RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00634
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070620

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Infantryman, medically separated for “chronic right shoulder pain,” with a disability rating of 10%.  

CI CONTENTION:  The applicant makes no specific contention in his application.  The applicant’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  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 Physical Evaluation Board (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 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:  

SERVICE PEB - 20070417	VARD - 20070712	
Condition	Code	Rating	Condition	Code	Rating	Exam	
…Right Shoulder Pain…	5099-5003	10%	…Syndrome, Right Shoulder…	5201-5019	10%	20070518	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Right Shoulder Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right hand dominant CI began experiencing pain in his right shoulder in 2005, with no associated trauma or injury.  Radiologic testing in July 2005 indicated mild degenerative changes that predisposed the CI to tearing of the rotator cuff (the group of muscles and tendons surrounding the shoulder joint).  Surgery was not indicated.  Despite conservative treatment, the CI’s shoulder condition could not be adequately rehabilitated to meet the physical requirements of his military specialty and he was referred for an MEB.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated 26 January (5 months prior to separation), the CI reported ongoing right shoulder pain and numbness.  Physical exam showed the right shoulder to have tenderness and painful motion.  Provocative testing indicated some instability of the shoulder ball and socket joint, with no laxity.  At the time of the physical therapy (PT) appointment on 2 February 2007, the CI reported shoulder pain with severity rated 3/10.  Examination revealed the ROM as depicted in the chart above.  

At the VA Compensation and Pension (C&P) examination on 3 October 2007 (a month prior to separation), the CI reported shoulder pain and numbness that caused weakness when trying to lift heavy objects, stiffness in the morning, and lack of endurance with continuous motion such as washing a window.  The pain occurred 2-3 times per day and lasted for an hour, and was rated at 8/10 severity.  Physical exam showed the right shoulder had weakness and abnormal movement, laxity of the rotator cuff (“approximately 1cm distraction”) and “symptomatology of instability of the acromioclavicular joint” (the acromioclavicular, or AC joint, is at the top of the shoulder).  Radiographic study was unremarkable.  

At the C&P examination on 2 January 2008, (6 months after separation), the CI reported, pain, give way, stiffness and weakness of the right shoulder.  Magnetic resonance imaging documented intact tendons with mild hypertrophic changes at the AC joint with minimal fluid.  Examination documented limited ROM as charted above with pain on repetition.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5099-5003 code (analogous to arthritis, degenerative), citing application of the US Army Physical Disability Agency Pain Policy.  The VA also assigned a 10% rating, but used a 5201-5019 code (limitation of motion of the arm - bursitis), citing painful or limited motion and the rating criteria of code 5019.  

The VASRD §4.71a code 5201 (arm limitation of motion) threshold for a minimum rating for ROM impairment is “at shoulder level” (90 degrees from the side), and the ROM in evidence demonstrated motion above this level.  Although the limitation of motion did not support a minimum rating under code 5201, Board members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion) as reported at the PT, MEB, and VA C&P examinations.  There was no malunion or recurrent dislocation of the humerus to justify a rating under the 5202 code (humerus, other impairment of); and no nonunion with loose movement of the clavicle to warrant the next higher 20% rating under the 5203 code (clavicle or scapula, impairment of).  While the VA C&P exam did report “symptomatology of instability of the acromioclavicular joint,” there was no evidence or history of separation, nonunion, or malunion of the AC joint.  

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:  In the matter of the chronic right shoulder pain 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.  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 20140128, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXX, AR20160005583 (PD201400634).

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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA