RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01327
BRANCH OF SERVICE:  MARINE CORPS 	SEPARATION DATE:  20090830

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2 (Basic Marine) medically separated for left shoulder pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was placed on limited duty (LIMDU) and eventually referred for a Medical Evaluation Board (MEB).  The “other joint derangement, not elsewhere classified, site unspecified” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated his left shoulder pain as unfitting and forwarded it to the Veterans Administrations Disability Rating Activity Site (DRAS) IAW the Disability Evaluation System (DES) Pilot Program for rating.  The DRAS proposed it be rated at 20%, citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The PEB applied the 20% rating to the unfitting left shoulder condition.  The CI made no appeals and was medically separated.  

CI CONTENTION:  His condition continues to worsen and negatively impact his daily activities.  His complete submission is at Exhibit A.

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 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 Naval 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 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:  

Recon PEB – Dated 20090709	VA* - (~4 Mos Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Shoulder Recurrent Posterior Instability	5202	20%	Chronic Instability of Left Shoulder (Non-Dominant)	5202	20%	20090424	
Other x 0 (Not In Scope)	Other x 0	
RATING:  20%	RATING:  20%	
*Derived from the proposed VA Rating Decision (VARD) dated 20090626 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Left Shoulder Condition.  The service treatment record (STR) documents that the CI dislocated his left shoulder while performing pull-ups in boot camp.  He was able to self-reduce (restore dislocation to the correct alignment) the dislocation.  The MRI showed an anterior labral (fibrocartilage ring surrounding shoulder blade cavity where humerus articulates) tear and likely disrupted joint capsule.  At an orthopedic surgery consultation, the CI complained of recurrent left shoulder dislocations.  He reported a total of four dislocations in the 5 months since the initial injury.  The CI reported daily subluxation (incomplete or partial dislocation) with mild trauma and he was unable to raise arm greater than 90 degrees without subluxation.  He had been wearing a sling without relief of symptoms.  The shoulder could be voluntarily dislocated and there was pain at the glenohumeral (shoulder blade and humerus) joint.  The left shoulder exam revealed very limited and abnormal motion do to recurrent subluxations.  The shoulder was voluntarily subluxed to the posterior with associated joint laxity and rotator cuff (RC) weakness. There was no tenderness or crepitus (grating sound or sensation).  The assessment listed left shoulder joint instability.  The surgeon discontinued the sling, prescribed a brace, and planned for continued physical therapy (PT) for strengthening and stabilization.  The narrative summary (NARSUM) by orthopedic surgery, 5 months before separation, recounted the history of injury and interventions.  The right-hand dominant CI complained of recurrent left shoulder instability.  He reported “…it feels out of place and he can dislocate it.”  The left shoulder exam revealed posterior and posterior-inferior instability.  There was no sternoclavicular (SC) or acromioclavicular (AC) tenderness.  Subscapularis (5/5) and RC (5/5) strength was normal.  The range-of-motion (ROM) documented flexion of 170 (normal 180), abduction of 170 (180), external rotation of 90 (90), and internal rotation of 50 (90) degrees.  The diagnosis listed left shoulder recurrent posterior instability.  

The compensation and pension (C&P) exam, 4 months before separation, recounted the history and interventions.  The CI was wearing a brace which limited left shoulder abduction to less than 45 degrees.  The CI stated his  “…shoulder is constantly popping out of socket and on at least 10 occasions he has required assistance by others in reducing dislocations.”  Wearing the brace, he experienced recurrent subluxations which he could self-reduce.  Without the brace, he could sustain complete dislocations which required manipulation and closed reduction.  The CI complained of left shoulder pain, and slight hand and finger numbness, with activity and dislocations.  He was unable to do pushups, pull-ups, or work at shoulder level or overhead.  The recurrent subluxations/dislocations would flare up sporadically and repetitive shoulder use was contraindicated.  The examiner opined that brace removal, repetitive shoulder movements, and a full ROM exam were contraindicated.  The physical exam was performed with the abduction restricting brace in place.  At 30 degrees of abduction, the CI demonstrated posterior subluxations with shrugging of the shoulder muscles.  The diagnosis listed chronic left shoulder instability with recurrent subluxations and dislocations.  The examiner opined that the disabling instability and pain significantly impacted left shoulder and arm function.  The impaired function had a major effect upon on daily and occupational activities.  

At an orthopedic surgery consultation, a month after separation, the CI complained of left shoulder pain and instability with occasional numbness into his hand.  He reported chronic subluxation and posterior dislocations with most movements above 30 degrees abduction.  His symptoms were not significantly relieved with PT or his brace.  The CI was not moving his left upper extremity because of the fear of subluxation and dislocation.  The left shoulder exam revealed good musculature and no evidence of muscle wasting.  Upon attempted abduction, his left humerus would visibly subluxate posteriorly at around 30 or 35 degrees of abduction.  With attempted forward elevation, he again had posterior subluxation/dislocation. The CI was unable to perform any other active ROM movements and with passive ROM would subluxate posteriorly.  While the supraspinatus muscle was unable to be tested, subscapularis (5/5) and infraspinatus (5/5) muscle strength was normal, and light touch sensation was intact.  The assessment listed a grossly subluxated and posteriorly laxed left glenohumeral joint.  The plan was for operative intervention to repair the gross shoulder instability.  An X-ray showed marked instability, with the humerus dislocated posteriorly, and a CT showed no degenerative changes, fractures, or dislocation. The MRI showed an intact RC and a suspected posterior labral tear.  The CI underwent a left shoulder arthroscopic procedure (anterior and posterior capsular shift).  At the orthopedic surgery follow-up, 6 weeks postoperative, the CI was no longer wearing his brace.  He was no longer taking opioids (Dilaudid) or NSAIDs (naproxen) for pain.  The CI stated that without movement he had no pain, but movement resulted in 8/10 pain.  The left shoulder exam revealed four well-healed incisions. There was no swelling, erythema (redness), or ecchymosis (bruising).  The exam documented the CI was “… able to abduct shoulder 60-70% from flank.  Shoulder extension is almost to level of shoulder and no higher.  Pt unable to circumvent arm at this time.”  There was 4/5 left biceps strength and sensation was intact.  The assessment listed healing left shoulder status post arthroscopic stabilization.  The examiner opined that the degree of stiffness was as expected 6 weeks postoperatively.  The plan was to start PT (12 visits), use a sling, and to continue the NSAID (naproxen) as tolerated to alleviate inflammation.

The Board directed attention to its rating recommendation based on the above evidence.  The preoperative PEB, two months before separation, rated the left shoulder condition at 20% (VA code 5202; humerus, other impairment of).  The PEB cited left shoulder recurrent posterior instability.  The preoperative VA rating decision (VARD), citing the C&P exam 4 months before separation, rated the left shoulder condition at 20% (5202; recurrent dislocation of at scapulohumeral joint with infrequent episodes, and guarding of movement only at shoulder level; humerus malunion of: moderate deformity).  The VARD cited chronic (non-dominant) left shoulder instability, instability by exam, recurrent posterior subluxation, recurrent posterior dislocation, immobilized by abduction type splint, and anterior labral tear with anterior capsule disruption by MRI.  The CI subsequently underwent a left shoulder arthroscopic procedure.  The postoperative VARD, 6 months after separation, and 4 months postoperatively, rated the left shoulder condition at 20% (5202).  The preoperative rating of 20% was increased to 100% at surgery based on treatment necessitating convalescence. The 20% rating was restored three months postoperatively.  The postoperative VARD cited interval treatment reports, chronic left shoulder instability, status post arthroscopic stabilization and capsulorrhaphy (surgical incision or repair of capsule), no surgical complications, no longer wearing a brace, PT participation, and pain with movement.  Board members agreed there was sufficient evidence of painful motion (§4.59) and functional loss (§4.40) to support a 10% rating.  Based upon the NARSUM exam, there was no compensable limitation of motion for consideration under code 5201.  The C&P examiner did not assess ROM because he felt brace removal, and a full ROM exam, was contraindicated.  The limitation of motion documented in the orthopedic surgery exam, 6 weeks postoperative, was consistent with the 20% rating (at shoulder level [90 degrees]) under 5201.  There was no evidence of scapulohumeral ankylosis to support a rating under 5200, and no evidence of malunion of the humerus, clavicle or scapula, or of dislocation, to support a rating under 5202 or 5203.  The Board assigned less probative value to the NARSUM and C&P exams as they occurred before the left shoulder surgery.  The Board assigned higher probative value to the postoperative orthopedic exam because it occurred after surgery and a short period of convalescence.  Recognizing the temporal relationship to separation, the Board judged the postoperative exam more accurately reflected the CI’s stable, post-treatment condition.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the left 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 left shoulder condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  

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 20140217, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 6 Jan 16

      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:

- XXXXXXXXXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXXXXXXXXX, former USMC  
- XXXXXXXXXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXXXXXXXXX, former USMC 
- XXXXXXXXXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXXXXXXXXX, former USN

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	     		Assistant General Counsel
					 (Manpower & Reserve Affairs)