RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03229
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030401

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Aviation Operations Specialist, medically separated for “post traumatic arthritis left shoulder,” with a disability rating of 0%.

CI CONTENTION:  “Please consider all conditions.”  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 based upon a 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 - 20021230	VARD - 20030708	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Post Traumatic Arthritis Left Shoulder 	5010	0%	Status Post Open Reconstructions x 2, Left Shoulder 	5201	0%	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Post Traumatic Arthritis Left Shoulder.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left shoulder (non-dominant) condition began in January 1996 when he dislocated his left shoulder.  He went to the emergency room and the dislocation was reduced.  Over the next 3 months the CI had several spontaneous dislocations, all reduced spontaneously.  The CI underwent left shoulder surgery in April 1996 for a Bankart repair with capsular shift.  In March 2000 the CI underwent a left shoulder arthroscopy and open revision capsular shift after two additional injuries in February 1998 and January 2000.  Following surgery, further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “post traumatic arthritis, left shoulder, causing constant pain and stiffness” for PEB adjudication.  
At the time of the orthopedic clinic appointment on 18 July 2002, 8 months prior to separation, the CI reported chronic left shoulder pain and intermittent left upper extremity paresthesia.  On examination there was a positive apprehension test (instability) with crepitus at extremes of abduction and external rotation.  The left shoulder range of motion (ROM) following repetitive movement showed flexion of 160 degrees (normal 180) and abduction of 160 degrees (normal 180).  Sensation was intact for the upper extremity.  No further surgery was recommended.  At the MEB examination dated August 2002, 8 months prior to separation, the CI reported left shoulder instability and pain.  Physical examination noted surgical scars and no tenderness to palpation or crepitus.  Apprehension testing was positive (guarding due to the possibility of dislocation).  The neurologic and vascular systems were intact distally.  The MEB NARSUM examination on 4 September 2002, 7 months prior to separation, the CI complained his left shoulder hurt all the time and he could not perform heavy lifting.  The pain increased with overhead activity, lifting over 30-40 pounds, and fully extending the arm.  Physical examination showed well healed surgical scars.  There was no tenderness to palpation or crepitus.  Apprehension test was positive.  Motor strength was 4/5 in the subscapularis and 5/5 on all other testing.  Sensation was intact.  Rotator cuff impingement signs were all negative.  The examiner referenced the 18 July 2002 orthopedic evaluation for ROM.  The CI failed to report for the VA Compensation and Pension (C&P) evaluation scheduled for 3 July 2003.   

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 0%, coded 5010 (arthritis, due to trauma), citing abduction of 135-160 degrees.  The VA rated the left shoulder condition 0% coded 5201 (arm, limitation of motion of), based on the available STR.  The VASRD §4.71a threshold for rating for ROM impairment (code 5201, arm limitation of motion) is “at shoulder level” (approximately 90 degrees from the side), and the examinations in evidence demonstrated motion above this level.  However, Board members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion) and §4.4O (functional loss).  There was no malunion or recurrent dislocation of the humerus and no dislocation or nonunion of the clavicle or scapula to justify a higher rating under the 5202 (humerus, other impairment of) or 5203 (clavicle or scapula, impairment of) codes.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left shoulder condition, coded 5009-5003.  

BOARD FINDINGS:  In the matter of the left shoulder pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  

The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Post Traumatic Arthritis Left Shoulder 	5099-5003	10%	

The following documentary evidence was considered:
Exhibit A.  DD Form 294, dated 20140522, with attachments
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), 

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160017167 (PD201403229)

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, accept the Board’s recommendation to modify the individual’s disability rating to 10% without re-characterization 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:

CF: 
(  ) DoD PDBR
(  ) DVA