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AF | PDBR | CY2013 | PD2013 01628
Original file (PD2013 01628.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX         CASE: PD1301628
BRANCH OF SERVICE: Army  BOARD DATE: 20140522
SEPARATION DATE: 20041221


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (92G/Cook) medically separated for right shoulder pain. He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB). The shoulder condition, characterized as “right shoulder pain” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB adjudicated “chronic pain, right shoulder with abduction limited by pain” as unfitting, rated 10%, citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals and was medically separated.


CI CONTENTION: “After the surgery that was done, before being released from the Army, I incurred some problems with my shoulder so far as lifting objects or moving objects. Since the surgery there has been a tingling sensation running up and down my right arm.”


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 pain condition is addressed below. Any condition or contention not requested in this application, 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 20041005
 VA* - (2 Yrs.,10 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Pain, Right Shoulder with Abduction Limited by Pain 5099 5003 10% Right Shoulder Condition 5203 10% 20071001
Other x 0 (Not in Scope)
 Other x 1 19930810
Rated: 10%
 Combined: 10%
* Derived from VA Rating Decision (VA RD ) dated 200 7113 (most proximate to date of separation ( DOS ))



ANALYSIS SUMMARY:

Right Shoulder Condition. Available treatment records evidence that the CI first presented with right shoulder pain on 27 August 2001 during combat training. He was treated conservatively for a right shoulder contusion/strain. The records were silent for right shoulder pain until March 2003 when the CI sustained a rollover injury in Iraq. He was treated conservatively, but continued to report right shoulder pain. A magnetic resonance imaging study performed on 15 October 2003 demonstrated a partial thickness tear of the supraspinatus tendon (one of the muscles of the rotator cuff) and mild acromiocalvicular (where the clavicle and shoulder meet) enlargement. The CI underwent right shoulder surgery on 23 April 2004 for repair of the rotator cuff tear and excision of the distal clavicle. An orthopedic treatment note dated 28 July 2004 documented persistent right shoulder pain with limitation of range-of-motion (ROM) and sleep disturbance. The physical examination was significant for pain limitation with ROM to 85 degrees for both forward flexion and abduction (180 degrees normal for both). The examiner diagnosed arthofibrosis and pain of the right shoulder and an MEB was initiated.

The narrative summary (NARSUM) dated 28 July 2004 noted that the CI was unable to run without right shoulder pain, could not lift greater than 10 pounds and had sleep disturbance secondary to right shoulder pain. The examiner noted that the CI had significant acromioclavicular tenderness to palpation. Tests for right shoulder impingement (Neer, Hawkins and O’Brien) were positive. There was right shoulder limitation of ROM to 85 degrees for forward flexion and abduction. Right upper extremity sensation was intact (no nerve involvement).

At the VA Compensation and Pension examination performed 2 years and 10 months after separation, the CI reported increased pain with overhead activities, lifting greater than 20 pounds and repetitive motion. He also reported intermittent “popping” which worsened his pain. The physical examination was significant for pain-free motion to 160 degrees forward flexion and abduction. Testing for right shoulder impingement was negative.

The Board directs attention to its rating recommendation based on the above evidence. The PEB adjudicated the chronic right shoulder pain condition as unfitting with a 10% disability rating, citing criteria of the USAPDA pain policy. The PEB’s 10% rating was supported by the USAPDA pain policy, but was not compliant with VA Schedule for Rating Disabilities (VASRD) §4.71a criteria. Board members agreed that at the time of separation, treatment records and the NARSUM evidenced arm limitation of motion at shoulder level and met the 20% criteria for compensation IAW VASRD code 5201 (arm limitation of motion). A higher rating of 30% for dominant shoulder limitation of ROM to midway between the side and shoulder level (45 degrees) was not evidenced in this case. There was no evidence of ratable peripheral nerve impairment, documentation of muscle injury, or scar pathology which would provide for additional or higher rating. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the right shoulder 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. As discussed above, PEB reliance on the USAPDA pain policy for rating the right shoulder pain condition was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the right shoulder pain condition, the Board unanimously recommends a disability rating of 20%, coded 5201 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:

UNFITTING CONDITION VASRD CODE RATING
Right Shoulder Pain 5201 20%
RATED 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130926, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record








                 
XXXXXXXXXXXXXXXXXX, DAF
President
Physical Disability Board of Review

SFMR-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 XXXXXXXXXXXXXXXXXX , AR20140009434 (PD201301628)
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                                                  XXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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