RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03813
BRANCH OF SERVICE:  Army  	SEPARATION DATE:  20011011	 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E2, Trainee, medically separated for “chronic pain right shoulder,” with a disability rating of 0%.  

CI CONTENTION:  The CI 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:  

SERVICE PEB - Dated 20010821	VARD - 20010716	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder	5099-5003	0%	Right Shoulder S/P Clavicle Fracture and Surgical Repair	5299-5203	10%	20010716 Not Available 	
COMBINED RATING:  0%	COMBINED RATING:  10%	

ANALYSIS SUMMARY: 

Right Shoulder.  During basic training the CI fell directly onto his right shoulder resulting in a mid-collar bone fracture and dislocation.  On 21 February 2001, the CI underwent surgical correction of the fracture/dislocation with instrumentation.  Post-operatively, the CI did well with physical therapy and rehabilitation.  Repeat X-rays revealed a healed fracture.  On 10 May 2001 the previous surgically placed instrumentation was removed because of persistent irritation.  Five weeks after the second surgery, the service treatment record noted no further pain to the clavicle, but rather right shoulder pain.  Additionally, the provider assessed the CI had “failed physical therapy” and recommended an MEB.  At the MEB narrative summary (NARSUM) examination on 26 July 2001 (10 weeks prior to separation), the CI’s chief complaint was chronic right shoulder pain.  “He endorsed pain in the right shoulder which prevents him from doing strenuous physical activity such as pushups, pull-ups, or any heavy repetitive lifting.  He has pain with any weight placed upon the right shoulder.”  The physical examination revealed mild tenderness below the right clavicle.  The adjacent right shoulder was without tenderness or instability and shoulder range of motion (ROM) was completely normal.  There were specific signs of impingement induced pain in the right shoulder.  His final diagnosis was listed as chronic right shoulder pain status post clavicle fracture.  The provider assessed the CI’s pain as slight and occasional.  As previously noted, the missing VA examination performed 10 days prior to the NARSUM had its physical findings documented on the VARD which indicated full but painful motion of the right shoulder. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 0% rating was analogously coded to 5003 (degenerative arthritis) and cited “slight/occasional” pain under the Army’s pain policy.  The VA analogously rated 10% utilizing primary VASRD code 5203 (clavicle impairment) and cited “shoulder impingement.”  Board members first discussed and agreed that the anatomy of the entire shoulder girdle encompasses numerous bones to include the clavicle; therefore, residual findings of the right shoulder were considered in the Board’s final recommendation.  Members then considered that in light of non-compensable shoulder ROM, the evidence of painful motion or impingement within 10 weeks of service separation supported a VASRD impairment level no greater than 10% under the application of either §4.59 or §4.40.  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 right shoulder condition.    

BOARD FINDINGS:  In the matter of the right shoulder condition, the Board unanimously recommends a disability rating of 10%, coded 5299-5203 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 his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Right Shoulder Pain Condition 	5299-5203	10%	
RATING	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140811, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20160009361, 

Dear 

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board's recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.

This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,

Enclosure