RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04270
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080527

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Cavalry Scout, medically separated for “chronic right shoulder pain,” with a disability rating of 10%.  

CI CONTENTION:  “Documented 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 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 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 - 20080211	VARD - 20080805	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Shoulder Pain	5304	10%	Degenerative Changes of the Right Shoulder, Status Post Bankart Repair with Three Faded Scars	5010-5203	10%	20080403	
Anxiety	Not Unfitting	PTSD	9411	10%	20080403	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Chronic Right Shoulder Pain.  According to service treatment record and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent right shoulder surgery in October 2006 to repair a labral tear and stabilize the shoulder.  After surgery he continued to have pain, but the instability resolved.  Despite treatment, the shoulder could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty, so he was referred for an MEB.  The MEB forwarded “right shoulder pain” for PEB adjudication.   

The orthopedic clinic appointment on 19 November 2007 (6 months prior to separation) recorded the CI’s report of occasional pain with extremes of range of motion (ROM).  On examination, there was absent of tenderness to palpation and absence of painful motion.  In addition, sensory and motor exams were normal.  At the MEB examination (recorded on DD Form 2807 and 2808) dated 29 November 2007, the CI reported right shoulder pain with numbness or tingling.  The examiner documented “decreased ROM [range of motion]” in the right shoulder.  At the MEB NARSUM examination 8 January 2008 (4 months prior to separation), the CI noted that his pain increased with overhead lifting and there was nothing that relieved his pain.  The physical exam revealed muscle strength of the right shoulder “slightly less than that of his left.”  There was tenderness to palpation of the right shoulder and ROM was recorded as full.  

At the VA Compensation and Pension (C&P) examination in April 2008 (6 weeks prior before separation) the physical examination of the right shoulder recorded absence of swelling, and no active dislocation.  ROM documented forward flexion and abduction to 180 degrees (180 normal each) with pain and stiffness.  
 
The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating for moderate muscle injury, coded 5304 (intrinsic muscles of the shoulder girdle, stabilization against injury in strong movement).  The VA assigned a 10% rating using an analogous 5203 code (impairment of clavicle or scapula) for functional loss IAW 4.40. The PEB noted the condition had 2 cardinal signs of muscle injury (fatigue pain and slight loss of strength).  The higher rating of 20% was not justified since there was no evidence of muscle atrophy, or any objective evidence of severe disability.  The Board considered all applicable coding options and noted the condition was not compensable under any code related to limitation of motion, or dislocation, or malunion.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded there was insufficient evidence to recommend a change from the PEB’s adjudication of the right shoulder condition.

Contended PEB Conditions:  Anxiety Disorder.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  
In the matter of the right shoulder pain condition and IAW VASRD §4.73, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended anxiety conditions, the Board unanimously recommends no change from the PEB determination as 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 20141111, w/atchs
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), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXX, AR20160011615 (PD201404270)

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