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AF | PDBR | CY2013 | PD-2013-01540
Original file (PD-2013-01540.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2013-01540
BRANCH OF SERVICE: Army  BOARD DATE: 20141028
SEPARATION DATE: 20050309


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve SFC/E-7 (92A/Material Control Supervisor) medically separated for left shoulder pain. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards. He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB). The left shoulder pain, characterized as “moderate, constant, chronic left shoulder pain status-post arthroscopic repair of distal clavicle, acromioclavicular joint, and deltoid reconstruction,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB adjudicated “left shoulder pain, status post arthroscopic repair of distal clavicle, acromioclavicular (AC) joint and deltoid reconstruction abduction limited to 90 degrees” as unfitting, rated 20%. The CI made no appeals and was medically separated.


CI CONTENTION: The CI writes: “I had the first surgery on my Right Shoulder on 3 November 2003 at Fort Stewart, GA and the second surgery on the same shoulder was done on 21 June 2004 at Fort Stewart, GA. Both Surgery was by MAJ K-- at Wenn Army Hospital, Fort Stewart, GA. In 2005 I was only medical boarded and rated 20% for my Right Shoulder. I should have been boarded and rated for all injury that happing while I was in military service: Bilateral Knee Injury: I injury my Right Knee in 1975 at Fort Benning. GA; Injury my Left Knee in 1978 at Fort Bliss. TX: I injury the lower part of my Back in 1979 at Fort Bliss, TX that started the (Degenerate Disk Disease/DOD); I was Diagnose [sic] with Hypertension in 1980 while have my Tonsil removed at Fort Bliss, TX. (As a result of my Hypertension I have had Open Heart Surgery to repair Five Blockage and as a result of the Bilateral Knee Injury I had to have Bilateral Hip Replacement done. the right hip was done in March 2010 and the left hip was done in March 2012).” [sic]


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 left shoulder pain condition is addressed below; no additional conditions (right shoulder, bilateral knees, low back injury, degenerative disc disease, hypertension, open heart surgery, bilateral hip replacement) 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 (BCMR).


RATING COMPARISON :

Service IPEB – Dated 20041215
 VA - (4 Mos. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Left Shoulder Pain, Status Post Arthroscopic Repair o f Distal Clavicle,
Acromioclavicular Joint And Deltoid Reconstruction 		5201 20% Left Shoulder Dislocation 5203 20% 20041215
Other x 0 (Not in Scope)
 Other x 4 20041215
Combined: 20%
 Combined: 60%
Derived from VA Rating Decision (VA RD ) dated 20050214 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY: The Board acknowledges the CI’s assertions that his disability disposition was incomplete and did not include all relevant medical conditions. It is noted for the record that the Board has no jurisdiction to investigate or render opinions in reference to such allegations. These issues may be addressed by the BCMR and/or the United States judiciary system

Left Shoulder Pain. The narrative summary noted the CI injured his left shoulder in early 2003; it was reported at the VA Compensation and Pension (C&P) examination as “jammed his shoulder” with dislocation. Magnetic resonance imaging showed a cartilage tear (labral) and degenerative changes of the AC joint. The CI had left shoulder surgery on 3 November 2003 to debride and repair the AC and shoulder joints (Mumford procedure). The CI continued to have pain and the orthopedic surgeon noted excess bone formation since the surgery and areas of soft tissues calcification causing impingement symptoms and questioned residual instability. A second surgery was performed to revise the clavicle and re-stabilize the shoulder on 21 June 2004. Physical therapy visits, following the second surgery, the CI was noted to have continued swelling, pain, limited shoulder range-of-motion (ROM) and mild muscle weakness of the left shoulder muscles.

At the MEB examination 30 September 2004, approximately 5 months prior to separation, the CI reported constant left shoulder pain and difficulty with lifting and overhead activities. The MEB physical exam noted the CI was right hand dominant. There was a palpable abnormality of the distal clavicle and AC joint with tenderness and weakness of the deltoid muscle. There were no neurological or vascular deficits and reflexes were normal in the left upper extremity. The physical therapy measured ROM noted shoulder abduction and flexion of 90 degrees (normal 180 degrees). All ROM was painful at the end ROM. The examiner indicated a pain rating of moderate/constant per the American Medical Association pain rating scale.

At the VA C&P examination performed on 15 December 2004, approximately 3 months prior to separation, the CI reported constant pain, but the shoulder did not “pop out of joint now.” The examination noted shoulder ROM of abduction and flexion of 135 degrees, with “some decreased strength” and normal neurological examination. Left shoulder X-rays showed widening of the AC joint with bony deformity at the lateral end of the clavicle and soft tissue calcifications, including near the AC joint area.

The Board directs attention to its rating recommendation based on the above evidence. The PEB rated the left shoulder condition 20%, coded 5201 (limited arm motion). The VA rated it 20% also, coded 5203 (recurrent dislocation of the scapulohumeral joint, infrequent episodes). The Board considered that following the two surgeries, the CI had painful limited left shoulder ROM with evidence of posttraumatic arthritis on X-rays. There was no instability noted following the second surgery and the CI reported there were no recurrent dislocations. The C&P examination, the most proximate exam to the DOS, noted nearly normal ROM, without specific mention of painful shoulder ROM. The Board agreed that the evidence in the record met the a 10% rating code with multiple applicable VASRD codes, such as 5010 for limited ROM with arthritis demonstrated by imaging studies or 5203 for impairment of the clavicle or scapula without loose movement. Members noted that the CI’s left shoulder ROM noted at the C&P exam did not support the 20% rating based on 5201 ROM criteria of arm motion limited “at shoulder level,” as did the earlier MEB examination. Board precedent when rating with 5201 has considered 90°of abduction or flexion “shoulder level.” The Board noticed that this improved examination was on a timeline consistent with further recuperation from the second surgery in June 2004, just 3 months prior to the MEB examination, but nearly 6 months prior to the C&P. However, IAW DoDI 6040.44 the Board may not recommend a lower combined rating than that conferred by PEB. The Board then considered if the left shoulder condition warranted a separate or additional rating for muscle or nerve injury due to the noted left shoulder weakness. However, there was no evidence in record to support a primary muscle disorder apart from lack of use due to the surgical convalescent periods and residual shoulder pain, and there were no neurological abnormalities noted at any examination. Therefore, 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. 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 left 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 20130919, w/atchs
Exhibit 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, AR20150004326 (PD201301540)

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                                                  XXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)
                                                     
CF:
( ) DoD PDBR
( ) DVA

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