RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00106
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060401

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

CI CONTENTION:  The CI contends that she was not evaluated for her head injury.  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 upon a 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 - 20060203	VARD - 20060906	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Shoulder Pain	5099-5003	10%	Left Shoulder Strain	5201-5010	10%	20060531	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Left Shoulder Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent left (non-dominant) shoulder surgery in February 2003 (debridement of a labral tear and repair of a partial rotator cuff tear). After a re-injury, the CI underwent a second shoulder surgery in December 2004 (additional debridement and sub-acromial decompression).  Following surgeries further treatment did not result in improvement sufficient to allow unrestricted duty.  Surgical results were insufficient to allow unrestricted duty and the CI was referred for a MEB.  The MEB forwarded “left shoulder pain” for PEB adjudication.  

At the time of the orthopedic appointment on 8 August 2005, 7 months prior to separation, the CI reported improved posterior shoulder pain.  The range of motion (ROM) examination showed forward flexion to 160 degrees (normal 180, minimum compensable 90) and abduction to 160 degrees (same parameters), with tenderness and signs of painful motion.  There was no post-operative STR evidence of minimum compensable ROM limitation, subluxation, instability or other VASRD ratable features.  

The MEB NARSUM evaluation on 9 January 2006, 3 months prior to separation, the CI complained of pain rated 7-8/10, aggravated by activity and overhead movement.  Shoulder dislocations were not reported.  The physical examination showed no evidence of instability, swelling, redness or warmth.  There was tenderness to palpation, no atrophy, and muscle strength was normal.  The ROM measurements were forward flexion to 110 degrees and abduction to 110 degrees.  

At the 31 May 2006 VA Compensation and Pension (C&P) evaluation, performed 2 months after separation, the CI reported constant pain rated 8/10.  Specific functional limitations were not elaborated; no history of subluxations was noted; and, the CI reported no incapacitation.  The physical examination recorded tenderness and guarding, without indication of instability or impingement.  Measured ROM was normal, but the examiner recorded a 20-degree reduction due to pain with repetition; thus, conceding DeLuca, forward flexion and abduction were each 160 degrees with painful motion.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5003 code (degenerative arthritis), referencing the US Army Physical Disability Agency (USAPDA) Pain Policy; but, was consistent with VASRD §4.71a criteria for the Service evidence.  The VA (based on the C&P findings) assigned a 10% rating under code 5201-5010 (limitation of motion rated as traumatic arthritis [5003]) citing painful motion.  The ROM evidence did not support the minimum compensable rating, except by application of VASRD §4.59 (painful motion).  There was no ankylosis or fracture (nonunion/malunion) that would support a higher rating under any other joint code; and, there was no history of dislocations or findings of instability that would support a higher rating under code 5202 (humerus, other impairment).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left shoulder condition.  

BOARD FINDINGS:  In the matter of the left shoulder condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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 20140412, w/attachments
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

02 DEC 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160017967 (PD201500106)

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