RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2014-01982
BRANCH OF SERVICE:  NAVY	BOARD DATE:  20140926
Separation Date:  20090724

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty AE3/E-4 (8303/Aviation Electrician Mechanic) medically separated for a left shoulder condition.  The left shoulder condition could not be adequately rehabilitated to meet the physical requirements of his Rating or satisfy physical fitness standards.  He was placed on limited duty [LIMDU] status and referred for a Medical Evaluation Board (MEB).  The MEB forwarded left shoulder condition, characterized as “superior glenoid labrum lesions (SLAP)”, to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The MEB also identified and forwarded two other conditions to the PEB.  The Informal PEB adjudicated “left shoulder slap tear, status post prior superior labral repair and prior open anterior stabilization of the left shoulder” as unfitting, rated at 10%.  The remaining conditions were determined to be Category III conditions.  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 rating for the unfitting left shoulder condition is addressed below.  The posttraumatic stress disorder (PTSD) and chronic foot pain which were determined to be Category III conditions are likewise addressed below; and, 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 20090609	VA - (1.25 and 7.5 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Shoulder SLAP Tear, s/p Superior Labral Repair and Open Anterior Stabilization	5099-5003	10%	Left Shoulder Impingement/Residuals, SLAP Procedure/Arthrosis	5201-5010	10%	20090831	
			Residuals, Scars Left Shoulder	7805	0%	20090831	
PTSD	Cat III	PTSD	9411	10%	20100310	
Chronic Foot Pain	Cat III	Right Foot Plantar Fasciitis	5099-5020	10%	20090831	
		Bilateral Mild Pes Planus	5276	0%	20090831	
		Residuals, Right Foot Fx	5284	0%	20090831	
Other x 0 (Not in Scope)	Other x 12	20090831	
Rating:  10%	Combined:  70%	
Derived from VA Rating Decision (VARD) dated 20091214 (most proximate to date of separation)

ANALYSIS SUMMARY:  IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VA Schedule for Rating Disabilities (VASRD) standards, based on ratable severity at the time of separation; and, to review those fitness determinations within its scope (as elaborated above) consistent with performance-based criteria in evidence at separation.

Left Shoulder SLAP Tear, s/p Superior Labral Repair and Open Anterior Stabilization Condition.  The CI had an initial left shoulder injury as a football player in 1996.  He had good results post operatively and was given a waiver for entrance into the Navy.  He reinjured his left shoulder with symptoms of subluxation and popping.  The CI was seen by orthopedics who recommended that based on the severity of symptoms the CI be sent state-side for further evaluation and treatment.  The CI underwent an arthrogram and a magnetic resonance imaging which demonstrated a superior labral tear, mild A-C joint degeneration and mild tendonitis of the biceps tendon.  He was followed by sports medicine for the shoulder sprain and glenoid labrum tear but did not show improvement.  The CI was placed on the first LIMDU status on 
10 June 2008 for the left shoulder SLAP tear through to 10 December 2008 with restrictions specific to the shoulder condition.  The CI underwent surgical repair on 23 January 2008.  The CI had extensive physical therapy (PT) after surgery.  The CI continued with popping, feelings of instability and pain in certain positions.  The CI’s second LIMDU chit dated 10 June 2008 referred to “now with recurrent subluxation of left shoulder status post multiple injuries.”  A PT entry dated a year prior to separation also documented continued recurrent subluxation and instability with pain.  

The MEB narrative summary (NARSUM) exam (approximately 4 months prior to separation) documented that the CI continued to have left shoulder pain with overhead activities, lifting heavy objects and difficulties with crawling on the ship.  The MEB NARSUM physical exam findings are summarized in the chart below.  The non-medical assessment indicated that the CI was unable to perform his MOS duties due to his medical condition.  

The VA Compensation and Pension (C&P) exam (performed approximately a month after separation) documented that the CI reported chronic weakness, stiffness, swelling, giving way, lack of endurance, tenderness, subluxation, pain and dislocation.  The flare-ups were precipitated by physical activity but relieved by rest.  The VA C&P physical exam findings are summarized in the chart below.

There were two goniometric range-of-motion (ROM) evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the following chart:

Left Shoulder ROM (Degrees)	MEB ~ 4 Mo. Pre-Sep	VA C&P ~ 1.25 Mo. Post-Sep	
Flexion (180 Normal)	180	180	
Abduction (180)	180	140	
Comments: Right Hand Dominant	Pain; Normal strength; Pos. voluntary subluxation with mild “anterior glide”	Pos. painful motion, weakness & guarding of movement; Pos. Deluca criteria; No instability/subluxation	
§4.71a Rating	20% (PEB 10%)	20% (VA 10%)	

The Board directs attention to its rating recommendation based on the above evidence.  The PEB coded the left shoulder SLAP Tear, s/p superior labral repair and open anterior stabilization condition as 5099 analogous to 5003 arthritis, degenerative (hypertrophic or osteoarthritis) and rated at 10%.  The VA coded the left shoulder impingement/residuals, SLAP procedure/arthrosis condition as 5201 (limitation of arm motion), with 5010 (arthritis due to trauma), and rated at 10%.  All exams proximate to separation documented painful motion (IAW §4.59 painful motion) with no ROM limitation to a compensable level.  The Board also noted that a post-surgical PT entry and the NARSUM exam documented continued left shoulder instability after surgery, while the VA C&P exam documented no instability/subluxation but did note “guarding of movement.”  Two of three pre-separation documents that addressed the post-surgical stability of the CI’s shoulder noted continued instability and the VA C&P exam noted guarding of movement.  All meet the 20% rating criteria under code 5202, other impairment of the humerus, with the relevant aspects copied below for the reader’s convenience:

5202 Humerus, other impairment of:
Recurrent dislocation of at scapulohumeral joint.
With frequent episodes and guarding of all arm movements .................................................. 30 ......... 20
With infrequent episodes, and guarding of movement only at shoulder level .......................... 20 ......... 20

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 left shoulder condition.

Contended PEB Conditions.  The contended conditions adjudicated as not unfitting by the PEB were chronic foot pain and PTSD.  The PEB adjudicated these conditions as Category III.  The Board’s first charge with respect to these conditions is an assessment of the appropriateness of the PEB’s fitness adjudications.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations and requires a preponderance of evidence.

Chronic Foot Pain.  The CI was diagnosed with plantar fasciitis of the right foot in February 2007.  He was seen by podiatry in 2008 for right foot pain.  This condition was not profiled, there was no assigned LIMDU status for this condition and it was not implicated in the commander’s statement.  This condition was reviewed by the action officer and considered by the Board.  There was no indication from the record that this condition significantly interfered with satisfactory duty performance.  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 chronic foot pain condition and so no additional disability rating is recommended.

PTSD.  The CI was referred to psychology after he attended a Warrior Transition brief and realized that he had experienced symptoms of PTSD due to his experiences in Iraq.  He endorsed symptoms of recurrent and intrusive recollections, intense distress at cues that resembled the events, efforts to avoid feelings associated with trauma, feelings of estrangement, restricted emotions, insomnia and outbursts of anger.  He was initially seen in Behavioral Health while in Theater for insomnia.  The mental status exam (MSE) showed irritability however there were no suicidal or homicidal ideations.  The Global Assessment of Functioning (GAF) was 70, some difficulty in social, occupational or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships.  Throughout 2007, the GAF score fluctuated between 70 and 80; if symptoms are present they are transient and expectable reactions to psychosocial stressors.  In 2009 (3 months prior to separation), the CI was seen by psychiatry and was diagnosed with PTSD; however, the treating psychiatrist noted that the CI reported that his symptoms were improving.  A psychology addendum to the MEB completed (approximately 3 months prior to separation), documented that the CI stopped going to cognitive processing therapy prior to completion of the 12 session protocol because he felt that he was getting better.  The MSE showed a dysphoric mood; however, the rest of the exam was normal.  The GAF was 55-60, moderate difficulty in social, occupational or school functioning.  

The VA C&P exam (performed approximately 7 months prior to separation) documented that the CI was pursuing a degree in education at a state college and was in a significant relationship.  He was able to maintain family relationships and had a hobby of gardening for relaxation.  He still had panic attacks twice monthly; however, he did not require any psychotropic medication nor was he in counselling.  Throughout the service treatment record, there is no documentation of hospitalizations for a mental health disorder, nor were there any emergency room visits needed.  There was no documentation of any suicide attempts or homicidal ideations.  This PTSD condition was not implicated in the commander’s statement.  This condition was reviewed by the action officer and considered by the Board.  There was no indication from the record that any of this condition significantly interfered with satisfactory duty performance.  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 PTSD condition and, therefore, no additional disability rating can be recommended.

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 SLAP tear, s/p superior labral repair and open anterior stabilization condition, the Board unanimously recommends a disability rating of 20%, coded 5202 IAW VASRD §4.71a.  In the matter of the contended chronic foot pain and PTSD conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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	
Left Shoulder SLAP Tear, s/p Superior Labral Repair and Open Anterior Stabilization	5202	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140506, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

						
XXXXXXXXXXXXXX
President
Physical Disability Board of Review

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
		   DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:   (a) DoDI 6040.44
       (b) PDBR ltr dtd 29 Mar 15 ICO XXXXXXXXXXXXXX  
	 (c) PDBR ltr dtd 29 Mar 15 ICO XXXXXXXXXXXXXX
	 (d) PDBR ltr dtd 29 Mar 15 ICO XXXXXXXXXXXXXX  

1.  Pursuant to reference (a) I approve the recommendations of the Physical Disability Board of Review set forth in references (b) through (d).

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXX, former USMC: Entitlement to disability severance pay with a 20 percent (increased from 10 percent) disability rating effective date of discharge.

     b. XXXXXXXXXXXXXX, former USN: Entitlement to disability severance pay with a 20 percent (increased from 10 percent) disability rating effective date of discharge.

     c. XXXXXXXXXXXXXX, former USN: Entitlement to disability severance pay with a 20 percent (increased from 10 percent) disability rating effective date of discharge.

3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are completed.

	XXXXXXXXXXXXXX
	Assistant General Counsel
                                      (Manpower & Reserve Affairs)