RECORD OF PROCEEDINGS
                     PHYSICAL DISABILITY BOARD OF REVIEW

NAME:                  BRANCH OF SERVICE:  Army
CASE  NUMBER:    PD1100369                                        SEPARATION
DATE:  20050802
BOARD DATE:  20120217


SUMMARY OF CASE:  Data extracted  from  the  available  evidence  of  record
reflects that this covered  individual  (CI)  was  an  active  duty  SPC/E-4
(52D10/Air Conditioner Mechanic),  medically  separated  for  chronic  right
shoulder pain.  The CI  sustained  a  complete  tear  of  his  subscapularis
tendon  in  June  2003  when  he  fell  from  a  generator  during  an  Iraq
deployment.  He underwent surgical repairs in September  2004  and  February
2005, without improvement in his pain or  functional  limitations.   Despite
surgical intervention, physical therapy and pain medication, the CI did  not
respond adequately to  treatment  and  was  unable  to  perform  within  his
Military Occupational  Specialty  (MOS).   He  was  issued  a  permanent  U3
profile and underwent a  Medical  Evaluation  Board  (MEB).   Chronic  right
shoulder pain, chronic right subscapularis tear and status  post  pectoralis
major tendon transfer were forwarded to the Physical Evaluation Board  (PEB)
as medically unacceptable IAW  AR  40-501.   Posttraumatic  stress  disorder
(PTSD) and anxiety were forwarded on the MEB submission as  conditions  that
do not fall below retention standards.   The  PEB  adjudicated  the  chronic
right shoulder pain condition as unfitting, rated 10%  with  application  of
the Veterans Administration Schedule for Rating Disabilities  (VASRD).   The
CI made no  appeals,  and  was  medically  separated  with  a  10%  combined
disability rating.


CI CONTENTION:  The CI states:  “Constant pain, loss of  mobility,  residual
scar.”  He elaborates no specific contentions regarding rating or coding.


RATING COMPARISON:

|Service IPEB – Dated 20050701  |VA (1 Mo. After Separation) – All       |
|                               |Effective 20050803                      |
|Condition                      |Code                                    |
|Combined:  10%                 |Combined:  60%*                         |


* Right subscapularis repair increased to 40% (coded change  to  5010-5201);
and  added  associated  brachial  neuritis  (8699-8619)  at  10%   effective
20070720 (combined 80%).  Ratings  increased  effective  20090212  (combined
100%).


ANALYSIS SUMMARY:  The Board acknowledges the  sentiment  expressed  in  the
CI’s  application  regarding  the  significant  impairment  with  which  his
service-aggravated condition  continues  to  burden  him.   It  is  a  fact,
however, that the DES has neither the role nor the authority  to  compensate
service members for anticipated future severity or  potential  complications
of conditions resulting in medical separation.  This role and  authority  is
granted by Congress to the Department of Veterans’ Affairs (DVA).  The  DVA,
operating under a different set of laws (Title 38, United States  Code),  is
empowered to compensate service connected conditions and to periodically re-
evaluate  said  conditions  for  the  purpose  of  adjusting  the  veteran’s
disability rating should his degree  of  impairment  vary  over  time.   The
Board utilizes DVA evidence  proximal  to  separation  in  arriving  at  its
recommendations; and, DoDI 6040.44 defines a 12 month interval  for  special
consideration  to  post-separation  evidence.   The  Board’s  authority   as
defined in DoDI 6044.40, however, resides in evaluating the fairness of  DES
fitness determinations and rating decisions for disability at  the  time  of
separation.  Post-separation evidence therefore is  probative  only  to  the
extent that it reasonably reflects the disability and  fitness  implications
at the time of separation.

Chronic Right Shoulder Pain.  The record indicates that  the  CI  is  right-
handed.  The CI had undergone pre-service surgery on his right  shoulder  in
October 1999 for an anterior labral tear.  That injury was considered  fully
recovered without sequelae at the time  of  entrance  onto  active  duty  in
2002.  In June 2003, while deployed in Iraq, the CI injured his shoulder  as
he fell from a generator.   He  was  initially  diagnosed  with  a  shoulder
sprain and was returned to duty without limitations.  Upon  redeployment  of
his unit in 2004, the CI was evaluated by orthopedics and diagnosed  with  a
full-thickness perforation of the subscapularis  tendon.   He  underwent  an
open subscapularis repair in September  2004;  however,  the  repair  failed
shortly  after  surgery,  with  recurrence  of  right  shoulder   pain   and
instability.  In an attempt to salvage shoulder function, the  CI  underwent
a  pectoralis  major  transfer  in  February  2005.   Despite  surgery,   he
continued to have significant pain with activities involving  abduction  and
external rotation.

There were three comprehensive shoulder evaluations in  evidence,  two  with
goniometric range-of-motion (ROM) measurements, which the Board  weighed  in
arriving at its rating recommendation.  These were  the  Orthopedic  Medical
Board Addendum exam, the MEB exam and the VA Compensation and Pension  (C&P)
exam.  The findings of the orthopedic addendum, combined and presented  with
the MEB exam findings, and the VA C&P  exam  are  summarized  in  the  table
below.

|Goniometric ROM  |MEB ~2 Mo. Pre-Sep|VA C&P ~1 Mo.     |
|–R Shoulder      |                  |After-Sep         |
|Flexion (0-180⁰) |0-150⁰   H&P 160⁰ |0-130⁰            |
|Abduction        |0-145⁰    H&P 130⁰|0-140⁰            |
|(0-180⁰)         |                  |                  |
|Internal Rotation|0-10⁰             |88⁰               |
|(0-90⁰)          |                  |                  |
|External Rotation|160 [sic- noted as|90⁰               |
|(0-90⁰)          |90⁰ on ortho      |                  |
|                 |addendum]         |                  |
|Comment:         |4/5 strength      |Painful motion; no|
|Last surgery ~ 6 |internal rotators |atrophy; no       |
|Mo. Pre-Sep      |and supraspinatus;|fatigue, impaired |
|                 |painful motion; no|endurance or      |
|                 |instability; mild |weakened movement |
|                 |biceps Popeye     |                  |
|                 |deformity         |                  |
|§4.71a Rating    |10%               |10%               |

At the MEB exam, two months  prior  to  separation,  the  CI  complained  of
significant  right  shoulder  weakness  and  6-7/10   pain   with   overhead
activities and abduction movements.  He reported being unable to  lift  more
than 10 pounds.  The examiner noted limitation  of  flexion,  abduction  and
internal rotation, with increased ROM on external rotation of the  shoulder.
 Additionally, the MEB exam documented  weakness  of  4/5  in  the  internal
rotators and the supraspinatous.   The  orthopedic  addendum  (three  months
post-operatively; three months pre-separation)  noted  painful  motion  with
abduction and external  rotation,  but  documented  no  instability  of  the
shoulder joint.

The VA C&P exam, one month post-separation,  documented  painful  limitation
of motion.  On repeat testing with a five pound  weight,  the  C&P  examiner
noted no additional loss of ROM, fatigue,  impaired  endurance  or  weakened
movement:  “Using the five pound weight and doing  repeated  active  motion,
the veteran evidenced painful motion at the end of elevation  and  abduction
which is 180 degrees with no fatigue, no  impaired  enduiance,  no  weakened
movement noted.  The  same  range  of  motion  was  noted  on  internal  and
external rotation, with pain at the end of each motion, with no fatigue,  no
impaired enduiance, no weakened movement  noted.”   The  C&P  exam  did  not
specifically  document  strength  testing,  nor  did  it  comment  on  joint
stability.  Plain films of the right shoulder  from  September  2005  showed
status  post  surgery  with  orthopedic  metallic  tacks.   There  were   no
degenerative changes and the AC joint appeared  normal.   A  July  2004  MRI
arthrogram  (pre-surgery)  demonstrated  a   chronic   near-complete   full-
thickness  perforation  of  the  subscapularis  tendon,  secondary  moderate
atrophy of the subscapular muscle, and a partial tear  of  the  supraspinous
portion of the rotator cuff.

A note  from  20  months  after  separation  (April  2007)  indicated  gross
instability  and  examiner  was  “able  to  freely  dislocate  his  shoulder
anterior/inferior and reduce it spontaneously.”  VA  exam  26  months  post-
separation documented gradual worsening of pain since the  initial  VA  exam
and marked dysfunction of  the  right  upper  extremity  and  narcotic  pain
medication.  ROMs were limited to forward flexion of 40⁰  and  abduction  of
35⁰ and there was loss of muscle mass and depression of  the  shoulder  with
documented muscle weakness to 3/5.  History indicated  shoulder  dislocation
averaging  4x/week.   This  note  and  exam  were  remote  from  separation,
indicated post-separation worsening, and were adjudged as not indicative  of
the CI’s condition proximate to separation.

The PEB and the VA chose different coding options, but both  codes  rate  as
arthritis,  degenerative.   The  PEB  coded  (5099-5003)   by   analogy   as
degenerative arthritis with loss of joint motion and rated at 10%.   The  VA
coded (5201-5010) for shoulder limitation of motion, analogous to  traumatic
arthritis and rated at 10% based upon pain limited ROM “with X-ray  findings
that are consistent with prior surgery.”   Neither  coding  is  predominant.
Alternate coding under 5304, group IV muscle injury,  was  also  considered,
given the  rotator cuff muscle group injury documented by MRI  and  at  time
of surgery of tendon transfer.  The 4/5 muscle strength at the MEB exam  was
proximate to surgery and potentially due  to  pain  and  not  found  at  the
proximate VA exam.  The Board considered alternative coding under  group  IV
muscle injury, considering the CI’s painful motion, slight muscle  weakness,
muscle surgery and muscle deformity as well as functional  loss.   Proximate
to separation, the CI’s condition was no greater  than  that  envisioned  in
the criteria for slight injury (0%).  The degree  of  limitation  of  motion
documented at the  service  and  VA  exams  is  not  compensable  under  the
specific joint coding, but does meet the criteria for the 10%  rating  under
degenerative arthritis coding, or with application of VASRD  §4.59  (painful
motion).  There was no route to rating higher than 10% under any  applicable
code and no coexistent pathology which would  merit  additional  rating  for
the right shoulder condition under a separate  code  without  violating  the
tenants of VASRD §4.14 (avoidance of pyramiding).  There was no evidence  of
dislocations, instability,  impaired  endurance  or  fatigue,  proximate  to
separation.  There was no weakness noted at the  VA  exam.   There  were  no
symptoms or  evidence  of  an  unfitting  peripheral  nerve  impairment  for
additional rating at separation.  All  evidence  considered,  there  is  not
reasonable doubt in the CI’s favor supporting a change from  the  PEB’s  10%
rating decision for the right shoulder condition.

Other  PEB  Conditions.   The  two  conditions  forwarded  by  the  MEB  and
adjudicated as not unfitting by the PEB were PTSD and anxiety.  At the  time
of the MEB psychiatric addendum, the examiner noted  that  the  CI  had  not
received any  treatment  for  his  mental  health  condition.   The  axis  I
diagnoses were PTSD, mild, and anxiety  disorder,  not  otherwise  specified
(NOS).  The examiner assessed that the PTSD resulted in mild impairment  for
military duty and stated that “with treatment his prognosis is  good.”   The
anxiety disorder was found to cause no impairment for  military  duty.   The
Global Assessment of Functioning (GAF) was assigned at 70, in the  range  of
mild symptoms.  The examiner concluded, “This soldier’s axis  I  psychiatric
conditions are not unfitting for military duty at this time.”

At the time of the VA C&P exam, one month after separation, the CI  endorsed
increasing  symptoms  of  anxiety  and   depression   with   chronic   sleep
impairment.  The examiner commented that the CI’s PTSD had improved  without
treatment since leaving Iraq; however it was noted that  “chronic  pain  has
led to depressive symptoms.”  The  axis  I  diagnoses  were  PTSD,  chronic,
mild, and depresseive disorder, NOS.  The GAF for PTSD was assigned  at  71,
in  the  range  of  transient  or  slight  impairment,  while  the  GAF  for
depressive disorder and the overall GAF were assigned at 56,  in  the  range
of moderate symptoms.  The examiner concluded that the C’s  symptoms  should
not “interfere with working at a sedentary job with minimal supervision  and
minimal interaction with the public.”  The  Board  adjudged  this  as  post-
separaton worsening and not indicative of  the  CI’s  level  of  functioning
during the MEB period or at time of  separation.   The  CI’s  mental  health
conditions did not result in any profile or  duty  limitations.   No  mental
health conditions were implicated in the commander’s statement or  noted  as
failing  retention  standards.   The  conditions  of   PTSD,   anxiety   and
depressive disorder were reviewed by the action officer  and  considered  by
the Board.  There was no indication from the record that any  mental  health
condition significantly interfered with satisfactory duty performance.   All
evidence considered, there  is  not  reasonable  doubt  in  the  CI’s  favor
supporting recharacterization of the PEB fitness adjudication for  the  PTSD
or anxiety disorder conditions.

Other Contended Conditions.  The CI’s application asserts  that  compensable
ratings should be considered for loss of  mobility,  and  a  residual  scar.
The CI’s shoulder injury and subsequent surgeries did result  in  limitation
of motion in the shoulder as discussed  and  rated  above.   The  degree  of
limitation of motion in the shoulder was not compensable under the  specific
joint coding, however the loss of mobility was  considered  in  the  overall
rating for the CI’s unfitting shoulder condition.  The CI did have  multiple
scars on the left shoulder as a result of his prior  surgeries.   There  was
no documentation that any of the  scars  interfered  with  the  satisfactory
performance of MOS duties and scars were not implicated in  the  commander’s
statement.  The scar condition  was  reviewed  by  the  action  officer  and
considered by the Board.  Any scar impairment to the  limitation  of  motion
was considered in the above shoulder rating.   There  was  no  evidence  for
concluding that the shoulder scars interfered with  duty  performance  to  a
degree that could be argued as unfitting.  The  Board  determined  therefore
that the scar condition was not subject to service disability rating.

Remaining Conditions.  Other conditions identified in the DES file  and  the
VARD within 12 months of separation, were neck pain, right wrist pain,  left
shoulder  pain  and  right  knee  pain.     Several   additional   non-acute
conditions or medical complaints were  also  documented  (trouble  breathing
after exercise, shortness of breath,  eyes  burning,  wears  glasses/contact
lenses, bilateral wrist pain, upper back pain and numbness; bilateral  knees
- pain, swelling, locking and giving out; bicep deformity, h/o  broken  nose
and rotator cuff injury s/p MVA in  1999,  peniciilin  causes  hives,  short
term memory loss, nervous around other people, trouble  sleeping  at  night,
depression  and  worry).   None  of  these  conditions  were   significantly
clinically or occupationally active during  the  MEB  period,  none  carried
attached profiles, and none were implicated in  the  commander’s  statement.
These conditions were reviewed by the action officer and considered  by  the
Board.  It was determined  that  none  could  be  argued  as  unfitting  and
subject to separation rating.  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 chronic right shoulder pain  condition  and
IAW VASRD §4.71a, the Board unanimously recommends  no  change  in  the  PEB
adjudication at separation.  In the matter of  the  PTSD,  anxiety  disorder
and depressive disorder conditions,  the  Board  unanimously  recommends  no
change from the PEB adjudications as not unfitting.  In the  matter  of  the
loss of mobility, residual scar, neck pain, right wrist pain, left  shoulder
pain and  right  knee  pain  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,  therefore,  recommends  that  there   be   no
recharacterization of the CI’s disability and separation  determination,  as
follows:

|UNFITTING CONDITION                             |VASRD CODE  |RATING  |
|Chronic Right Shoulder Pain                     |5099-5003   |10%     |
|COMBINED    |10%     |


The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20110425, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record


                 President
                 Physical Disability Board of Review
SFMR-RB


MEMORANDUM FOR Commander, US Army Physical Disability Agency

SUBJECT:   Department  of  Defense  Physical  Disability  Board  of   Review
Recommendation

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
            Deputy Assistant Secretary
             (Army Review Boards)