RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03162
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070214

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Infantryman, medically separated for “chronic pain left shoulder status post multiple surgeries after dislocations and clavicular fracture which has a malunion,” with a disability rating of 20%.

CI CONTENTION:  The CI requested the Board consider all conditions to include PTSD.  The CI’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 - 20070103	VARD - 20070727	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Shoulder Fracture with Malunion	5009-5003	20%	Residuals Fracture, Left Shoulder (non-dominant) S/P Open Reduction	5299-5201	20%	20070319	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Left Shoulder.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right hand dominant CI dislocated his left shoulder in 2003 while deployed.  It was relocated and he did well, but later fractured his clavicle in an ATV accident in 2004.  Ongoing pain led to open reduction internal fixation of left mid-shaft clavicle fracture in January 2005.  In July 2005, the hardware was removed due to shoulder pain.  His shoulder was dislocated again during a subsequent deployment in 2006 and he was medically evacuated for further care.  Magnetic resonance imaging of the left shoulder on 25 April 2006 showed a tear of the posterior labrum (the rim of cartilage around the cup shaped joint).  The CI underwent arthroscopic surgery for repair of the labral tear and was able to rejoin his deployed unit.  However, he experienced LUE numbness when wearing full gear and following another fall on the shoulder he was medically evacuated again.  Cervical studies, including MRI and electrodiagnostic studies were performed to evaluate the LUE symptoms, but those studies were normal and did not show evidence of a cervical radiculopathy.  Shoulder X-rays on 9 September 2006 noted an old clavicle fracture, but reported as otherwise unremarkable.  The cause of the CI’s symptoms was thought likely to be malunion of the clavicle fracture.  Further surgery was discussed, but it was not thought that it would allow the CI to perform the duties required of a Soldier and he was referred for an MEB.

The range of motion (ROM) evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Right Shoulder ROM
(Degrees)	MEB/PT ~ 3 Mo. Pre-Sep	VA C&P ~ 1 Mo. Post-Sep	
Flexion (180 Normal)	140	80	
Abduction (180)	175	90	
Comments	Painful motion	Limited motion; painful motion	
§4.71a Rating	10%	20%	

According to the MEB NARSUM evaluation on 14 December 2006, 2 months prior to separation, the CI complained of constant shoulder pain.  Shoulder dislocations were not reported.  Physical examination showed a “palpable and visual deformity of left clavicle.”  Shoulder ROM was as indicated in the chart above, with painful motion and the exam was otherwise unremarkable.  At the VA Compensation and Pension (C&P) examination on 19 March 2007, performed a month after separation, the CI reported symptoms of left shoulder pain, stiffness, limited motion, and swelling, with weekly flares weekly that lasted a day or two.  Physical exam showed no, effusion, tenderness, or laxity.  There was swelling of the left clavicle.  Shoulder ROM was limited as indicated in the chart above and motion was painful in all planes of movement.  There was no upper extremity (UE) motor or sensory loss and reflexes were normal.  

At a VA emergency room visit 5 July 2007 for shoulder pain the CI reported increased pain since working overhead putting in air conditioning ducts.  At VA primary care visit 20 July 2007, the CI reported that he had undergone another surgery with placement of hardware in the clavicle again in May 2007.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under an analogous 5003 code (degenerative arthritis), citing “marked and constant” pain IAW the US Army Physical Disability Agency Pain Policy.  The VA also assigned a 20% rating using an analogous 5201 code (limitation of motion of arm) for limitation of arm motion at shoulder level.  The Board reviewed to see if a higher rating than that of the PEB was supported for the shoulder condition with any applicable coding approach.  The 5201 threshold for the next higher rating for the non-dominant UE is arm motion limited “to 25° from side”, and there was no evidence of such limited arm motion in record.  There was no fibrous union, nonunion or other impairment of the humerus or shoulder joint ankylosis to justify a higher rating under the respective codes (5202, 5200).  Although the CI’s was diagnosed with malunion of the clavicle fracture, this warrants a 10% rating under the 5203 code (clavicle/scapula impairment).  Post-separation evidence indicated the CI underwent additional surgery for the clavicle with placement of hardware again shortly after separation, but those records are not available for the Board’s review.  However, whether the surgery was to repair the malunion of the clavicle, or was for nonunion or dislocation of the clavicle, there is no higher rating than 20% available under the 5203 code.  Thus, the Board determined that the evidence supports a 20% rating for the shoulder condition and no higher.  The Board also noted that the PEB’s reliance on the pain policy was not detrimental to arriving at the highest rating and therefore, no change to the PEB’s code is recommended.  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 condition.

BOARD FINDINGS:  In the matter of the left shoulder 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.  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 20140628, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander, US Army Physical Disability Agency (AHRC-00), 2900 Crystal Drive, Suite XXX, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXXXX AR20160007965  (PD201403162)

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: