RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00431
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20020615

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Tool Issue Custodian, medically separated for “right shoulder stiffness,” with a disability rating of 20%.  

CI CONTENTION:  The CI requests the Board consider all conditions.  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 - 20020124	VARD – 20030702	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder Stiffness following Shoulder Arthroscopy	5201	20%	Status Post Right Shoulder Surgery	5201	NSC	N/A	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:  

Right Shoulder Stiffness following Shoulder Arthroscopy.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right shoulder condition began in 1998 after starting a new weight lifting regimen and then increased after the CI reached for a heavy falling hatch.  The CI was determined to have sustained a right shoulder traction injury with possible rotator cuff injury.  X-rays showed acromioclavicular joint arthrosis with a Type II acromion.  Conservative treatment followed.  The CI complained of radicular type symptoms resulting in a referral to Neurology for evaluation and pain clinic for epidural steroid injections.  Electrodiagnostic studies were negative and radiculopathy was ruled out.   The CI continue to complain of paresthesia’s involving her right hand.  In October 2002, while performing push-ups, the CI re-injured her shoulder.  In May 2001, the CI underwent a right shoulder arthroscopy with subacromial decompression and arthroscopic resection of the lateral aspect of the clavicle (Mumford procedure).  Despite treatment, the right shoulder condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty.  The MEB forwarded “right shoulder stiffness following shoulder arthroscopy” for PEB adjudication.  

The MEB history and physical examination on 12 April 2001, 14 months prior to separation, noted complaints of impingement type symptoms.  Physical examination showed the range of motion charted below as well as deltoid strength of 5/5, positive cross-arm (test for acromioclavicular arthritis pain), with negative apprehension.  The MEB report of medical board examination on 15 August 2001, 10 months prior to separation, noted complaints of tenderness over the anterior portal and pain with range of motion.  Physical examination showed range of motions (listed below), and tenderness to palpation over the anterior portal.  The range of motion (ROM) examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Right Shoulder ROM
(Normal Degrees)	MEB ~14 Mos. Pre-Sep
	MEB ~10 Mos. Pre-Sep
	ORTHO ~8 Mos. Pre-Sep
	
Flexion (180)	180	90	90	
Abduction (180)	160	90	90	
Comments	Tenderness over the acromioclavicular joint	Tenderness to palpation over the anterior portal	Tenderness to palpation at the supraspinatus muscle	
§4.71a Rating	0%	20%	20%	

There was no VA Compensation and Pension (C&P) evaluation in evidence.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder condition 20%, coded 5201 (arm, limitation of motion).  The VA rated the right shoulder condition as not service connected (NSC) coded 5024 (tenosynovitis), citing the CI failed to present for the scheduled VA C&P examination and the  STR was not available for review.  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 highest 30% rating for a non-dominant arm requires motion limited to “25 degrees from side,” but examinations did not reflect this degree of limitation.  There was no fibrous union or nonunion 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 Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right shoulder condition.  

BOARD FINDINGS:  In the matter of the right 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 20150530, with attachments
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 13 Dec 16

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

						XXXXXXXXXXXXXXXXXX	     				  					Assistant General Counsel
					    	(Manpower & Reserve Affairs)