Search Decisions

Decision Text

AF | PDBR | CY2013 | PD-2013-01923
Original file (PD-2013-01923.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2013-01923
BRANCH OF SERVICE: Army  BOARD DATE: 20150303
SEPARATION DATE: 20050608


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Infantryman) medically separated for right shoulder pain. The shoulder 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). “Chronic right shoulder pain status post (s/p) superior labrum anterior and posterior (SLAP) repair” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other condition was submitted by the MEB. The Informal PEB adjudicated “chronic pain, right shoulder, following SLAP repair” as unfitting, rated 0%, c iting application of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals and was medically separated.


CI CONTENTION: “I had more than one issue pending at that time, and was told they would take care of that. The board pick one and told me the VA would do the rest. The back issue was more severe along with the shoulder and right leg. From this seperation until now, I have been on a downward spiral. I have tried many jobs and continue to fail at them because of the back and leg issue. From June 8, 2005 - I have lived in pain on a daily basis. I continue to seek treatment to find a balance. This whole event has cause me major mental problems such as daily panic attacks. I no longer walk striaght an use a cane for support. As for quality of life, I do what I can to keep weight down and to keep me moving. It is very difficult to find work, because it hurts to stand, walk, sit, or drive for any lenght of time. Cannot support any heavy weight with movement. Cannot work using arms over my head. This is the the basic's of what I deal with.”


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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting. Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records. Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate. The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions. That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws. The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.


 RATING COMPARISON :

IPEB – Dated 20050331
 VA* - (~4 Mos. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Pain, Right Shoulder, Following SLAP Repair 5099-5003 0% Chronic Right Shoulder Pain Status Post Labral Repair 5099-5024 10% 20050201
Other x 0 (Not In Scope)
 Other x 9
RATING: 0%
 RATING: 10%
* Derived from VA Rating Decision (VA RD ) dated 200 50721 (most proximate to date of separation [ DOS ] ) .


ANALYSIS SUMMARY:

Right Shoulder Condition. In August 2003, the CI first sought treatment for right shoulder pain. Absent direct injury, the CI related his symptom onset to performance on the obstacle course. Initially treated as a simple sprain, the CI failed conservative treatment to include local injections. Subsequent radiographs revealed a labrum tear in the right shoulder. On 19 April 2004, he underwent an uncomplicated arthroscopic repair of the labrum. Post-operatively, he did well for approximately 4 months, but painful symptoms returned and he was referred for an MEB. No service treatment record entries documented shoulder instability, subluxation, or any positive neurovascular findings. He was permanently profiled in October 2004 with a diagnosis of right shoulder pain. At the narrative summary (NARSUM) dated 10 February 2005 (4 months prior to separation and 10 months after surgery) the CI endorsed significant pain with any lifting of objects above his shoulder level. He also reported the inability to carry a rucksack, fire a rifle or perform his primary MOS. His physical examination (PE) revealed painful and limited motion and tenderness of the right shoulder. There was no evidence of neurologic deficit or instability of the right upper extremity. The examiner rated the CI’s pain as ‘constant’ and ‘minimal’. The commander’s letter implicated the shoulder condition and recommended an extension of military duty.

At the VA Compensation and Pension (C&P) examination dated 1 February 2005 (4 months prior to separation) the CI endorsed constant right shoulder pain with occasional swelling. His functional impairment was stated as “difficulty reaching above his head.” The PE was brief and normal. The goniometric range-of-motion evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Right Shoulder ROM
(Degrees)
VA C&P ~4 Mo. Pre-Sep

MEB ~4 Mo. Pre-Sep
Flexion (180 Normal) 180 180
Abduction (180) 180 121
Comments - painful motion
§4.71a Rating 0% 10%

The Board directed attention to its rating recommendation based on the above evidence. Utilizing the Army pain policy, the PEB rated 0% under the analogous code of 5003 (degenerative arthritis), whereas the VA rated 10% analogously coded under 5024 (tenosynovitis) citing painful motion. Board members first acknowledged that both the NARSUM and VA examinations were done within 9 days of each other and those findings were different in regards to the VASRD rating impairment. Although there was a significant decrease in shoulder abduction between the two examinations, all measurements remained non-compensable according to VASRD criteria. There was no after separation examination and therefore, the Board considered probative value assignment. The Board also agreed that the MEB was a more detailed, accurate, and clinically intensive examination as compared to the C&P exam. Therefore, a higher probative value was given to the MEB examination. The painful motion finding is easily supported under VASRD §4.59 to achieve the minimal compensable 10% rating. There was no clinical evidence of ankylosis or nonunion/malunion of any component of the shoulder girdle; and, no history of recurrent shoulder dislocation; thus, no shoulder joint code under VASRD §4.71a would yield a rating greater than 10%. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% 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. As discussed above, PEB reliance on the USAPDA pain policy for rating the right shoulder was operant in this case and the condition was adjudicated independently of that policy by this Board. In the matter of the right shoulder condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a. 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:

CONDITION VASRD CODE RATING
Right Shoulder Condition 5099-5003 10%
RATING 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131022, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record






XXXXXXXXXXXXXXX
President
DoD 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, AR20150011203 (PD201301923)


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 10% 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 of the Army
                                    (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

Similar Decisions

  • AF | PDBR | CY2013 | PD-2013-02325

    Original file (PD-2013-02325.rtf) Auto-classification: Denied

    The Board noted that the C&P exam, which was almost 3 years after separation, documented that the CI did not have any recurrent dislocations. 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...

  • AF | PDBR | CY2014 | PD 2014 01982

    Original file (PD 2014 01982.rtf) Auto-classification: Denied

    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 VA Schedule for Rating Disabilities (VASRD) standards, based on ratable severity at the time of separation; and, to review those fitness determinations within its scope (as elaborated above) consistent with performance-based criteria in evidence at separation. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment...

  • AF | PDBR | CY2014 | PD-2014-01676

    Original file (PD-2014-01676.rtf) Auto-classification: Denied

    SEPARATION DATE: 20030212 Neck Condition . Right Shoulder Condition .

  • AF | PDBR | CY2013 | PD-2013-01108

    Original file (PD-2013-01108.rtf) Auto-classification: Approved

    CI CONTENTION : “The Physical Evaluation Board (PEB) medically separate [ sic ] me with a 10% rating and I contend that it should have been more than what the medical board granted! The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. BOARD FINDINGS : IAW DoDI 6040.44,...

  • AF | PDBR | CY2011 | PD 2011 00812

    Original file (PD 2011 00812.txt) Auto-classification: Approved

    He was determined to have non-specific right shoulder pain. The VA initially rated the shoulder at 30% for a limitation in motion not in evidence on the VA examination or any other examination proximate to separation. 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 Pain, Right (Dominant) Shoulder 5099-5003 10% COMBINED 10% The following...

  • AF | PDBR | CY2014 | PD-2014-00180

    Original file (PD-2014-00180.rtf) Auto-classification: Approved

    Left Shoulder Condition . The PEB adjudicated the left shoulder at 0% coded 5099-5003, citing degenerative arthritis with loss of joint motion due to pain alone.The VA originally rated the left shoulder at 0%,coded 5201-5010 (arm; limitation of motion-traumatic arthritis) with an increase to 10% subsequent to C&P summary examinations citing painful motion.The left shoulder limited ROM of 90 degrees supports a20%minimum rating with application of code 5201.After due deliberation, considering...

  • AF | PDBR | CY2014 | PD-2014-02741

    Original file (PD-2014-02741.rtf) Auto-classification: Denied

    The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation. Chronic Right Shoulder Pain. PT, activity modification, and pain medications did not relieve the right shoulder pain and the CI was referred to the MEB.

  • AF | PDBR | CY2009 | PD2009-00498

    Original file (PD2009-00498.docx) Auto-classification: Denied

    The CI was referred to the Physical Evaluation Board (PEB), found unfit for the condition, and separated at 10% disability using the Veterans Affairs Schedule for Ratings Disabilities (VASRD) and applicable Naval and Department of Defense regulations. Surgery 2: 20040209 revision SLAP repair However, at the time of separation from service in 2005 the condition warrants a 10% rating as was applied by both the Navy and the VA.

  • AF | PDBR | CY2013 | PD-2013-01636

    Original file (PD-2013-01636.rtf) Auto-classification: Approved

    The left shoulder, neck and bilateral feet, characterized by the MEB as “left shoulder impingement syndrome,” “adhesive capsulitis of the left shoulder,” “cervical spondylolysis,” “cervical stenosis” and “bilateral plantar fasciitis,” wereforwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating...

  • AF | PDBR | CY2009 | PD2009-00480

    Original file (PD2009-00480.docx) Auto-classification: Denied

    He was on two periods of limited duty for his right shoulder and he was then referred to the Navy Physical Evaluation Board (PEB). Other conditions rated by the VA (left knee, right knee and Anxiety Disorder) as well as heart condition and right wrist not rated by the VA appear to be what the CI is contending for in addition to re-rating his right shoulder. Service Treatment Record.