Search Decisions

Decision Text

AF | PDBR | CY2014 | PD-2014-01676
Original file (PD-2014-01676.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX       CASE: PD-2014-01676
BRANCH OF SERVICE: NAVY  BOARD DATE: 20150107
SEPARATION DATE: 20030212


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PO3/E-4 (STG3/Sonar Technician Surface) medically separated for neck and right shoulder conditions. The neck and right shoulder problems could not be adequately rehabilitated to meet the physical requirements of his Rating or satisfy physical fitness standards. He was placed on light duty and referred for a Medical Evaluation Board (MEB). The neck and right shoulder conditions, characterized as “chronic cervical pain”, “right shoulder subacromial impingement, status post arthroscopic subacromial decompression and bursectomy”, “right shoulder acromioclavicular arthrosis, status post open acromioclavicular resection” and “right shoulder superior labral anterior posterior tear (slap tear), status post repair”, were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E. The Informal PEB (IPEB) adjudicated “chronic cervical pain” and “right shoulder subacromial impingement, status post arthroscopic subacromial decompression and bursectomy” as fitting, rated 10% each with likely application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD). Additionally, the IPEB adjudicated “right shoulder acromioclavicular arthrosis, status post open acromioclavicular resection” and “right shoulder superior labral anterior posterior tear (slap tear), status post repair” as Category II (conditions that contributed to the unfitting condition). The CI made no appeals and was medically separated.


CI CONTENTION: “Please consider all conditions.”


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 ratings for the unfitting neck and right shoulder conditions are addressed below; no additional conditions 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 Naval Records.


 RATING COMPARISON :

Service IPEB – Dated 20021119
 VA - (1.2 Mos. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Cat I - Chronic Cervical Pain 5021-5003 10% Cervical Disc disease 5290 0% 20030106 *
Cat I - R Shoulder Subacromial Impingement… 5299-5003 10% Right Shoulder Repair (Major) 5203 10% 20030106 *
R Shoulder Acromioclavicular… Cat II
R Shoulder Superior… Cat II
Other x 0 (Not in Scope)
 Other x 6 20030106 *
Combined: 20%
 Combined: 10%
Derived from VA Rating Decision (VA RD ) dated 200 30414 ( most proximate to date of separation [ DOS ] ). *C&P missing


ANALYSIS SUMMARY: The Board notes that the CI was separated on 30 November 2002, a year prior to a significant change in VASRD codes and criteria for the spine and during the transition period when the interim spine rules were in effect. These codes and criteria were applied to rating by the PEB and the VA. The Board’s recommendation, IAW DoDI 6040.44, must be premised on the VASRD in effect at separation.

Neck Condition. The CI was first evaluated for chronic neck pain in April 2000 while in dive school. He denied trauma and had an unremarkable examination including full range-of-motion (ROM). He was managed conservatively with medications and duty limitations without adequate benefit. He discontinued dive training and was returned to shipboard duty. On 10 July 2000, he fell descending a ladder and injured his neck and right shoulder. Again, the ROM was essentially normal and he was treated conservatively. His pain persisted and an X-ray on 2 November 2000 was normal. A magnetic resonance imaging (MRI) on 10 January 2001 showed multilevel degenerative disc disease (DDD) and degenerative joint disease without herniation or nerve impingement. Electrodiagnostic testing of the right upper extremity (the symptomatic side) was normal on 3 April 2001. A second MRI on 31 August 2001 showed multilevel DDD, but again there was no nerve impingement. He continued duty limitations including placement on LIMDU as well as medications, physical and chiropractic therapy and heat. During his treatment, the neurological examination and ROM were typically normal or near normal. Incapacitation was not recorded. The narrative summary (NARSUM) dated 9 September 2002, noted the ROM was decreased, spasm was present, but provocative compression of the spine was negative. The VA Compensation and Pension (C&P) examination performed on 6 January 2003, approximately a month prior to separation, was not in evidence, but was referenced in the VARD dated 14 April 2003. The CI was noted to have normal neck motion, but tenderness on left lateral rotation. An emergency room visit on 26 March 2003, 7 weeks after separation, noted an exacerbation of his pain since a motor vehicle accident the previous day. On examination, the combined flexion and extension of his neck was 80 degrees (90 is normal) and no neurological deficit was present.

The Board directed its attention to its rating recommendation based on the above evidence. The PEB rated the neck condition at 10% using the codes 5021 (myositis) and 5003 (degenerative joint disease). The VA coded the neck condition as 5290 (limitation of cervical motion) but rated it 0% as there was no arthritis on imaging and no limitation in motion. Both use the same rating criteria. Absent incapacitation or a significant loss of motion, with a normal neurological examination, the Board found no route to a rating higher than the 10% rating adjudicated by the PEB. 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 neck pain condition.

Right Shoulder Condition. As noted above, the right dominant CI injured his right shoulder in a fall in 2000 while aboard a ship. An X-ray on 31 July 2000 was normal. Conservative management was not successful and he had problems with overhead activities. An orthopedic evaluation on 1 February 2001 was significant for impingement, but with full strength and ROM. He was given a trial injection for pain relief and referred to physical and chiropractic therapy. His symptoms persisted and an MRI on 6 November 2001 showed a possible tear of the shoulder joint cartilage lining (labrum) and the biceps tendon. A bone scan on 17 January 2002 showed increased uptake at the joint between the collar bone and shoulder blade (AC joint). He underwent surgical repair and decompression of the right shoulder on 7 February 2002 for the labrum and AC joint. He did well post-operatively, but did not regain full function. The NARSUM, 7 months after surgery, documented a full ROM of the right shoulder with tenderness at the site of the AC joint resection. Impingement signs persisted as did irritation of the labrum; these improved after an injection of the AC joint. He was noted to have 50% improvement from prior to surgery, but to not be able to meet full duty. The VA C&P examiner noted a well healed scar and normal ROM other than abduction which lacked 10 degrees of full motion. Both painful motion and DeLuca criteria were considered in rating the shoulder. The 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.

Right Shoulder ROM
(Degrees)		 MEB 5.2 Mo. Pre-Sep VA C&P 1.2 Mo. Pre-Sep
Flexion (180 Normal) FROM Motion was normal
Abduction (180) FROM Lacking 10 degrees full abduction
Comments Impingement persisted Painful motion not documented
§4.71a Rating 10 % (painful motion) 10 %

The Board directed its attention to its rating recommendation based on the above evidence. The PEB rated the shoulder at 10%, coding it 5299-5003 (degenerative arthritis) and cited both the resection of the AC joint (arthrosis) and SLAP tear surgery (repair of the labrum). The Board observed that these were part of the treatment for the shoulder condition. The VA also rated the shoulder at 10%, but used code 5203 (impairment of the clavicle or scapula [collar bone and shoulder blade, respectively]). The Board considered the codes available for rating the shoulder and found no route to a rating higher than the 10% adjudicated by both the PEB and VA. 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 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. 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 chronic neck pain and right shoulder conditions 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 20140417, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record








                 
XXXXXXXXXXXXXXXXXXXX, DAF
President
DoD Physical Disability Board of Review
MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS
 Subj:    PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATION
Ref:     (a) DoDI 6040.44
(b) CORB ltr dtd 13 May 15

In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual's records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy' s Physical Evaluation Board:

-        XXXXXXXXXXXXXXXXXXXX, former USMC
-        XXXXXXXXXXXXXXXXXXXX, former USN
-        XXXXXXXXXXXXXXXXXXXX , former USMC
-        XXXXXXXXXXXXXXXXXXXX, former USN
-        XXXXXXXXXXXXXXXXXXXX , former USN
-        XXXXXXXXXXXXXXXXXXXX, former USMC
-        XXXXXXXXXXXXXXXXXXXX, former USN
-        XXXXXXXXXXXXXXXXXXXX, former USN






XXXXXXXXXXXXXXXXXXXX
Assistant General Counsel (Manpower & Reserve Affairs)


Similar Decisions

  • AF | PDBR | CY2010 | PD2010-00719

    Original file (PD2010-00719.doc) Auto-classification: Approved

    His treatment included medications, physical therapy, subacromial and nerve root injections, and three arthroscopic surgeries, without significant improvement. The PEB rated the shoulder condition as a muscle injury IAW §4.73, while the VA used §4.71a to rate the condition for impairment of the clavicle or scapula. These conditions likely contributed to the CI’s overall shoulder impairment, however, and are considered in the Board’s recommendations.

  • AF | PDBR | CY2014 | PD 2014 00204

    Original file (PD 2014 00204.rtf) Auto-classification: Denied

    The FPEB exam indicated right shoulder pain-limited motion to 90 degrees of flexion and extension (180 degrees normal) without winging of the shoulder blade (indicating good muscle strength). RECOMMENDATION : The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination. Physical Disability Board of Review

  • AF | PDBR | CY2014 | PD-2014-00630

    Original file (PD-2014-00630.rtf) Auto-classification: Approved

    Left Shoulder Condition . At the VA C&P examination, performed 16 months prior to separation, the CI reported a cervical spine injury in 1998 with continual pain accompanied by a left upper extremity radiculopathy. Based on the ROMs in the record the Board was unable to find a route to a higher rating.The MEB referred cervical spondylosis with C7-8 radiculopathy; however, the PEB noted cervical spondylosis “without significant neurologic abnormality.” The Board considered whether an...

  • AF | PDBR | CY2011 | PD2011-00485

    Original file (PD2011-00485.docx) Auto-classification: Approved

    The PEB adjudicated the bilateral shoulder pain condition as unfitting, rated 10%; with application of the US Army Physical Disability Agency (USAPDA) pain policy. The Board considered the evidence of the service treatment record and MEB examination, as well as the C&P examination at the time of separation. In the matter of the left and right shoulder conditions and IAW VASRD §4.71a, the Board unanimously recommends a change in rating to 10% for the left shoulder condition and 10% for the...

  • AF | PDBR | CY2011 | PD2011-00346

    Original file (PD2011-00346.docx) Auto-classification: Approved

    The CI was then medically separated with a 0% disability rating. Right Shoulder Pain . In the matter of the neck and right shoulder condition, for a separation rating after TDRL, the Board unanimously recommends that it be rated as two separate unfitting conditions with rating, by a vote of 2:1, as follows: a cervical spine condition coded 5290 and rated 10%; and, a right shoulder condition coded 5099-5003 and rated 10%; both IAW VASRD §4.71a.

  • AF | PDBR | CY2013 | PD-2013-01771

    Original file (PD-2013-01771.rtf) Auto-classification: Approved

    SEPARATION DATE: 20040520 SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) was an active dutyE-6 (Infantryman)medically separated for right shoulder, neck and right temporomandibular pain.Theseconditions could not be adequately rehabilitated to meet the physical requirementsof hisMilitary Occupational Specialty or satisfy physical fitness standards.He was issued a permanent U3 profileand referred for a Medical Evaluation Board...

  • AF | PDBR | CY2013 | PD-2013-01319

    Original file (PD-2013-01319.rtf) Auto-classification: Approved

    Chronic neck pain continued and she was referred for a MEB.At the MEB examination (3 months prior to separation), the CI reported“spasms in her neck and flares in her neck pain,” with “herniated discs in my neck which are irreparable.”She reported that “load bearing equipment and Kevlar headgear worsen her neck pain.”The Report of Medical History (DD Form 2807) for the MEB reported the presence of herniated discs with “no surgery.”The MEB physical exam noted surgical scars on the right palm...

  • AF | PDBR | CY2012 | PD-2012-01730

    Original file (PD-2012-01730.txt) Auto-classification: Denied

    The left shoulder condition, characterized as “Chronic left shoulder pain,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40- 501. The PEB adjudicated the “Chronic pain, left shoulder, rated as slight/constant” condition as unfitting and rated it 10% IAW the US Army Physical Disability Agency (USAPDA) pain policy. RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows: UNFITTING...

  • AF | PDBR | CY2009 | PD2009-00009

    Original file (PD2009-00009.docx) Auto-classification: Denied

    The PEB adjudicated only the cervical condition as unfitting and the CI was medically separated with a 10% disability rating. The Board’s primary consideration regarding the psychiatric conditions is the PEB’s determination that they did not ‘independently, or combined, render the Soldier unfit for his assigned duties.’ The CI had a history of outpatient psychiatric treatment in 1999 and some of his documented PTSD stressors were derived from experiences before deployment. Other Conditions .

  • AF | PDBR | CY2009 | PD2009-00403

    Original file (PD2009-00403.docx) Auto-classification: Denied

    The VA rated his shoulder as a separate condition as described below. Right Shoulder Pain/Impingement: The VA examination on 20081105 documented Pain to palpation of the right shoulder, painful motion of right shoulder, and crepitation in right shoulder.