RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00646
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070816

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Fire Support Specialist, medically separated for “left shoulder (non-dominant),” with a disability rating of 0%.  

CI CONTENTION.  The CI contends he is still having pain and discomfort in my shoulder and the injury limits his ability to perform duties of his job.  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 - 20070509	VARD - 20070821	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Shoulder (Non-Dominant)	5303	0%	Status Post (S/P) Repair of Traumatic Injury to Left Shoulder with Residual Scar	7804	0%	20070117	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Left Shoulder (Non-Dominant).  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s initial condition began when he dislocated his shoulder in November 2003 during an airborne operation.  In February 2004 he reinjured it again due to a dislocation during another airborne operation.  He underwent a left shoulder arthroscopic surgery in July 2004 to remove excess scar tissue and repair a tear of the cartilaginous rim of the shoulder socket.  A year later, the CI experienced recurrent symptoms of pain and instability.  Diagnostic imaging (MRI with arthrogram) of the left shoulder on 28 April 2006 showed evidence of the bony injury from the prior dislocations (called a Hill-Sachs deformity).  There was a possible tear of the labrum (cartilage rim); however, the radiologist noted the appearance could be due to a biceps anchor and that the imaging appearance was unchanged from an imaging study on 11 May 2004.  The subscapularis tendon appeared thickened but was said to likely represent artifact.  The bony structures were otherwise normal, the tendons were normal, and the bone anchor sutures from the prior surgical repair were intact.  An orthopedic surgery examination on 16 June 2006 noted that the CI had not had any recurrent dislocations since the 2004 surgery but had pain for 1 year.  On examination the shoulder was stable with normal strength.  Despite additional physical therapy he did not improve sufficiently to allow unrestricted duty.  The MEB forwarded “left shoulder instability” for PEB adjudication.  

The MEB NARSUM examination on 17 April 2007, approximately 4 months prior to separation, noted complaints of limited overhead activities and an inability to run, ruck or perform airborne operations because of left shoulder pain.  The range of motion (ROM)  recorded for examination was flexion of 160 degrees after repetition (normal 180).  Abduction was 140 degrees (normal 180).  Strength was mildly decreased and there was mild shoulder muscle atrophy.  At the 18 June 2007 VA Compensation and Pension (C&P) evaluation, performed 2 months before separation, the CI reported constant pain, weakness, stiffness, lack of endurance, fatigability, and pain rated at 3/10 elicited by physical activity and relieved by rest.  He reported he could function without medication and did not have any incapacitating flares.  His functional impairment was described as “just weak”.  On examination there was a well healed scar on the left shoulder which was 13 cm in length and the surface was flush with surrounding skin without keloid formation or adherence to underlying structures.  The left shoulder flexion and abduction were normal and strength was normal.  The examiner noted that there was no detectable alteration in form or function of the right or left shoulders.  The examiner also noted that pain, weakness, lack of endurance, fatigue or incoordination did not impact the shoulder motion after use.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left (non-dominant) shoulder condition 0%, coded 5303 (Group III. Function), citing slight painful motion.  The VA rated the status post (S/P) repair of traumatic injury to left shoulder with residual scar condition 0% coded 7804 (scar(s), unstable or painful), based on the VA C&P examination 2months before separation, citing a lack of objective evidence of painful motion or limited motion and a lack of residual pathology, other than scars.  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 above this level.  Although there was insufficient limitation of motion to support a rating under the 5201 code, Board members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion) and coding 5099 analogous to 5003 (arthritis, degenerative).  There was no malunion or recurrent dislocation of the humerus to justify a rating under the 5202 code (humerus, other impairment of); and no nonunion with loose movement of the clavicle to warrant the next higher 20% rating 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 recommends a disability rating of 10% for the left shoulder condition, coded 5099-5010.  

The Board then deliberated if the scar was separately unfitting and ratable.  The Commander’s statement focused only on the left shoulder condition, there was no mention of the scar interfering with the CI’s ability to function.  The scar was not listed on the NARSUM as not meeting retention standards and was not on the MEB or PEB forms.  There was no mention of the scar by the CI throughout the STR as being painful or tender.  The VA examiner did not note that the scar had any keloid formation or adherence to underlying structures.  There was no mention that Kevlar or rucksack irritated the scar.  The Board adjudged that that there was not a preponderance of evidence that the scar condition caused duty limitations.  The Board concluded therefore that the scar condition could not be recommended for additional disability rating.  

BOARD FINDINGS:  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	
Left Shoulder (Non-Dominant)	5099-5010	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150604, 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 
XXXXXXXXXXXXXXXXXX, AR20170000441 (PD201500646)

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 10% 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