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AF | PDBR | CY2013 | PD 2013 01187
Original file (PD 2013 01187.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX     CASE : PD -20 13 - 0 1187
BRANCH OF SERVICE: Army   BOARD DATE: 201 4 0626
Separation Date: 20060116


SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (93A/Automated Logistical) medically separated for chronic left should er pain. The condition could not be adequately rehabilitated 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 chronic left should er pain condition characterized as “ left shoulder posterior instability, status post revision ” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The I nformal PEB adjudicated “chronic left should er pain , status post capsulolabral reconstruction with subsequent recurrent instability ” as unfitting, rated 0% with application of the US Army Physical Disability Agency (USAPDA) pain policy . The CI made no appeals and was medically separated.


CI CONTENTION : “After my first surgery was done on my left glenoid labrum tear, about one year later I had to go back into the surgery room for a second surgery to repair the same injury. After being discharged from the military with injuries pertaining to both my shoulders, I have not been able to have a descent night of sleep due to pain and dislocation of both my shoulder joints. I have quite (sic) jobs due to surgeries on my shoulders and there is a popping feeling coming from my shoulders. During a routine checkup with a VA orthopedic my shoulder slipped out of joint and was witness by the doctor. I have had numerous MRI and the most recent one show possible labral tears and osteoarthritis.”


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 chronic left shoulder condition is addressed below . In addition, the CI was notified by the Service that his case qualifies for review of his mental health (MH) condition in accordance with the Secretary of Defense directive for a comprehensive review of Service members who were referred to a disability evaluation process between 11 September 2001 and 30 April 2012, and whose MH diagnoses were unfavorably changed or eliminated during that process. In response to said notification, it is presumed that the CI has elected review by this Board for the MH condition. Accordingly, the case file was reviewed regarding unfavorable diagnosis change, fitness determination, applicability of the VA Schedule for Rating Disabilities (VASRD) §4.129, and rating (via §4.129 or §4.130 as appropriate) of the MH condition adjudicated as not unfitting. The rating for the unfitting left shoulder condition and the above considerations for the MH condition are addressed below. 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.

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RATING COMPARISON :

Service IPEB – Dated 20051202
 VA - (2 Mos. Post Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Left Shoulder Pain 5099-5003 0% Left Shoulder Pain, History of Dislocation 5202-5024 10% 200603/06
Other x 0 (Not in Scope)
 Other x7
Rating: 0%
 Combined Rating: 40%
Derived from VA Rating Decision (VARD) dated 20060921 (most proximate to date of separation [DOS])


ANALYSIS SUMMARY : IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations. The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to the VASRD standards, based on ratable severity at the time of separation.

Chronic Left Shoulder Pain Condition . There were two 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) MEB ~ 2 Mo s . Pre-Sep VA C&P 3 Mo s . Post-Sep (Documented by VARD)
Flexion (180 Normal) 180
Abduction (180 Normal) ) 70 100
Comments : R ight hand dominant “ pain with activities ” Motor 4/5; Pos. apprehension test ( instability ) ; A dditional pain on ROM after repetitive motion
§4.71a Rating 1 0 % 10 %
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The CI i n jured his left shoulder in April 2004 when he jumped over a fence and tried to catch himself with his left arm when he fell. The CI felt a pop in his left shoulder and was painful. The exam findings were full active ROM with pain in overh ead ROM, tenderness to palpation anteriorly and a positive Hawkins test (shou l der tendon impingement). The examiner diagnosed possible rotator cuff injury. The CI had a history of the left shoulder dislocations and would need to manipulate the shoulder back in place. The CI underwent a left shoulder arthroscopy with post erior stabilization-revision o n 12 October 2004. Despite surgery, the CI continued with left shoulder constant pain, stiffness and difficulty sleeping due to the pain. He attempted to lift a heavy object while on duty and compromised his recovery. The physical exam findings were significant for posterior instability with load shift. The CI underwent a left shoulder arthroscopy with arthroscopic posterior labral repair on 23 August 2005. The CI underwent aggressive p hysical t herapy (PT) for left shoulder rehabilitation. T he CI was given a permanent U3 p rofile for left shoulder posterior instability . The c ommander’s s tatement noted that the CI’s current physical condition limited him from performing his MOS in a safe manner , as the items that he had to lift weighed approximately 40 to 75 pounds. The MEB n arrative s ummary (NARSUM) exam approximately 2 months prior to separation documented that the CI was slowly progressing through PT and he had pain with all activities . The MEB NARSUM physical exam findings are summarized in the chart above. The VARD dated 21   September 2006 referenced the VA Compensation and Pension (C&P) exam , approximately 2.5 months after separation , document ing the CI reported left shoulder la ck of endurance, pain, limited motion and fatigue ability . The C&P exam findings are summarized in the chart above.

The Board directs attention to its rating recommendation based on the above evidence. The PEB coded the chronic left shoulder pain as 5099 analogous to 5003 and rated at 0% with application of the USAPDA pain policy rated as moderate, intermittent pain. The VA coded the left shoulder pain , history of dislocation as 5202 (h umerus, and other impairment of ) with 5024 ( t enosynovitis ) and rated at 10%. The CI was given and permanent U3 p rofile for left shoulder posterior instability with a Code G (n o assignment requiring prolonged handling of heavy materials ) . The c ommander’s s tatement documented functional limitations of an inability to lift objects that weighed approximately 40 to 75 pounds. All exams proximate to separation documented painful motion. The VA C&P exam documented a thorough goniometric examination and provided more details of painful motion and instability along with additional limitations on repetitive testing. All exams for the left shoulder were adjudged to m eet the intent of VASRD §4.59 (p ainful motion) that states that a joint with painful motion is entitled to at least the minimum compensable rating for that joint. The Board considered the question of shoulder instability in the s ervice t reatment r ecord (STR) and considered coding 5202 ( h umerus, other impairment of ) and rating at 20% , w ith infrequent episodes and guarding of movement only at shoulder level. The Board reviewed the documentation in the STR and the MEB NARSUM documented that although there was no direct evidence of recurrent dislocation after surgical correction, the evidence did adequately document continued instability of the shoulder. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 2 0% for the chronic left shoulder pain condition.
Contended MH/Anxiety Condition. The Board determined that it was appropriate that no MH diagnosis was identified by the MEB or adjudicated by the PEB and therefore, no MH diagnoses was changed to the CI’s possible disadvantage during the Disability Evaluation System process. This applicant therefore did not meet the inclusion criteria in the Terms of Reference of the MH Review Project. The Board adjudged this to constitute a “de facto” determination by medical providers that no duty limiting MH condition existed. One mention of a MH condition (anxiety & marriage counseling) was when the applicant documented on his MEB physical DD Form 2807 (Report of Medical History) where he annotated “yes” for “Frequent trouble sleeping, Anxiety” and “Received counseling of any type.” Further annotation by the provider was “shortness of breath with anxiety attacks – may have one every month or two for a couple of minutes at a time.” There was no mention of a MH condition in the service treatment records. Although anxiety was mentioned, there was no indication that it caused any duty impairment. The well-established principle for fitness determinations is that they are performance-based and the Board’s threshold for countering PEB not-unfit determination requires a preponderance of evidence. The Board considered evidence related to “fitness” for an indication of any service related functional impairment caused by a MH condition prior to separation. No MH condition was ever profiled or implicated by the commander’s statement. The MEB physical exam did note “mild anxiety attacks” in the summary of defects and diagnosis section; however, the provider annotated “normal” in the psychiatric portion of the clinical evaluation section. There were no psychiatric hospitalizations for any MH condition and the VA did not identify any MH condition. After due deliberation in consideration of the preponderance of the evidence, the Board agrees that there is insufficient cause to recommend that an unfitting MH condition be added 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 the c hronic l eft s houlder p ain condition was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the c hronic l eft s houlder p ain condition, the Board by a vote of 2:1 recommends a disability rating of 2 0 %, coded 5 202 IAW VASRD §4.71a. The single voter for dissent elected not to submit a minority opinion. In the matter of the contended MH/Anxiety condition, the Board unanimously recommends it was not unfitting and therefore cannot recommend an additional disability rating. 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:

UNFITTING CONDITION VASRD CODE RATING
Chronic Left Shoulder Pain 5202 2 0%
RATING 2 0 %
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The following documentary evidence was considered:
Exhibit A. DD Form 294, dated 20 130829 w/atchs
Exhib it B. Service Treatment Record
Exhibit C. Department of Veterans ’ Affairs Treatment Record








                          
XXXXXXXXXXXXXXX
President
Physical Disability Board of Review


SAMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557


 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXX, AR20140019335 (PD201301187)
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                                                  XXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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