RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03812
BRANCH OF SERVICE:  Army  	SEPARATION DATE:  20050120

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Carpentry and Masonry Specialist, medically separated for “bilateral shoulder pain and instability,” rated 10% left and 10% right, respectively, for a combined disability rating of  20%.  

CI CONTENTION:  The applicant requests the Board 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 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:  

IPEB - Dated 20041119	*No VA Claim	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Shoulder Pain and Instability…	5099-5003	10%	No VA Claim or Rating
	
	5099-5003	10%		
Major Depressive Disorder	Not Unfitting		
Obsessive Compulsive Disorder	Not Unfitting		
Hemorrhoids	Not Unfitting		
Neck Pain	Not Unfitting		
Low back Pain	Not Unfitting		
Other MEB/PEB Conditions x 0 (Not In Scope)		
RATING:  20%	RATING:  N/A	
*As of 20141007, the VA has not received a claim from the CI.

ANALYSIS SUMMARY:  

Bilateral Shoulder Pain and Instability.  The CI had a history of bilateral shoulder laxity prior to entry into Service.  In October 2002 he sustained a left shoulder injury.  He was treated with activity modification, physical therapy and pain medications.  A magnetic resonance imaging study was performed on 11 February 2003 demonstrated a possible labral (tissue lining the shoulder socket) tear.  On 9 October 2003 the CI underwent surgical labral repair.  Post-operatively the CI reported improved left shoulder laxity, continued left shoulder pain and continued right shoulder laxity.  At the narrative summary examination performed 6 months prior to separation the CI reported bilateral shoulder pain and laxity with intermittent left upper extremity numbness and tingling.  The physical examination was significant for decreased left shoulder range of motion (ROM), negative left upper extremity instability and impingement testing; positive left shoulder pain with use; and positive right shoulder instability and apprehension (guarding) testing.  

The goniometric 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.

Shoulder ROM
(Degrees)	Ortho ~8 Mo. Pre-Sep	MEB~6 Mo. Pre-Sep	
	Left	Right	Left	Right	
Flexion (180 Normal)	160	180	160	180	
Abduction (180)	150	175	150	175	
Comments	Pain/instability	Pain	Instability	
§4.71a Rating	10%	10%	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the each shoulder at 10%, coded 5099-5003 (analogous to degenerative arthritis).  Board members agreed that multiple treatment records documented postsurgical left shoulder painful motion and pain with use for a 10% rating. There was no evidence of limitation of motion at shoulder level or other criteria for a higher rating.  Multiple treatment notes also documented right shoulder pain and persistent right shoulder instability for a 10% rating. There was no evidence of recurrent dislocations for a higher rating under VASRD code 5202 (humerus other impairment of).  Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that a combined disability rating of 20% for the bilateral shoulder condition was appropriately recommended in this case. 

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that major depressive disorder, obsessive compulsive disorder, hemorrhoids, neck pain and low back pain were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The conditions were not profiled and were not judged to fail retention standards.  There was minimal performance based evidence from the record that any of these conditions 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 contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the bilateral shoulder condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended major depressive disorder, obsessive compulsive disorder, hemorrhoids, neck pain, and low back pain conditions, the Board unanimously recommends no change from the PEB determinations of not unfitting.  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 20140515, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

28 JUL 2016

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 AR20160009358 (PD201403812)

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
( ) DVA