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AF | PDBR | CY2013 | PD 2013 00894
Original file (PD 2013 00894.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXX     CASE: PD-2013-00894
BRANCH OF SERVICE: AIR FORCE     BOARD DATE: 20140325
SEPARATION DATE: 20011214


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSGT/E-5 (3P051/Security Forces Journeyman) medically separated for chronic right shoulder pain. The CI reportedly injured her shoulder while in technical school training. She underwent arthroscopy in 1998, but continued to have pain and weakness despite medications and physical therapy (PT). The right shoulder condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty or satisfy physical fitness standards. She was issued a 4T profile and referred for a Medical Evaluation Board (MEB). Chronic right shoulder pain was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123. No other conditions were submitted by the MEB. The Informal PEB adjudicated the right shoulder pain as unfitting, rated 10%, with likely application of the VA Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated with a 10% disability rating.


CI CONTENTION: “ In December 2001, I was honorably but medically discharged from the Air Force and given a 20% disability rating for a right shoulder chondral fracture which I had surgery on while still in the military. I did not dispute this rating, although it has limited and impeded employment opportunities for me since being discharged. When I claimed this, I also claimed "nerves and anxiety" associated with insomnia and occupational problems. My claim for this was denied, and I would like to dispute this. My military medical records clearly show documentation of mental health problems I was (and still am) suffering from. Although this claim was denied and I did not receive a rating for it, I have been progressively getting worse over the years since my military service. I continue to seek treatment for my mental health problems, but my private medical insurance covers most of the bills. I have incurred financial co-payments out of my own pocket for doctor visits, medication and one hospitalization due to my anxiety disorder and PTSD over the last 11 years. I do not believe this should be the case since these mental problems were caused by my service and began while I was still on active duty (which is well documented). I currently see a therapist at James A. Haley VA Hospital in Tampa, FL and have been diagnosed as having PTSD, Generalized Anxiety Disorder and a specific medical phobia; all of which started while I was in the military and was caused by my service. Please see the attached letter which explains this. When I was discharged from the military in 200I, I had never heard of PTSD and it was not a common term back then. That is why I called my original claim "anxiety and nerves", and my military medical records indicate I had insomnia and occupational problems (along with many references to anger, frustration and referrals to see a mental health counselor). It is unfortunate that no one put all of the pieces together back then to diagnose me properly, but all of the symptoms of my anxiety disorder and PTSD were documented.” The CI attached a nine page statement to her application which was reviewed by the Board and considered in its recommendations.

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SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The rating for the unfitting right shoulder condition is addressed below. The requested mental health conditions ( nerves and anxiety" associated with insomnia and occupational problems, anxiety disorder, posttraumatic stress disorder and specific medical phobia) were not identified by the MEB or PEB, and thus are not within the DoDI 6040.44 defined purview of the Board. No additional conditions are within the DoDI 6040.44 defined purview of the Board. 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 Board for Correction of Military Records.


 RATING COMPARISON :

Service IPEB – Dated 20011102
 VA - Based on Service Treatment Records (STR)
Condition
 Code Rating Condition Code Rating Exam
Chronic Right Shoulder Pain 5304 10% Residuals of Right Chondral Fracture s/p Arthroscopy 5299-5201 0%* STR
No Additional MEB/PEB Entries
 Other x 4 STR
Rating: 10%
 Combined: 0%
Derived from VA Rating Decision (VA RD ) dated 200 20812 ( most proximate to date of separation [ DOS ] ). 20021214 VARD increased to 20%


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 VASRD standards, based on severity at the time of separation. 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. The Board has neither the jurisdiction nor authority to scrutinize or render opinions in reference to the CI’s statements in the application regarding suspected DES improprieties in the processing of her case.

Right Shoulder. The first record in evidence for the right (dominant) shoulder was an emergency room visit on 5 August 1994 while still in training. The CI reported no history of trauma, but a month long history of “vague, non-focal” pain. The range-of-motion (ROM) was limited by pain; no instability was present. However, when seen in orthopedics 4 days later, she reported that the pain started after her arm was internally rotated (while wrestling per subsequent notes.) She was noted to have multi-directional instability and probable anterior sub-luxation. She was managed conservatively over the next few months. At an orthopedic appointment on 11 May 1995, she was found to have right shoulder impingement. However, 2 weeks later, the shoulder pain was resolved and she was able to PCS (permanent change of station) to a remote base. She next presented on 20 December 1997 with extreme pain after playing pool. She was evaluated in orthopedics and reported that she had initially injured the shoulder 3 years previously while wrestling, but that it had become progressively symptomatic over the past 6 months. She had impingement and subluxation. X-rays were normal. Further conservative management was not adequate and she was referred for arthroscopy which was accomplished on 5 April 1999. On examination, she was found to have a tear of the cartilage lining the joint which was debrided. She continued to have shoulder pain after the procedure, despite rehabilitation. At the 13 June 2001 orthopedic appointment, she had normal ROM, but positive tests for a rotator cuff injury. A magnetic resonance imaging 2 weeks later was normal. She was seen 2 weeks after that in orthopedics and the ROM was reduced to 100 degrees of abduction and 110 degrees of flexion. A shoulder injection provided some relief, but her symptoms persisted. Electrodiagnostic studies were normal on 1 August 2001. A 31 August 2001 memorandum, written by her treating orthopedic surgeon, noted that she had good ROM and strength of the right shoulder without gross instability. It was thought that the continued pain stemmed from the cartilage defect in the shoulder dating to the arthroscopy. A second arthroscopy and additional injections were discussed, but not pursued. She was thought to not be fit to continue as a dog handler and cross-training was recommended. She was seen in flight medicine a week later and an MEB was recommended. In the narrative summary (NARSUM), the CI reported that she had chronic pain and weakness which precluded her ability to work as a dog handler and normal physical activities. On examination, she was noted to have reduced ROM and strength of the right shoulder which was not further specified. It did note that she could not raise the arm above the chest level without severe pain, but did not state what the limit was. The CI failed to report for the VA Compensation and Pension (C&P) examination. The VARD dated 14 December 2002 referenced out-patient notes. In these, flexion was limited to 90 degrees and abduction to 100 degrees at an appointment on 28 October 2002, over 10 months after separation. It was not recorded if there had been progression of pain since separation or if there had been subsequent trauma, reducing the probative value of this information for rating at separation.

The Board directs attention to its rating recommendation based on the above evidence. The PEB rated the chronic right shoulder pain condition at 10% and coded it 5304, for a moderate rotator cuff injury. The VA coded the shoulder condition as 5299-5201, analogous to limitation of arm motion, but assigned no rating as the CI did not report for the C&P examination. Subsequently, the VA increased the rating to 20% based on the 28 October 2002 examination at a clinical appointment. The Board considered the evidence and noted that the treating orthopedist had consistently noted good strength and a ROM greater than the shoulder level for both abduction and flexion. The electrodiagnostic studies were normal indicative of normal motor function. The NARSUM examiner documented reduced strength and ROM, but did not further specify these. The action officer opined that the limitations observed could be best accounted for by pain the day of the examination. The VA outpatient note, as recorded in the 2002 VARD, showed a reduction of flexion to the shoulder level, but without context. Regardless, the evidence is consistent with the level of disability adjudicated by the PEB and reasonable doubt does not support a higher rating under the 5304 code or any other coding option. 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 right 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. 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 §4.71a, 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 re-characterization of the CI’s disability and separation determination.


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130621, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record








                 
XXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAF/MRB
Dear XXXXXXXXXXXXXX:

         Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2013-00894.

         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 appropriate. Accordingly, the Board recommended no re-characterization or modification of your separation.

         I have carefully reviewed the evidence of record and the recommendation of the Board. I concur with that finding and their conclusion that re-characterization of your separation is not warranted. Accordingly, I accept their recommendation that your application be denied.

                                                               Sincerely,
XXXXXXXXXXXXXX
Director
Air Force Review Boards Agency
Attachment:
Record of Proceedings

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