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AF | PDBR | CY2012 | PD2012 01628
Original file (PD2012 01628.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    BRANCH OF SERVICE: Army
CASE NUMBER: PD1201628   SEPARATION DATE: 20041116
BOARD DATE: 20130425


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, SSG/E-6 (13M/MLRS Crewmember), medically separated for chronic pain of the left shoulder with instability/subluxation, acromioclavicular degenerative joint disease (DJD) and left cubital tunnel syndrome. The CI had a history of chronic left shoulder pain for several years and left cubital tunnel syndrome for several months prior to separation. Despite conservative treatment and surgery, the left shoulder and cubital tunnel syndrome did not improve adequately to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded no other conditions for Physical Evaluation Board (PEB) adjudication. The PEB adjudicated the left shoulder and left cubital tunnel conditions as unfitting, rated 10% and 10%, with application of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals and was medically separated with a combined 20% disability rating.
CI CONTENTION: “I was separated for my shoulder and received 20%. The VA has rated me at 70% service connected. I feel the Army should have taken all medical conditions into consideration towards a retirement rather than a disability.”


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 ratings for unfitting conditions will be reviewed in all cases. The remaining conditions which were rated by the VA at separation are not within the Board’s purview (sleep apnea, left knee, left hand fracture, tinnitus, and hypertension). Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the respective Service Board for Correction of Military Records.


RATING COMPARISON :

Service IPEB – Dated 20040903
 VA (1 Mos. Pre-Separation) – All Effective Date 20041117
Condition
 Code Rating Condition Code Rating Exam
L shoulder DJD with instability/subluxation 5099-5003 10% L shoulder DJD w/postop scar and recurrent dislocation 5202 20% 20041020
L Cubital Tunnel Syndrome 8516 10% L cubital tunnel syndrome… 8515 0% 20041020
↓No Additional MEB/PEB Entries↓
 Sleep Apnea w/CPAP 6847 50% 20041020
L hand fx residuals 5299-5215 10% 20041020
L knee patella subluxation 5257 10% 20041020
L knee condition 5260 10% 20041020
Tinnitus 6260 10% 20041020
0% X 2 / Not Service-Connected x 3
Combined: 20%
 Combined: 70%


ANALYSIS SUMMARY: The Disability Evaluation System (DES) is responsible for maintaining a fit and vital fighting force. While the DES considers all of the member's medical conditions, compensation can only be offered for those medical conditions that cut short a member’s career, and then only to the degree of severity present at the time of final disposition. The DES has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation nor for conditions determined to be service-connected by the Department of Veteran Affairs (DVA) but not determined to be unfitting by the PEB. However, the DVA, operating under a different set of laws (Title 38, United States Code), is empowered to compensate all service-connected conditions and to periodically re-evaluate said conditions for the purpose of adjusting the Veteran’s disability rating should the degree of impairment vary over time. The Board’s role is confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards, based on severity at the time of separation.

Left Shoulder Condition. There were three goniometric range-of-motion (ROM) evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.

Left Shoulder ROM
(degrees) (non-dominant)
 Ortho 9 ~ Mo Pre-Sep MEB /Ortho ~ 5 Mo. Pre-Sep VA C&P ~ 1 Mo. P re -Sep
Flexion (180 Normal )
 180 180 120 (Onset of pain)
Abduction ( 180 )
 180 160 110 (O nset of pain)
Comments
 Painful motion Motor 4-5/5 Motor 4+/5 Pain on ROM testing; a dditional limitation w/rep use
§4.71a Rating
 10% 10% 10%

T he right hand dominant CI in itially presented in November 1994 with a 2 week history of atraumatic left shoulder pain which was worse in the morning , but improved as the day progressed. He was diagnosed with probable bursitis and prescribed non-steroidal anti-inflammatory drugs ( NSAIDs ) . The left shoulder pain continued and the CI was referred to physical therapy and then orthopedics. The CI was felt to have left shoulder impingement syndrome and was treated conservatively without adequate improvement . He underwent an open left shoulder acromioplasty on 7 November 1996 with removal of a large anterior osteophyte. The rotator cuff was intact and the shoulder stable . The CI continued to e xperience pain and catching in h is left shoulder despite the surgery and post-operative rehabilitation. On 27 January 1998, the CI underwent resection of posterior labral adhesions. Again, the rotator cuff was intact, but minimal translation with load shift was noted prior to surgery. He continued to be symptomatic and noted subjective instability. On 19 January 1999, he underwent his third surgical procedure with thermal tightening (to cause capsular shift with tightening of the shoulder ligaments) of the shoulder capsule. The CI was noted to have some instability when examined under anesthesia (EUA) which had improved after the thermal tightening. He apparently improved with rehabilitation and was noted to be playing soccer a year later. However, on 2 March 2001, he was evaluated for a day history of left shoulder pain and fo u nd to have a normal examination. He was managed conservatively. He was not seen again until 15 August 2001 when he noted that he had worsening pain which would wake him up a night and felt like it might lock up. Again, the examination was normal, including ROM and strength, and the CI managed conservatively. The record then falls silent until 3 July 2002 when the CI was evaluated for ongoing shoulder pain complaining of difficulty with overhead movements and difficulty sleeping. The ROM and strength were normal, but the arc painful between 90 and 120 degrees. He was evaluated in physical therapy (PT) on 24 October 2003 and noted to have full ROM which was painful in abduction past 100 degrees and reduced strength at 4+/5 in internal rotation and 4/5 in external rotation. Flexion and abduction were normal. He was seen again in PT on 21 November 2003 and noted to still be running and to be ignoring the restrictions of his profile (lifting) to meet the requirements of his MOS. The ROM was noted as painful. He was evaluated in orthopedics on 11 February 2004 and noted to have intermittent numbness in an ulnar distribution. His shoulder pain increased with pushups, running, and repetitive motion. His strength was reduced to 4/5 on internal rotation. He was assessed with left shoulder impingement and cubital tunnel syndrome. A P3 profile was issued and the CI referred to MEB. The n arrative s ummary (NARSUM ) was dictated on 22 June 2004 . T he CI reported a history of impingement syndrome and recurrent “ dislocations ” which had no t responded to extensive treatment and surgeries . The examination reveale d ROM measurements as shown in the chart above . The examiner noted that the CI’s strength during ROM testing was 4+/5. The CI had positive signs for acromioclavicular joint arthritis (C ross arm test ) , supraspinatus tendon impingement ( Hawkins sign ) , anterior glenohumeral instability (R elocation sign ) , and anterior g lenohumeral instability (A pprehension sign ) . There was subacromial crepit us present on examination . There was no muscle at rophy not ed. The NARSUM diagnosis of the chronic left shoulder condition was dictated as recurrent dislocations and acromioclavicular DJD ; however , a memorandum from the dictating orthopedist , dated
31 August 2004 , clarified that the left shoulder condition was better described as r ecurrent subluxation (instability) of the shoulder . According to the NARSUM, X-ray examination of the left shoulder revealed a flattened inferior surface of the acromion and degenerative changes of the acromioclavicular joint. At t he VA Compensation and Pension ( C&P ) examinatio n,
2 0 October 2004 , the CI report ed worsening pain . The CI reported that he was having stiffness and locking of the shoulder, especially during push-ups. The examiner reported ROM testing as displayed in the chart above. The CI had very guarded ROM and limitatio n of motion with repetitive use; there was tenderness to palpation in the AC joint and suprascapular region. Internal and external rotation was normal. The acromio-clavicle joint was tender as was the suprascapular region. No muscle spasm or atrophy was noted. No comment was made on strength and no X-rays were performed.

The Board directed its attention to the rating recommendation based on the above evidence. The PEB rated the chronic left shoulder pain using an analogous code 5099-5003 with 10% disability. The VA used code 5202, recurrent dislocation of the humerus and assigned a 20% rating which correlates with infrequent episodes and guarding of movement at the arm at the shoulder area. The Board initially reviewed VASRD code for limitation of motion of the shoulder (5201) and agreed the evidence supported a minimal compensable rating by invoking either VASRD §4.59 (painful motion), §4.40 (functional impairment), or §4.45 (Deluca). The Board then reviewed the VASRD code 5202, other impairment of the humerus, as chosen by the VA. The service treatment records (STRs) evidenced recurrent subluxation or instability of the shoulder without full dislocations; in fact, dislocations were specifically excluded. A finding of recurrent dislocation of the scapulohumeral joint with infrequent episodes and guarding of movement at the shoulder level is required for a 20% disability rating using this code. The Board agreed that the STRs did not support evidence of complete dislocation and therefore would support only a minimal rating of 10% by using code 5202. Finally, the Board looked at the use of code 5003 for degenerative arthritis of the shoulder. The Board agreed that there was evidence supporting X-ray findings of DJD and the evidence supported a 10% rating for painful motion. 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.

Left Cubital Tunnel Syndrome. There were two left elbow ROM evaluations in evidence, as is as shown in the chart below. There was a positive Tinel’s sign in the cubital tunnel, consistent with an irritated ulnar nerve.


Left Elbow ROM
( N on- dominant)
(Degrees)
 Ortho OP note ~9 Mo. Pre-Sep Ortho ~5 Mo. Pre-Sep VA C&P ~ 1 Mo. P re -Sep
Flexion (145 )
F ull ROM
 135 N/A
Extension
F ull ROM
 0 N/A
Comment
Strength 5/5; + Tinels
 Strength 5/5; + Tinel’s + Tinel’s
§4.71a Rating
0 %
 0 % 0 %

The CI initially reported numbness in his left forearm and hand around February 2004. An outpatient orthopedic referral, to evaluate the patient for a MEB for the left shoulder, was performed on 11 February 2004 and noted that the CI experienced intermittent numbness in the ulnar distribution. The examiner noted that the elbow had full ROM and 5/5 strength, as noted in the chart above. The MEB examination performed on 22 June 2004 reported that the CI was having numbness whenever there he had increased elbow ROM or direct pressure on his ulnar nerve. The ROM examination and other exam findings are as shown in the chart above. There was no muscle atrophy noted on examination. At the VA Compensation and Pension (C&P) examination on 20 October 2004, a month prior to separation, the CI reported that he had been experiencing left forearm and hand numbness for about 9 months. The CI reported that his symptoms were aggravated when he leaned on the table with his elbow. The examination revealed a positive Tinel’s sign in the cubital tunnel, indicating irritation of the ulnar nerve, and decreased sensation in the ulnar aspect of his forearm and hand. His hand grip was decreased on the left, but no muscle atrophy was noted.

The Board directed its attention to the rating recommendation based on the above evidence. The PEB coded the left cubital tunnel syndrome using VASRD code 8516, paralysis of the ulnar nerve with a rating of 10%. The VA coded the condition using the code 8515 for median nerve paralysis with a 0% rating (an administrative error which did not impact the rating). The STRs indicate a history of mild numbness of the ulnar nerve, approximating a rating closer to a 0% rating. 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 cubital syndrome 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 chronic left shoulder pain and the cubital tunnel conditions was operant in this case; these were adjudicated independently of that policy by the Board. In the matter of the chronic left shoulder pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the left cubital tunnel syndrome condition and IAW VASRD §4.124, 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
Chronic Pain Left Shoulder, with Instability/Subluxation and Acromioclavicular DJD 5099-5003 10%
Left Cubital Tunnel Syndrome 8516 10%
COMBINED
 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120514, 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 AR20130011062 (PD201201628)

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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