however, and are considered in the Board’s recommendations.

The  Board  considered  other  rating  options  for  the   CI’s   condition,
including:  5304 (Group I  muscles)  at  20%  (moderately  severe,  dominant
side); analogous coding to 5203 (Clavicle  or  scapula,  impairment  of)  at
20%; and analogously to 8510 or 8511 (incomplete paralysis of the  upper  of
middle radicular groups, respectively) at  40%  (moderate,  dominant  side).
With no indication of significant weakness in muscles of the  elbow,  wrist,
or hand, the evidence did  not  support  analogous  coding  to  neurological
diagnoses.  The CI’s muscle and bone pathology,  with  degenerative  disease
in the shoulder joint and tears of  the  rotator  cuff  suggested  the  most
anatomically accurate  coding  would  include  5304  for  the  rotator  cuff
impairment; however analogous coding to 5301  was  sufficiently  descriptive
of the CI’s impairment (weakness and limited motion  in  elevating  the  arm
above shoulder  level,  and  shoulder  droop)  at  30%  (moderately  severe,
dominant side), and resulted in  a  rating  that  was  closer  to  the  CI’s
disability  picture  and  reflected  the  contributions  of  all   pathology
contributing to the CI’s greater overall  shoulder  impairment.   After  due
deliberation, considering all of the evidence  and  mindful  of  VASRD  §4.3
(reasonable doubt), the Board majority recommends  a  separation  rating  of
30% for the right shoulder condition, coded 5099-5301.

Other PEB  Conditions:   The  other  condition  forwarded  by  the  MEB  and
adjudicated as not unfitting by the PEB was hearing  impairment,  bilateral,
worse in left ear (VA 0% each).   Otolaryngologic  evaluation  in  September
2002 found no tumors or other  retrocochlear  disease,  and  recommended  he
return to flying duties.  An aeromedical summary in November 2002 noted  the
CI had the H3 profile since  1994,  and  recommended  waiver  for  continued
flying duty.  An addendum to the aeromedical summary in  May  2003  reported
an in-flight hearing test  was  performed  in  February  2003,  with  normal
results.  The NARSUM noted the CI had received  a  waiver  for  his  hearing
loss.  An audiogram in September 2004 showed an acoustic  notch  typical  of
noise induced hearing loss (with left ear thresholds of 40 dB  at  3000  Hz,
60 dB at 4000 Hz, and 45 dB at 6000 Hz).  Although  the  left  ear  acoustic
notch was noted on entrance audiogram in December 1981, it had  worsened  by
20 dB, and the audiologist stated the CI was a candidate for a  hearing  aid
in the left ear.  The examiner also documented  100%  speech  discrimination
bilaterally.  The condition was not implicated in the commander’s  statement
or noted as failing retention standards.  The condition was reviewed by  the
action officer and considered by the Board.  There was  no  indication  from
the record that the condition  significantly  interfered  with  satisfactory
performance of duty requirements.  All evidence  considered,  there  is  not
reasonable doubt in the CI’s favor supporting recharacterization of the  PEB
fitness adjudication for the stated condition.

Other Contended Conditions:  The CI’s application asserts  that  compensable
ratings  should  be  considered   for   his   other   VA-rated   conditions:
posttraumatic stress disorder (PTSD), mood disorder  secondary  to  shoulder
condition (VA 30% effective 33 months post-separation);  degenerative  joint
disease, cervical spine with disc herniation  (VA  10%  at  separation,  20%
effective 19 months post-separation); bilateral  tinnitus  (VA  10%);  right
ulnar neuropathy (VA 10%); scar right shoulder  (VA  0%);  and  degenerative
joint disease, right ankle, status  post  fracture  (VA  NSC).   The  NARSUM
noted cervical spondylosis with posterior disc herniation at C 5-6 and C  6-
7 (encroaching upon the thecal sac; no impingement of nerve roots).  The  CI
experienced neck pain and sensory deficits in  the  C6  and  C7  nerve  root
distribution.  Muscle weakness of C6 and C7 reported in the NARSUM  was  not
substantiated in the  source  document  (orthopedic  consult)  to  which  it
referred, was not further elaborated in the NARSUM  or  confirmed  elsewhere
in the  record.   The  VA  reported  a  normal  neurological  exam.   Muscle
weakness likely arose from the shoulder  pathology  (rotator  cuff  injury).
Nerve conduction studies demonstrated entrapment of the  right  ulnar  nerve
at the elbow.  Although selective nerve root injections  produced  transient
pain relief and full cervical ROM, and the commander’s  statement  mentioned
nerve damage in the neck, the exams  prior  to  separation  did  not  reveal
significant  cervical  spine-related  impairment;  the  VA  exam  documented
cervical  ROM  decrements  meeting  the  10%  criteria,   with   no   spasm,
tenderness,  or  signs  of   intervertebral   disc   syndrome.    The   CI’s
arthroscopic surgical scars were  not  noted  to  be  symptomatic  prior  to
separation,  or  otherwise  impairing  of  MOS  duty   performance.    PTSD,
tinnitus, and the right ankle condition  were  not  documented  in  the  DES
file.  The Board does not have the authority under DoDI  6040.44  to  render
fitness or rating recommendations for any conditions not considered  by  the
DES.  The cervical spine condition, ulnar  neuropathy,  and  right  shoulder
scar conditions were reviewed by the action officer and  considered  by  the
Board.  There was no evidence for concluding  that  any  of  the  conditions
interfered with duty performance  to  a  degree  that  could  be  argued  as
unfitting.   The  Board  determined  therefore  that  none  of  the   stated
conditions were subject to Service disability rating.

Remaining Conditions:  No other conditions  were  noted  in  the  NARSUM  or
found elsewhere in the DES file.  The Board  does  not  have  the  authority
under DoDI 6040.44 to render  fitness  or  rating  recommendations  for  any
conditions not  considered  by  the  DES.   The  Board,  therefore,  has  no
reasonable basis for recommending any additional  unfitting  conditions  for
separation rating.


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 right  shoulder  condition  and  IAW  VASRD
§4.73, the Board by a vote of 2:1 recommends a rating  of  30%  coded  5099-
5301 IAW VASRD §4.73.  The single voter  for  dissent  (who  recommended  no
recharacterization) did not elect to submit  a  minority  opinion.   In  the
matter  of  the  bilateral  hearing  impairment,   the   Board   unanimously
recommends no  change  from  the  PEB  adjudications  as  Category  II,  not
compensable or ratable.  In the matter of the  cervical  spine  degenerative
joint disease, right  ulnar  neuropathy  conditions  or  any  other  medical
conditions eligible for Board consideration; the  Board  unanimously  agrees
that it cannot recommend any findings of  unfit  for  additional  rating  at
separation.


RECOMMENDATION:  The Board recommends that the CI’s prior  determination  be
modified  as  follows  and  that  the  discharge  with  severance   pay   be
recharacterized to reflect permanent disability retirement, effective as  of
the date of his prior medical separation:

|UNFITTING CONDITION                               |VASRD CODE  |RATING  |
|Right Shoulder Muscle Impairment                  |5099-5301   |30%     |
|COMBINED    |30%     |


____________________________________________________________________________
__

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20100603 w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans' Affairs Treatment Record



            President
            Physical Disability Board of Review
SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews MD  20762



      Reference your application submitted under the provisions of DoDI
6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2010-00719.

      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 not appropriate under the guidelines of
the Veterans Administration Schedule for Rating Disabilities.
Accordingly, the Board recommended your separation be re-characterized to
reflect disability retirement, rather than separation with severance pay.

      I have carefully reviewed the evidence of record and the
recommendation of the Board.  I concur with that finding, accept their
recommendation and determined that your records should be corrected
accordingly.  The office responsible for making the correction will inform
you when your records have been changed.

      As a result of the aforementioned correction, you are entitled by law
to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of
this letter, you must contact the Air Force Personnel Center at 1-800-531-
7502 to make arrangements to obtain an SBP briefing prior to rendering an
election.  If a valid election is not received within 30 days from the date
of this letter, you will not be enrolled in the SBP program unless at the
time of your separation, you were married or had an eligible dependent
child, in such a case, failure to render an election will result in
automatic enrollment.

                                        Sincerely,






                                       Director
                                       Air Force Review Boards
                                       Agency

Attachment:
Record of Proceedings

cc:
SAF/MRBR
DFAS-IN
PDBR PD-2010-00719




MEMORANDUM FOR THE CHIEF OF STAFF

      Having received and considered the recommendation of the Physical
Disability Board of Review and under the authority of Section 1554, Title
10, United States Code (122 Stat. 466) and Section 1552, Title 10, United
States Code (70A Stat. 116) it is directed that:

      The pertinent military records of the Department of the Air Force
relating to xxxxxxxxxxx, be corrected to show that:

            a.  The diagnosis in his finding of unfitness was Right
Shoulder Muscle Impairment, VASRD code 5099-5301, rated at 30% rather
than Right (dominant) Shoulder Pain, VASRD code 5304, rated at 20%.

            b.  On 5 July 2005, he elected not to participate in the
Survivor Benefit Plan and on that same date, his spouse, xxxxxxxxxx
concurred with his election.

            c.  He was not discharged on 6 July 2005; rather, on that
date, he was relieved from active duty and on 7 July 2005, his name was
placed on the Permanent Disability Retired List.







  Director

  Air Force Review Boards Agency