RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX		CASE:  PD-2015-00043
BRANCH OF SERVICE:  Army 		SEPARATION DATE:  20061101

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4, Information Technology Specialist, medically separated for a “chronic left [non-dominant] shoulder pain” with a disability rating of 0%.

CI CONTENTION:  His condition continues to worsen.  His 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 - 20060809	VARD - 20070821	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left (Non-Dominant) Shoulder Pain	5099-5003	0%	Left Shoulder Superior Labrum Anterior and Posterior Lesion	5201-5024	10%	20070717	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:

Left Shoulder.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI injured his shoulder after a roller blading accident in 2002.  Diagnostic imaging (MRI) in December 2002 and April 2005 documented a superior labral tear (SLAP tear).  Electrophysiologic studies in May 2006 showed no evidence of radiculopathy (nerve damage) of the left upper extremity.  The CI declined surgery.  Therapy did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic left (non-dominant) shoulder pain” for PEB adjudication.

At the MEB examination in 26 January 2006 (9 months pre-separation), the CI reported pain, popping, and limited shoulder range of motion (ROM).  Physical examination showed ROM of abduction to 55 degrees (normal 180) with pain.  At a physical therapy visit dated 13 April 2006 (7 months pre-separation), revealed ROM of flexion to 135 degrees (normal 180) and abduction to 105 degrees with pain.  At the MEB orthopedic NARSUM examination dated 19 April 2006 (6 months pre-separation), the CI reported debilitating pain limiting his function as a soldier.  The physical examination showed shoulder tenderness without muscular atrophy or instability.  Physical examination showed ROM of flexion to 60 degrees and abduction also to 60 degrees with pain.

At the VA (C&P) examination dated 17 July 2007, (9 months post-separation), the CI reported pain and stiffness on awakening, weakness when lifting to shoulder level, giving way, lack of endurance, locking and fatigability.  Physical examination showed shoulder tenderness with guarding on external rotation without instability.  ROM was flexion to 140 degrees and abduction to 130 degrees with painful motion during repetition without additional limitations.  Radiographic imaging (X-ray) showed no additional bony, soft tissue, or joint abnormalities.

The Board directed attention to the rating recommendation based on the above evidence.  The PEB rated the left shoulder 0%, analogously coded 5099-5003 (degenerative arthritis) citing the US Army Physical Disability Agency (USAPDA) pain policy rated for pain minimal/occasional.  The VA rated the left shoulder condition 10%, analogously coded 5201-5024 (arm, limitation of motion-tenosynovitis) based on the C&P examination 8 months after separation, citing limitation of motion.

The Board deliberated the examinations in evidence, and concluded that the aforementioned STR examinations (MEB NARSUM, physical therapy, and orthopedics) reflect a 20% shoulder rating, coded 5201 (arm, limitation of motion) at the time of separation.  There was no evidence of a ROM that was limited “to 25 degrees from the side” for the non-dominate shoulder to support a higher rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the left shoulder condition coded analogously as 5201-5024 (arm, limitation of motion; tenosynovitis).

BOARD FINDINGS:  In the matter of the chronic left shoulder pain condition and IAW VASRD §4.71a, the Board unanimously recommends a 20% rating, coded 5201-5024.  There were no other conditions within the Board’s scope of review for consideration.  T

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	
Chronic Left (Non-Dominant) Shoulder Pain	5201-5024	20%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150114, 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 XXXXXXXXXXXXXXXXXXXXX, AR20160018798   (PD201500043)

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 20% 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