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AF | PDBR | CY2012 | PD2012 01550
Original file (PD2012 01550.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:   BRANCH OF SERVICE: Army
CASE NUMBER: PD1201550   SEPARATION DATE: 20030325
BOARD DATE: 20130416


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty Soldier, PVT/E-1(13F00/Fire Support Specialist in training), medically separated for chronic pain, left shoulder. The CI initially injured his left shoulder while doing push-ups during the first week of advanced individual training (AIT). His shoulder pain increased after a 15 kilometer road march while carrying a 60–70 pound backpack. Due to continued shoulder pain, the CI was not able to complete AIT. The CI’s shoulder could not be adequately rehabilitated; he was issued a permanent U3 profile, and referred for a Medical Evaluation Board (MEB). The MEB forwarded chronic left shoulder pain as medically unacceptable IAW AR 40-501. The MEB forwarded no other conditions for Physical Evaluation Board (PEB) adjudication. The PEB adjudicated the chronic pain, left shoulder as unfitting, rated 10%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) and the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals, and was medically separated with a 10% disability rating.
CI CONTENTION The CI elaborated no specific contention in his application.


SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 6040.44 Enclosure 3, paragraph 5.e.(2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The unfitting left shoulder pain condition meets the criteria prescribed in DoDI 6040.44, and is accordingly addressed below. No other conditions are within the Board’s purview. Any condition outside the Board’s defined scope of review may be eligible for future consideration by the Army Board for Correction of Military Records.


RATING COMPARISON :

Service PEB – Dated 20030131
 VA (4 Mos. Pre-Separation) – All Effective Date 20030326
Condition
 Code Rating Condition Code Rating Exam
Chronic Pain, L Shoulder 5099-5003 10% Residuals of Scapulothoracic Injury, Left Shoulder 5203 10% 20021216
↓No Additional MEB/PEB Entries↓
 0% X 0 / Not Service-Connected x 0 20021216
Combined: 10%
 Combined: 10%


ANALYSIS SUMMARY:

Left Shoulder. The record indicates the CI is left hand dominant. The CI was treated with non-steroidal anti-inflammatory medications and physical therapy with no improvement of left shoulder pain. Orthopedic exam of his left shoulder joint was normal with scapulothoracic pain. There were no indications for surgery. At the time of the narrative summary exam (11 July 2002), the CI reported he was taking no medication, could no longer work in his regular job as a construction worker, could no longer play sports, or perform the duties of his Military Occupational Specialty (MOS). Physical exam noted full range-of-motion (ROM) of the left shoulder, with CI complaint of discomfort at the full end point of abduction and internal rotation. There was no muscle atrophy. He had good muscle and grip strength with full pulse. Neurologic exam was normal. X-ray of the left shoulder was normal. Pain was stated as slight but constant. DD Form 2808 exam indicated abduction to 175° (normal 180°), and multiple exam notes indicated crepitus.

At the VA Compensation and Pension exam (16 Dec 2002), 2 weeks prior to separation, the CI reported pain every time his shoulder was moved but did not require treatment by a physician. He used Naprosyn and could perform daily chores. Exam showed normal appearing left shoulder joint with tenderness to palpation and crepitus over the posterior left scapula. There was pain throughout left shoulder movement. ROM was noted as painful throughout with flexion and abduction to 180° (normal 180°). There was pain and weakness on repetition without additional limitation of motion. Diagnosis was left scapulothoracic strain with chronic pain.

The Board carefully reviewed all evidentiary information available. The PEB rated the left shoulder condition at 10% analogous to code 5003 (arthritis, degenerative) and the VA 10% rating was coded 5203 (clavicle or scapula, impairment of). Using clinical data in the treatment record, the CI’s left shoulder was essentially non-compensable based on the VASRD §4.71a codes for loss of shoulder/arm motion (5200 and 5201). However; IAW VASRD §4.40, §4.45, and §4.59, a 10% rating is warranted when there is satisfactory evidence of functional limitation due to painful motion of a major joint. There was not sufficient evidence to justify a rating higher than 10% for the left shoulder. Neither code choice of 5099-5003 or 5203 was predominate.

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left shoulder condition.
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. As discussed above, PEB reliance on the USAPDA pain policy for rating the left shoulder condition was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the left shoulder pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. There were no other conditions within the Board’s scope of review for consideration.


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
Left Shoulder Pain 5099-5003 10%
COMBINED
 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120828, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




         Physical Disability Board of Review


 SFMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(TAPD-ZB),

 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for AR20130010192 (PD201201550)

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                                                 
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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