RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00647
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040701

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Reserve E3, Combat Engineer, medically separated for “chronic left shoulder pain,” with a disability rating of 0%.

CI CONTENTION:  The CI made no specific contention.  The CI’s complete submission is 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 - 20040512	VARD 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Shoulder Pain	5099-5003	0%	No VA examination in evidence	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  	

ANALYSIS SUMMARY:  

Chronic Left Shoulder Pain.  The CI is right-hand dominant.  According to service treatment record and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left shoulder pain condition began in August 1999 while performing an active training exercise.  Initial imaging studies did not reveal significant bony abnormality and his treatment remained with physical therapy and local injections.  Despite treatment, his pain continued and on 20 November 2002 the CI underwent left shoulder surgery that included a distal clavicular (collar bone) resection and joint stabilization.  Following surgery, further rehabilitative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “left shoulder pain post surgery” for PEB adjudication.  

According to the MEB NARSUM evaluation on 15 March 2004 (4 months prior to separation) the CI’s chief complaint was left shoulder pain.  Physical examination revealed full active range of motion (ROM) of the left shoulder without evidence of instability.  Neuromuscular strength and sensation of the upper extremities was normal and intact.  There was marked tenderness present over the surgical site of the left shoulder and his pain was assessed as “slight” and “occasional.”  There was no comment with regards to painful motion.  His final diagnosis remained unchanged.  

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

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 0%, analogously coded as 5099-5003 (degenerative arthritis), citing arthritis without significant loss of motion.  The VASRD §4.71a minimal threshold for rating a shoulder for ROM impairment (code 5201, arm limitation of motion) is “at shoulder level” (approximately 90 degrees from the side), and the MEB examination in evidence demonstrated motion well above this level.  In the absence of bony malunion or recurrent dislocation of the humerus and no dislocation or nonunion of the clavicle or scapula, there was no justification for a positive impairment rating under the 5202 (humerus, other impairment) or 5203 (clavicle or scapula, impairment) codes.  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 chronic left shoulder pain 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 modification or re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150603, 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

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX, AR20170000445 (PD201500647)

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