RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02738
BRANCH OF SERVICE:  Army	BOARD DATE:  20150605
Separation Date:  20080227

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5, Track Vehicle Repairer, medically separated for left shoulder pain.  The left shoulder condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS), but was authorized to perform an alternate physical fitness test (per PROFILE).  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The “left shoulder instability status post (s/p) stabilization procedure,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “left shoulder pain and guarding, s/p left arthroscopic anterior stabilization procedure” as unfitting, rated 10%, citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.  In February of 2009, the USAPDA produced an administrative correction PEB that did not change the condition description or rating.

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:

Admin Corr PEB – Dated 20090223	VA* - (~2 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Shoulder Instability S/P Stabilization Procedure	5099-5003	10%	S/P Left Shoulder Anterior Instability	5299-5203	10%	20080104	
Other x 0 (Not In Scope)	Other x 8	
RATING:  10%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20080229 (most proximate to date of separation [DOS]).
ANALYSIS SUMMARY:

Left Shoulder Instability s/p Stabilization Procedure Condition.  The CI dislocated his left shoulder during a boxing incident in April 2001 which occurred as he was striking outward with his left upper extremity.  Subsequent to the initial injury, had recurrent dislocations including two frank dislocations which required shoulder joint reduction in a medical facility and a May 2006 dislocation ;while in Theater and was MediVac’d to Landstuhl for an instability workup.  A left shoulder X-ray showed no osseous (bony) abnormality.  The Orthopedist noted that the CI underwent a course of physical therapy (PT) without any improvement in the pain.  Physical examination findings of tenderness to palpation in the supraspinatus muscle, glenohumeral joint, and bicipital groove; pain was elicited at the end range-of-motion (ROM), and with external rotation against resistance; shoulder instability, weakness; and pain on active motion.  A left shoulder magnetic resonance imaging arthrogram demonstrated with small Hill-Sach’s lesion associated bone marrow edema indicative of frequent dislocations and suggestive for tear of the antero-inferior glenoid labrum.  The CI underwent a left shoulder arthroscopy with anterior stabilization on 29 September 2006.  Post-operatively, the CI was referred to PT for left shoulder evaluation and 10 treatments sessions.  The CI continued to report left shoulder pain and limited ROM with activity.  The commander’s statement indicated that the CI‘s disability prevented him from performing his MOS duties.  The MEB narrative summary (NARSUM) examination approximately 4 months prior to separation documented that the CI was unable to perform several duties specific to his MOS, had left shoulder pain, and was unable to perform several activities of daily living and recreation (playing sports such as boxing, weightlifting or jogging).  The examiner rated the pain according to the American Medical Association pain scale at slight and frequent.  The MEB NARSUM physical examination findings are summarized in the chart below.  The VA Compensation and Pension (C&P) examination approximately a month prior to separation documented that the CI had constant, localized sharp, aching left shoulder pain with weakness, stiffness with driving, giving way while driving or lifting, lack of endurance with sudden movements, locking with sleeping, and fatigability with moving.  He required several pain medications for pain relief.  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)	MEB ~4 Mo. Pre-Sep
	PT ~3 Mo. Pre-Sep
	VA C&P ~1.5 Mo. Pre-Sep
	
Flexion (180 Normal)	110	115/115/115	150	
Internal rotation 70	-	40/40/40	70	
External rotation 90	-	30/30/30	70	
Extension 50	50 (55)	50 (55/55/55)		
Abduction (180)	110*	100/100/100	120	
Right Hand Dominant 	*ROM limited due to apprehension; scars from arthroscopic portholes anterior, posterior; guarding; 4 inch difference in left shoulder secondary to pain; strength LUE 4/5, 4+/5 at biceps; deltoid strength 4/5 flexion, abduction, external rotation; radial, ulnar axillary and median nerve distributions are intact; elbows, wrists, hands FROM; Neer test is equivocal-due to both apprehension and pain; pain with thumbs up, down	ROM tolerated with increased pain, facial grimacing2 inch difference in distance left due to pain; strength4/5 flexion, abduction, adduction, internal/external rotations secondary to pain; sensory intact	Weakness, tenderness; + Deluca- after repetitive use-pain, weakness fatigue, lack of endurance; pain has the major functional impact; joint additionally limited by 5 degrees	
§4.71a Rating	10%	10%	10%	
The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the left shoulder instability s/p stabilization procedure condition as 5099-5003 arthritis, degenerative (hypertrophic or osteoarthritis) and rated at 10% with application of the USAPDA pain policy.  The VA coded the s/p left shoulder anterior instability condition as 5299-5203 clavicle or scapula, impairment of and rated at 10% - Malunion of.  The CI was given a permanent U3 profile for left shoulder pain (s/p reconstruction) restrictions of no running, pushups or overhead lifting, no parade rest, ellipse or swim in gym for PT, no LBE however he could do the alternate PFT walk and bike.  The commander’s statement indicated that the CI‘s disability prevented him from performing his MOS duties.  The totality of the evidence proximate to separation documented that there was painful motion with all activities.  VASRD §4.71a specifies for 5003 that satisfactory evidence of painful motion limitation of motion and specifies a 10% rating for each major joint or group of minor joints affected by limitation of motion.  The Board considered coding as 5299-5203, however using alternate rating schema would not result in a higher rating.  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 left shoulder instability s/p stabilization procedure 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.  As discussed above, PEB reliance on the USAPDA pain policy (AR 635-40) for rating the left shoulder instability s/p stabilization procedure condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the left shoulder instability s/p stabilization procedure condition 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.

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 20140609, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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, AR20160003090  (PD201402738)

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 ( ) OVA