RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04213
BRANCH OF SERVICE:  NAVY 	SEPARATION DATE:  20071003

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Systems Organizational Initial Maintenance Technician, medically separated for “subjective right shoulder dysfunction,” with a disability rating of 20%.   

CI CONTENTION:  The CI did not submit a contention.  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on 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(s) at the time of separation.  The panel 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 panel 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 - 20070403	VARD - 20080131	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Subjective Right Shoulder Dysfunction	5201	20%	Status Post Nonunion Right Clavicle Fracture with Residual Scar	5201	30%	20080817	
S/P Right Clavicle Fracture Nonunion Takedown, Open Reduction Internal Fixation (ORIF), and Bone Grafting	Cat II					
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40% 	

ANALYSIS SUMMARY:  

Subjective Right Shoulder Dysfunction.  According to the service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-hand dominant CI underwent right shoulder surgery on 1 June 2006 for right clavicle nonunion surgical repair, to include plate placement and bone graft.  The fracture healed well with a decrease in pain at the fracture site.  During the post-operative course, the CI noted difficulty with right shoulder range of motion (ROM).  There was no further surgical indication and additional conservative treatment did not result in improvement sufficient to allow unrestricted duty.  At the time of the 19 September 2006 Bone and Joint Center clinic appointment, 13 months prior to separation, the CI reported decreased ROM and pain with extreme ROM of his right shoulder.  The examiner recorded that the incision was well healed.  On examination, ROM measurements were recorded as active forward elevation to 85 degrees (normal 180) and abduction to 90 degrees (normal 180).  He had global weakness to his rotator cuff 4+/5.  He was noted to have positive impingement signs and pain with extremes of ROM.  At the 17 October 2006 orthopedic clinic appointment, 12 months prior to separation, the CI reported shoulder pain and decreased ROM despite physical therapy (PT).  He also had some pain at night and with overhead/reaching activities.  The examiner recorded that the CI had a follow-up with the surgeon who stated the fracture was healed.  He noted the surgical site was well healed and not tender to palpation.  On examination there was no atrophy.  ROM measurements were recorded as active forward elevation to 90 degrees (normal 180) and abduction to 90 degrees (normal 180).  Rotator cuff motor strength was reported as 5/5 (normal).  The orthopedic surgeon diagnosed rotator cuff tendinitis and treated the CI with a sub-acromial steroid injection.  During the 15 November 2006 orthopedic clinic appointment, 11 months prior to separation, the CI denied neck pain or radiculopathy.  He had no pain at the fracture site.  The examiner recorded that despite a steroid injection at the previous visit there was no improvement in ROM.  On examination there was minimum atrophy, ROM measurements were recorded as active forward elevation to 90 degrees (normal 180) and abduction to 90 degrees (normal 180).  There was minimum scapular winging (weakness of one of the rotator cuff muscles).  Upper extremity motor strength was reported as 4+/5.  

At the time of the 5 December 2006 neurology clinic appointment, 10 months prior to separation, the CI denied any persistent loss of sensation or paresthesias.  There was no functional weakness in his right hand.  The CI complained of the inability to raise his arm above his head.  He reported no radicular pain.  The examiner noted that the CI would not actively raise his arm past 90 degrees.  The examiner then stated, “However, when I raise the arm above his head and let go he is able to give at least antigravity strength.”  There was no obvious atrophy to the shoulder girdle or upper extremity.  There was no scapular winging.  No fasciculations were noted.  The remainder of upper extremity strength including internal and external rotation, elbow and wrist flexion and extension, and intrinsic hand strength was normal.  The neurologist performed an electrodiagnostic nerve test which showed no evidence of a brachial plexus lesion (group of nerves coming from the neck through the arm pit to the arm) or focal upper extremity nerve lesion.  The neurologist characterized the study as normal.  At the 20 December 2006 orthopedic clinic appointment, 10 months prior to separation, the CI reported pain of 5/10.  On examination there was 4+/5 strength and the shoulder displayed distal neurovascular systems intact.  ROM measurements were recorded as active forward elevation to 90 degrees (normal 180) and abduction to 90 degrees (normal 180).

According to the 11 January 2007 MEB NARSUM evaluation (9 months prior to separation) the examiner noted there was 4+/5 strength.  ROM measurements were recorded as active forward elevation to 90 degrees and abduction to 90 degrees.  Prior to appearing before a Formal PEB the CI presented to PT for documentation of a recent set of ROM measurements in support of his rebuttal and request for a 30% rating.  At the time of that visit 8 June 2007, 4 months prior to separation, the CI reported pain and limited motion.  ROM measurements were recorded as active forward elevation to 50 degrees and abduction to 65 degrees.  

At the 17 August 2008 VA Compensation and Pension (C&P) examination, 10 months after separation, the CI reported stiffness and fatigability and trouble lifting more than 5-10 pounds.  He reported his shoulder pain traveled down the right arm occurred and 6 time(s) per day lasting for one hour each time.   The pain was elicited by physical activity and certain movements or positions with a reported level of 6/10.  At the time of pain he could function without medication.  He stated his condition did not cause incapacitation.  Physical examination showed tenderness and distal right clavicle bony deformity.  There was no edema, effusion, weakness, redness, heat, guarding of movement or subluxation.  ROM measurements were recorded as active forward elevation to 45 degrees (normal 180) and abduction to 90 degrees (normal 180). There was painful motion.  The joint function was additionally limited by pain and weakness on repetitive motion but not additionally limited by fatigue, lack of endurance, or incoordination after repetitive use.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under the 5201 code (limitation of motion of arm), citing limitation of arm movement is to shoulder level only.  The PEB also listed “status post right clavicle fracture nonunion takedown, ORIF, and bone grafting as a related Category II condition (a condition that contributed to the primary unfitting condition but was not separately ratable).  The impairment from the status post right clavicle fracture nonunion takedown, open reduction internal fixation, and bone grafting was properly subsumed under the overall rating for the subjective right shoulder dysfunction condition IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  The VA assigned a 30% rating using the 5201 code (limitation of motion of arm) for limitation of arm motion midway between side and shoulder level based on the C&P evaluation 10 months after separation.  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 limited to this level.  The next higher 30% rating for the dominant arm requires motion limited to “midway between side and shoulder level.” However, the preponderance of examinations proximate to separation did not reflect this degree of limitation.  There was no malunion with marked deformity or frequent episodes of recurrent dislocation of the humerus to justify a higher rating under the 5202 code (humerus, other impairment of), and no higher ratings available under the 5203 code (clavicle or scapula, impairment of).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right shoulder dysfunction condition.  

BOARD FINDINGS:  In the matter of the right shoulder dysfunction condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20141027, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 25 Apr 17

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC 
		- XXXXXXXXXXXXXXXXXX, former USN 
		- XXXXXXXXXXXXXXXXXX, former USN 
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC