RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01051
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040819

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E2, Signal Support Systems Specialist, medically separated for “right shoulder pain and stiffness” with a disability rating of 0%.  

CI CONTENTION:  He was given a higher rating for his condition by the VA and contends for a condition not on the MEB or PEB.  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 Physical Evaluation Board (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 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 - 20040707	VARD - 20050202	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder Pain and Stiffness	5099-5003	0%	Right Shoulder Condition	5299-5201	NSC	20041118	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:  

Right Shoulder Pain and Stiffness.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right hand dominant CI began to notice bilateral shoulder pain in June 2001, without trauma or injury.  Arthrogram documented a supraspinatus labral tear.  Ongoing pain in the right shoulder and multidirectional instability led to an open inferior capsular shift surgical procedure in April 2003.  The CI’s shoulder condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and was referred for a MEB.  

There were multiple physical therapy (PT) treatment notes from May 2003 through November 2003 indicating limited shoulder flexion to 90 degrees and 95 degrees (normal 180).  An Orthopedic exam from November 2003 documented right scapular winging and a February 2004 exam documented abduction to 90 degrees (normal 180).  

At an Orthopedic visit in March 2004, 5 months prior to separation, the CI complained that he could not work overhead due to his shoulder, and had pain when carrying a briefcase or lifting greater than 5 pounds.  Physical exam noted mild tenderness over the interior aspect of the right shoulder and the greater tuberosity, negative sulcus and apprehension signs, and no instability.  ROMs are summarized above.  The Orthopedist indicated that the CI “probably also has rotator cuff tendinopathy” and that further surgery was unlikely to improve the CI’s range-of-motion or pain.  The NARSUM, written in May 2004, 3 months prior to separation, noted the CI had no history of post-surgical dislocation.  Physical exam noted tenderness to palpation over the anterior aspect and about the scar line and about the greater tuberosity.  There was negative acromioclavicular joint tenderness, a negative apprehension test, no instability, and 5/5 strength.  There was pain with abduction and external rotation.  

At the VA Compensation and Pension (C&P) examination on 18 November 2004, performed 3 months after separation, physical exam showed no redness, heat, swelling or instability of either shoulder.  The shoulder exam is summarized above.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under analogous code 5099-5003 (arthritis, degenerative), citing the US Army Physical Disability Agency pain policy.  The VA adjudicated not service connected using analogous code 5299-5201 (arm, limitation of motion of) based on the VA C&P examination 3 months after separation, citing non-receipt of service medical records to establish that the shoulder condition was incurred during, or caused by, military service.  

The VASRD §4.71a (code 5201, arm limitation of motion) threshold for a minimum rating for ROM impairment is “at shoulder level” (approximately 90 degrees from the side), and the ROM in evidence demonstrated motion that approximated this level.  The CI’s functional loss impacting overhead work and prior treatment notes and subsequent VA exam supported the “at shoulder level” disability picture.  The next higher 30% rating for the dominant arm requires motion limited to “midway between side and shoulder level.”  However, examinations did not reflect this degree of limitation.  There was no malunion with marked deformity or frequent episodes of recurrent dislocation of the humerus to justify a higher rating under the 5202 code (humerus, other impairment of), and no higher ratings available under the 5203 code (clavicle or scapula, impairment of).  

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 condition, coded 5201-5003.  

BOARD FINDINGS:  In the matter of the right shoulder condition, the Board unanimously recommends a disability rating of 20%, coded 5201-5003 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior to medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Shoulder Pain and Stiffness	5201-5003	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140210, 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, AR20160005598 (PD201401051)

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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization 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:

CF: 
(  ) DoD PDBR
(  ) DVA