RECORD OF PROCEEDINGS

PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX BRANCH OF SERVICE: Army

CASE NUMBER: PD1200164 SEPARATION DATE: 20040524

BOARD DATE: 20120810

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (31R20/Communication Specialist), medically separated for left shoulder impingement syndrome. The CI initially injured his left shoulder prior to military service. The shoulder was asymptomatic and fully functional for over 5 years until he reinjured the shoulder while performing on an obstacle course 4 months into his military service. He had non-surgical treatment then surgical intervention in attempt to correct this shoulder and changed his Military Occupational Specialty (MOS) in attempt to meet his physical requirements. The left shoulder impingement syndrome condition could not be adequately rehabilitated and the CI did not improve adequately with treatment to meet the physical requirements of his MOS or satisfy physical fitness standards. He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded the left shoulder impingement syndrome as the only unfitting condition for Physical Evaluation Board (PEB) adjudication. The fitting conditions of hypertension, tinnitus and hypertriglyceridemia, identified in the rating chart below, were also identified and forwarded by the MEB. The PEB adjudicated the left shoulder impingement syndrome condition as unfitting, rated 10%, with reliance on the US Army Physical Disability Agency (USAPDA) pain policy. The PEB adjudicated the conditions of hypertension, tinnitus and hypertriglyceridemia as not unfitting and therefore not ratable. The CI made no appeals, and was medically separated with a 10% disability rating.

CI CONTENTION: “I would like to have my discharge disability rating reviewed for my left shoulder and also I have been diagnosed with PTSD from the VA with a rating of 50% and [sic] and Sleep Apnea. I would like to have my PTSD and Sleep Apnea added to my disability discharge rating. I also had a heart condition while I was on active duty.”

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 unfitting left shoulder impingement syndrome and the heart condition of hypertension requested for consideration meet the criteria prescribed in DoDI 6040.44 for Board purview, and are accordingly addressed below. The other requested conditions of PTSD, sleep apnea, and heart condition are not within the Board’s purview. 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 Army Board for the Correction of Military Records.

RATING COMPARISON:

* Shoulder code later changed to 5010-5201 at 20%; PTSD, 9411 at 50% added effective 20101210 (combined 70%)

ANALYSIS SUMMARY:

Left Shoulder Condition. The CI was right-hand dominate. The narrative summary (NARSUM), performed approximately 2 months prior to separation, notes initial left shoulder dislocation and reconstructive surgery in 1993 prior to entering active duty. The CI entered active duty and reinjured the shoulder in February 1998 on the air assault obstacle course. He was treated conservatively, underwent MOS reclassification, and had an additional shoulder injury. He subsequently underwent surgery in November 2000 to correct acromial impingement of the rotator cuff with successful return to duty. He had a gradual progression of symptoms and evaluation by two orthopedic surgeons concurred that additional surgery was unlikely to help.

There were two 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.

At the MEB exam 2 months prior to separation, the CI reported left shoulder grinding weakness, and pain with movement. No post-surgical dislocations were noted. Shoulder imaging documented post-surgical changes and posttraumatic degenerative arthritis. The MEB physical exam is charted above with the examiner statement of functional limitations noted. Profiles and treatment notes documented that the CI had had moderate functional limitation with repetitive use and lifting restriction.

At the VA Compensation and Pension (C&P) exam, performed 3 months prior to separation, the CI reported a similar history. Subjective complaints were constant pain, grinding, and “loose” feeling. Weakness was noted with lifting and push-up ability decreased from greater than 85 in 2001 to less than 40 currently. The physical exam is charted above with the examiner’s statement on moderate decreased function with repetitive use.

The Board directs attention to its rating recommendation based on the above evidence. The PEB coded the left shoulder impingement syndrome analogously as 5099-5003 and rated it at 10% (with an undetermined [0%] EPTS deduction) IAW the USAPDA pain policy in effect at the time. The VA coded this condition analogously to 5203 (clavicle or scapula, impairment) at 20% (with loose movement). Although initial VA coding included 5001 (bones and joints, tuberculosis of, active or inactive), review of the service treatment record (STR) fails to reveal any indication that the CI had tuberculosis. This almost certainly represents a typographical error from correct VASRD coding using 5010 (arthritis, due to trauma). The Board deliberated if the functional loss and weakness with overhead use and repetition, impingement signs, crepitus and subjective frequent looseness of the shoulder more closely approximated the 20% criteria for either code 5201 for arm limitation of motion at shoulder level, 5203 for loose movement, or code 5202 (humerus impairment) for guarding at shoulder level.

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), §4.7 (higher of two evaluations), §4.40 (functional loss) and DeLuca, the Board recommends a disability rating of 20% for the left shoulder impingement syndrome condition, coded 5010-5201 with no existed prior to service (EPTS) deduction.

Contended PEB Conditions. The contended condition adjudicated as not unfitting by the PEB was hypertension (“heart condition”). The Board’s first charge with respect to this condition is an assessment of the appropriateness of the PEB’s fitness adjudication. The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. Hypertension was not profiled; not implicated in the commander’s statement; and, not judged to fail retention standards. Hypertension was reviewed by the action officer and considered by the Board. Hypertension was well controlled on medication. There was no indication from the record that hypertension significantly interfered with satisfactory duty performance. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended hypertension condition; and, therefore, no additional disability rating can be recommended.

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 5099-5003 was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the left shoulder impingement syndrome condition, the Board unanimously concurs that it was EPTS and was permanently service-aggravated, with no ratable deduction for EPTS. In the matter of the left shoulder impingement syndrome condition, the Board unanimously recommends a disability rating of 20%, coded 5010-5201 IAW VASRD §4.71a. In the matter of the contended hypertension condition, the Board unanimously recommends no change from the PEB determination as not unfitting. There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120216, w/atchs

Exhibit B. Service Treatment Record

Exhibit C. Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXXXXX

President

Physical Disability Board of Review

SFMR-RB

MEMORANDUM FOR Commander, US Army Physical Disability Agency

(TAPD-ZB / ), 2900 Crystal Drive, Suite 300, Arlington, VA 22202

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation

for XXXXXXXXXXXXXXXXXXXXXXXXXXXXX, AR20120015471 (PD201200164)

1. 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 to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation. This decision is final.

2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.

3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

Encl XXXXXXXXXXXXXXXXXXXXXX

Deputy Assistant Secretary

(Army Review Boards)

CF:

( ) DoD PDBR

( ) DVA