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AF | PDBR | CY2013 | PD-2013-02154
Original file (PD-2013-02154.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX  CASE: PD-2013-02154
BRANCH OF SERVICE: Army  BOARD DATE: 20140625
SEPARATION DATE: 20050623


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (88M/92Y/Truck Driver/Unit Supply and Armor) medically separated for a bilateral shoulder pain and chronic left ankle pain. The conditions 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/L2 profile and referred for a Medical Evaluation Board (MEB). The shoulder and ankle conditions, characterized as “bilateral shoulder pain and chronic left ankle pain”, were the only two conditions forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The Informal PEB adjudicated “bilateral shoulder pain and left ankle pain, chronic” as unfitting, rated 0% and 0% respectively with likely application of the VA Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION: “After evaluation from the VA hospital, I was placed on 4,600mg of OxyContin and 12,000mg of Tramadol per month to impede the ongoing pain issues from my condition. That is approx. 160mg of Oxycodone & 400mg of Tramadol per day for the last 8 ½ yrs. It has been very difficult for me to get, keep or maintain a job for any amount of time. Originally treated in Hawaii for 8 yrs., I am now in Austin, TX where they have decreased my dependency and found abnormal damage to my liver, kidneys, adrenal gland and urinary tract. I underwent an ultrasound and CT scan the latter part of October and am being urgently referred to a specialist this beginning of November. After my surgeries, I never regained full strength or range of motion. I am unemployed at this date.” (sic)


SCOPE OF REVIEW: The Board’s scope of review is defined in DoD 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 ratings for the unfitting shoulder and ankle conditions are addressed below; and, no additional conditions are within the DoD 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.

The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected condition continues to burden him; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation. That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.


RATING COMPARISON :

Service IPEB – Dated 20050408
 VA - (3 Mos. Pre/Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Bilateral Shoulder Pain 5203-5299-5003 0% Status Post Open Mumford Procedure, Left Shoulder 5203 10% 20050923
Status Post Open Mumford Procedure, Right Shoulder 5203 10% 20050923
Chronic Left Ankle Pain 5099-5003 0% Left Ankle Sprain 5271 0% 20050923
MEB/PEB Entries x 0
 Other x 6 20050923
Combined: 0%
 Combined: 40%
Derived from VA Rating Decision (VA RD ) dated 20060217 ( 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 VASRD standards, based on ratable severity at the time of separation.

Bilateral Shoulder Pain Condition. The PEB combined the left and right shoulder conditions under a single disability rating, coded analogously to 5003. Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints. The Board must follow suit (IAW DoDI 6040.44) if the PEB combined adjudication is not compliant with the latter stipulation, provided that each “unbundled” condition can be reasonably justified as separately unfitting in order to remain eligible for rating. If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB. The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.

Review of the service treatment record (STR) found that the CI first presented with shoulder pain (right) in 2002 after repetitive lifting. By 2003 bilateral shoulder pain was present. Although general overuse of the shoulders was reported, the CI denied a history of specific injury. Due to worsening pain and radiographic evidence of bilateral tendinopathy and acromioclavicular joint arthritis, surgery on each shoulder was performed. In March 2004, arthroscopic decompression of the left subacromial space was accomplished. Severe hypertrophy and arthritis of the acromioclavicular joint was treated with open resection of the distal most aspect of the clavicle (Mumford procedure). Similar surgical procedures were performed on the right shoulder in April 2004. The MEB separation physical exam on 23 December 2004 (6 months prior to separation) noted tenderness at the area of the distal clavicle. Impingement signs were present bilaterally, indicating the presence of pain during passive range-of-motion (ROM) maneuvers designed to detect rotator cuff tendon compromise. At a final follow-up visit with the operating orthopedic surgeon on 23 February 2005 (4 months prior to separation) the CI stated that he was “quite satisfied with the results.” Examination showed mild tenderness over both acromioclavicular joints and range of motion was “full.” At the narrative summary (NARSUM) on 7 March 2005 (3.5 months prior to separation) the CI complained of bilateral shoulder pain with any overhead activities or with pressure or weight on his shoulders. He could not perform pushups or sit-ups due to shoulder pain. Examination noted tenderness in multiple areas of the shoulder. An impingement sign was present bilaterally. Examination maneuvers for ligament instability were normal.

At the VA Compensation and Pension (C&P) exam performed 3 months after separation, the CI reported that pain was constant prior to surgery, but now was intermittent and occurred once per week. Lifting more than 20 pounds or performing overhead work for more than 10-15 minutes caused bilateral shoulder pain. Examination showed no additional limitation with repetitive motion. Strength in each shoulder was mildly reduced. The examination was silent regarding tenderness or painful motion. The goniometric ROM 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.


Shoulder ROM
(Degrees)		 NARSUM ~ 3 Mo s . Pre-Sep VA C&P ~ 3 Mo s . Post-Sep
Left Right Left Right
Flexion (180 Normal) 160 160 180 180
Abduction (180) 135 140 1 1 0 1 1 0
Comments +Tenderness , painful motion
§4.71a Rating 10% * 10% * 0% or 10% (VA 10%) 0% or 10% (VA 10%)
         *Conceding VASRD § 4.59 (painful motion)

The Board directs attention to its rating recommendation based on the above evidence. The Board first considered if each shoulder condition, having been de-coupled from the combined PEB adjudication, remained unfitting as established above. There was no consistent indication from the record that one shoulder was significantly less severe than the other, clinical examination findings were similar and each shoulder required the same surgical intervention. The Board considered the option of recommending only the left or right shoulder as unfitting, but agreed that it would be overly speculative to conclude that either shoulder was not itself independently unfitting; and, accordingly separate ratings for each shoulder are recommended.

The PEB assigned a rating under an analogous 5003 code (degenerative arthritis) combined with a 5203 code (clavicle or scapula, impairment of). The VA assigned a 10% rating for each shoulder under the 5203 code presumably for “malunion” of the clavicle. The Board deliberated if ratings higher than 0% for each shoulder were justified. The VASRD §4.71a threshold for compensable ROM impairment is “at shoulder level” (90 degrees from the side), but all ROM in evidence demonstrated motion above this level. However, although limitation of motion was non-compensable, Board members agreed that sufficient evidence of painful motion (VASRD §4.59) was present to support a 10% rating in each shoulder. There was no history of shoulder dislocations or of humerus malunion to support any rating under the 5202 code (humerus, other impairment of); or of dislocation or non-union with loose movement of the clavicle to warrant a rating higher than 10% under the 5203 code. 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 pain condition and 10% for the left shoulder pain condition, coded 5203-5299-5003.

Chronic Left Ankle Pain Condition. The CI sustained an ankle sprain in 2001 while playing basketball. He subsequently experienced chronic ankle pain. X-rays did not show a fracture or arthritis. Review of the STR showed a permanent L2 profile written in February 2002, which was maintained until separation. There were no clinical notes in evidence addressing the ankle condition after February 2002. At the MEB separation exam 6 months prior to separation, the CI reported pain with running or jumping. The separation physical exam noted decreased ROM due to pain, but measurements were not provided. Lateral ankle tenderness was present. The commander’s statement on 5 January 2005 (5.5 months prior to separation) emphasized the limitations imposed by the CI’s shoulder condition, but was silent regarding an ankle problem. The NARSUM physical examination (3.5 months prior to separation) noted some tenderness along the anterolateral aspect of the ankle. There was no evidence of ligament instability. He could perform repetitive single heel rises.

At the VA C&P exam performed 3 months after separation, the CI reported no problems with walking or standing. Pain was stated to occur only with running. “Otherwise, he has no pain or no limitations.” Examination showed a normal gait, and no ankle swelling or diminished strength. Repetitive motion caused no additional limitation. X-rays were normal. The goniometric ROM 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.

Left Ankle ROM
(Degrees)		 MEB ~3 Mos. Pre-Sep VA C&P ~3 Mos. Post-Sep
Dorsiflexion (20 Normal) 10 20
Plantar Flexion (45) 55 45
Comment +Tenderness
§4.71a Rating 0% or 10%* 0%
                 *Conceding VASRD § 4.40 (functional loss) or § 4.59 (painful motion)

The Board directs attention to its rating recommendation based on the above evidence. The PEB relied on an analogous 5003 code for a 0% rating while the VA also assigned a 0% rating, but under code 5271 (ankle, limited motion of). Board members agreed that “moderate” limitation of ankle motion was not reflected in the evidence and therefore the 10% rating was not justified on that basis. Since ankylosis was not present, there were no routes to a higher rating under the 5270 or 5272 codes. Functional loss (§4.40) and painful motion were also considered, but examination findings did not support a 10% rating using these pathways. 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 chronic left ankle pain 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. In the matter of the bilateral shoulder pain condition, the Board unanimously recommends that it be rated for two separate unfitting conditions as follows: right shoulder pain condition coded 5203-5299-5003 and rated 10%; and left shoulder pain condition coded 5203-5299-5003 and rated 10%; both IAW VASRD §4.71a. In the matter of the chronic left ankle pain 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 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
Right Shoulder Pain 5203-5299-5003 10%
Left Shoulder Pain 5203-5299-5003 10%
Left Ankle Pain 5099-5003 0%
COMBINED (w/ BLF) 20%






The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131103, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record



                                   
XXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXX, AR20150002596 (PD201302154)
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                                                  XXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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