RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00377
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20071001

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Light Wheel Vehicle Mechanic, medically separated for “chronic right shoulder pain,” with a disability rating of 0%.  

CI CONTENTION:  His shoulder condition has worsened and negatively impacts his daily life.  He was not evaluated for his hearing loss condition.  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 – 20070823	VARD – No Claim	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Shoulder Pain and Subluxations	5099-5003	0%	CI did not submit a VA Claim	
Chronic Left Shoulder Pain and Instability	5099-5003	---%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Right Shoulder Condition.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-hand dominant CI injured his right shoulder approximately 2 years prior to referral for MEB.  An 11 April 2007 right shoulder X-ray showed minimal acromioclavicular (AC) joint space narrowing, no demonstrable dislocation (complete joint disruption requiring reduction/relocation), and was otherwise negative.  The MEB forwarded “bilateral multidirectional shoulder instability with voluntary right shoulder subluxations” for PEB adjudication.  At the 30 April 2007 orthopedic surgery encounter, the CI complained of right shoulder instability since March 2005.  He reported he was trying to catch a tow bar falling from a wrecker and injured his right shoulder.  “He felt a pop; however, does not describe any dislocation and did not need to have his shoulder relocated.”  The right upper extremity was neurovascularly intact and the right shoulder examination revealed no AC joint tenderness, and “good” active range of motion (ROM).  The O’Brien’s (assesses glenoid labrum and AC joint), sulcus (assesses inferior instability), load and shift (assesses anterior and posterior instability) tests were positive.  The Hawkin’s (assesses rotator cuff impingement), Neer’s (assesses rotator cuff impingement), cross arm (assesses AC joint), and apprehension relocation (assesses anterior and posterior instability) tests were negative.  The assessment listed right shoulder multidirectional instability (symptomatic laxity of the glenohumeral joint) and the examiner recommended a physical therapy (PT) consultation to begin periscapular stabilization and rotator cuff strengthening.  

At the 20 June 2007 Family Medicine encounter, the CI complained of right shoulder joint pain, instability, and a clicking sensation.  He denied weakness or catching during movement.  The CI reported intermittent right radicular arm pain with occasional numbness/tingling from the shoulder to fingers.  The right shoulder examination revealed no swelling, erythema (redness), warmth, deformity, atrophy (wasting), tenderness, or AC joint tenderness.  Pain-free active flexion, abduction, adduction, external rotation, and internal rotation ROM were normal.  The Codman (assesses for of the supraspinatus tendon rupture) and apprehension relocation tests were negative.  The assessment listed right shoulder localized joint pain.  A 9 July 2007 right shoulder diagnostic imaging (MRI) study was unremarkable.  At the 13 July 2007 orthopedic surgery encounter, the CI complained of bilateral shoulder instability and discomfort since the 2005 injury.  He reported an ability to voluntarily sublux (incompletely dislocate) his shoulders, particularly when lifting his arms above his shoulders.  The CI denied a history of traumatic dislocations or ligamentous laxity.  The physical examination documented the CI could voluntarily sublux both shoulders upon request and could forward flex his thumb to his forearm (evidence of ligamentous laxity).  The bilateral shoulder examination revealed no AC joint tenderness.  Active ROM was flexion of 180 (180 normal) degrees.  The subscapularis lift-off (assesses rotator cuff subscapularis muscle), scapular winging (medial scapula protrudes from muscle weakness/paralysis), sulcus, load and shift, and apprehension relocation tests were positive.  The drop arm (assesses for rotator cuff tears), Hawkin’s, and Neer’s tests were negative.  Strength was normal (5/5).  The assessment listed bilateral shoulder multidirectional instability and subluxation (incomplete dislocation with spontaneous relocation).  

The MEB NARSUM examination on 3 August 2007, 2 months before separation, the CI complained of right shoulder instability since 2005.  He reported bilateral (R>L) spontaneous shoulder subluxations with abduction, flexion, or rotation, followed by spontaneous replacement.  Following the 2005 injury, the CI progressed to being able to voluntarily sublux the right shoulder and noted gradual increasing dull to sharp 5/10 pain.  Symptoms were exacerbated in the Parade Rest position and with overhead lifting activities.  The PT strengthening and rehabilitation program did not correct the shoulder instability, and surgery was not recommended.  The physical examination documented “Easily removed T-shirt without difficulty or pain.  Upon lifting 25 pound box overhead, right shoulder spontaneously subluxed and was replaced with the CI experiencing pain with grimace.  He voluntarily subluxed the right shoulder at 0° abduction with the subluxed humeral head going posteriorly and downward without noticeable pain or grimace.”  Right shoulder repetitive (X3) active ROM was flexion of 180/180/180 (180), and abduction of 180/180/180 (180) degrees.  There was spontaneous anterior subluxation and spontaneous replacement noted on passive rotational and flexion ROM. The examiner recounted the findings of the right shoulder X-ray and MRI and the 13 July 2007 orthopedic surgery encounter.  The impression listed bilateral multidirectional shoulder instability with voluntary right shoulder subluxations.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating for the right shoulder under an analogous 5003 code (arthritis, degenerative) citing chronic right shoulder pain due to March 2005 injury, multiple subsequent subluxations, no dislocations reported in the health records or on X-ray, generalized joint laxity, permanently service aggravated by joint trauma, and rated for moderate, intermittent pain. Serial examinations documented evidence of generalized ligamentous laxity.  Based upon the proximate examinations, there was no compensable limitation of motion for consideration under 5201 (at shoulder level [90 degrees] is minimum 20% rating).  There was no evidence of scapulohumeral ankylosis to support a rating under 5200 and no evidence of nonunion or malunion of the clavicle or scapula to support a rating under 5203.  While the CI was able to induce voluntary subluxation and relocation of the shoulder, there was no evidence of recurrent dislocations, loss of humeral head, nonunion, fibrous union, or malunion of the humerus, to support a rating under 5202.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  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, coded 5099-5003.  

Left Shoulder Condition.  According to STRs and the MEB NARSUM, the left shoulder condition began approximately 2 months prior to referral for MEB.  At the 30 April 2007 orthopedic surgery encounter, the CI complained of right shoulder instability.  The left upper extremity was neurovascularly intact and the left shoulder examination revealed no deformity, no tenderness, and “full” active ROM.  There was evidence of instability with positive sulcus and load and shift tests. At the 13 July 2007 orthopedic surgery encounter, the CI complained of bilateral shoulder instability and discomfort, and painful catching to the left shoulder.  The CI denied a history of traumatic dislocations.  He reported an ability to voluntarily sublux his shoulders.  The physical examination documented the CI could voluntarily sublux both shoulders and showed evidence of ligamentous laxity in that he could forward flex his thumb to his forearm.  The bilateral shoulder examination revealed no AC joint tenderness.  Active ROM was flexion of 180 (180) degrees.  There was evidence of instability with positive subscapularis lift-off, scapular winging, sulcus, load and shift, and apprehension relocation tests.  The drop arm, Hawkin’s, and Neer’s tests were negative. Strength was normal (5/5).  The assessment listed bilateral shoulder multidirectional instability and subluxation.  In the NARSUM the CI reported bilateral (R>L) spontaneous shoulder subluxations followed by spontaneous replacement.  He denied pain with left shoulder subluxations.  The PT program did not correct the shoulder instability, and surgery was not recommended.  Left shoulder repetitive (X3) active ROM was flexion of 180/180/180 (180), and abduction of 180/180/180 (180) degrees.  There was pain with rotational ROM.  The examiner recounted the findings of the 13 July 2007 orthopedic surgery encounter.  The impression listed bilateral multidirectional shoulder instability with voluntary right shoulder subluxations.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB did not rate the left shoulder under an analogous 5003 code (arthritis, degenerative), citing chronic left shoulder pain and instability, without recorded episode of dislocation or trauma, considered result of generalized joint laxity, existed prior to enlistment, had followed a course of normal progression, without permanent service aggravation, according to accepted medical principles (Rheumatology, Klippel & Dieppe, 2nd Ed, Vol 2, pg 8.51.1-6), and was therefore not compensable.  Serial examinations documented evidence of generalized ligamentous laxity.  Based upon the proximate examinations, there was no compensable limitation of motion for consideration under 5201 (at shoulder level [90 degrees] is minimum 20% rating).  There was no evidence of scapulohumeral ankylosis to support a rating under 5200 and no evidence of nonunion or malunion of the clavicle or scapula to support a rating under 5203.  While the CI was able to induce voluntary subluxation and relocation of the shoulder, there was no evidence of recurrent dislocations, loss of humeral head, nonunion, fibrous union, or malunion of the humerus, to support a rating under 5202.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  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 left shoulder condition, coded 5099-5003.  

BOARD FINDINGS:  In the matter of the right shoulder condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the left shoulder condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Right Shoulder Pain and Subluxations	5099-5003	10%	
Chronic Left Shoulder Pain and Instability	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150601, 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

21 DEC 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160018705 (PD201500377)

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