RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02364
BRANCH OF SERVICE:  Army	BOARD DATE:  20150325
Separation Date:  20071027

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Wheeled Vehicle Mechanic) medically separated for a left shoulder instability condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) although he was authorized to perform an alternate physical fitness testing.  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  Left shoulder pain and instability was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “left (non-dominant) shoulder instability” as unfitting, rated 0%, citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy.  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 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/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 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 IPEB – Dated 20070925	VA* - (~3 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left (Non-Dominant) Shoulder Instability	5099-5003	0%	Recurrent Subluxation, Left Shoulder	5201	20%	20080128	
Other x 0 (Not In Scope)	Other x 1	
Combined:  0%	Combined:  20%	
*Derived from VA Rating Decision (VARD) dated 20080625 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:  IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board reviews medical records and other available evidence to assess the fairness of PEB rating determinations, using the VASRD standards, based on ratable severity at the time of separation.

Left (Non-Dominant) Shoulder Instability Condition.  The CI sustained bruises to his left shoulder during a sledding accident in 2004 while in Germany when he hit a tree.  In June 2006, while riding his ATV he hit a rock, fell off and fell flat on his chest and dislocated his shoulder.  The shoulder naturally popped back in and the CI was seen in primary care.  The examiner noted that the CI reported increased pain with raising arm in any direction, and the shoulder joint felt unstable.  There were physical exam findings of tenderness to palpation (TTP) of the acromioclavicular joint, TTP of the glenohumeral joint region, laxity, a positive apprehension test and a positive anterior drawer test.  The left shoulder X-ray was normal.  The physical therapist (PT) noted physical exam findings of TTP at the glenohumeral joint, TTP upper trapezius muscles, scapula and special testing was not done due to pain.  The primary care provider noted that the CI dislocated his shoulder the day before while doing pushups and it was reduced, and the CI now had constant pain and a decreased ability to move the shoulder.  There were physical exam findings of range-of-motion (ROM) abduction and flexion to 10 degrees and weak, painful left shoulder in all directions , and TTP anterior and posteriorly.  The orthopedist documented physical exam findings of deltoid muscle atrophy, TTP anterior deltoid muscle, TTP upper trapezius muscle, TTP rhomboid muscles, TTP vertebral border of the scapula, rhomboid muscle spasm, and a positive apprehension test and relocation test.  The examiner opined that the findings were consistent with joint instability.  The arthrogram/MRI demonstrated no gross evidence for rotator cuff or labral tear.  A repeat left shoulder X-ray was normal with no impingement noted.

The MEB narrative summary (NARSUM) exam approximately 2 months prior to separation documented that the CI’s shoulder had been aggravated by active duty, overhead activities and tasks for that were required in his MOS.  He could not perform push-ups as well.  The MEB examiner diagnosed left shoulder pain and disability.  The PT approximately 2 prior to separation performed ROM’s for the MEB which are summarized below.

The VA Compensation and Pension exam approximately 3 months after separation documented that the examiner could not assess left shoulder stability as the CI complained of pain and guarding and he further requested that the examiner “not move his shoulder because he’s afraid of the pain it will elicit.”

There were ROM evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.

Left Shoulder ROM (Degrees)	NARSUM ~3 Mos. Pre Sep	PT 2.5 Mos. Pre-Sep	VA C&P ~3 Mos. Post-Sep	
Flexion (180 Normal)	Full ROM	130	CI asked VA examiner not to move shoulder	
Internal rotation 70		90		
External rotation 90		90		
Abduction (180)		135		
Comments:
Right hand dominant	Pos. apprehension; No rotator cuff weakness or impingement	Pos. painful motion & apprehension	Guarding; diagnosed with recurrent subluxation	
§4.71a Rating	20% (PEB 0%)	20% (PEB 0%)	20% (VA 20%)	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the left (non-dominant) shoulder instability condition with analogous code 5099-5003 (degenerative arthritis) rated 0% citing the USAPDA pain policy.  The VA coded the recurrent subluxation, left shoulder condition as 5201 (limitation of arm motion) rated at 20%.  All evidence proximate to separation documented pain with all activity and motion.  Additionally, both prior to separation exams document “apprehension” on exam and numerous service treatment entries document recurrent dislocation/subluxation of the left shoulder.

The Board considered VASRD code 5202; the pertinent aspects of that code are 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

The Board notes that the rating for the non-dominant shoulder under 5202 is the same regardless of the frequency of instability episodes or the position where the guarding was present.  There is no coding or rating scheme that would grant the CI a rating greater that 20% for his left shoulder condition.  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 (non-dominant) shoulder instability condition coded 5202.

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.  As discussed above, PEB reliance on the USAPDA pain policy for rating the left (non-dominant) shoulder instability condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the left (non-dominant) shoulder instability condition, the Board unanimously recommends a disability rating of 20%, coded 5202 IAW VASRD §4.71a.  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 (Non-Dominant) Shoulder Instability	5202	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140521, 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 XXXXXXXXXXXXXXXXXXXX, AR20150014414 (PD201402364)

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,   I accept the Board’s recommendation to modify the individual’s disability rating to 20% without recharacterization 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:

Encl						    

CF: 
(  ) DoD PDBR
(  ) DVA