RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00765
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061215

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, AH-64 Armament/Electrical/Avionic Systems Repairer, medically separated for “right shoulder injury,” with a disability rating of 0%.

CI CONTENTION:  His condition continues to worsen and impact his daily activities.  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 – 20061129	VARD - 20070619	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder Injury	5099-5003	0%	Residuals, Status Post Trauma, Right Shoulder Injury	5203	20%	20070611	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Right Shoulder Injury.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-hand dominant CI injured his right shoulder in 2006 during the 6th week of basic training.  Physical therapy did not improve his symptoms. Magnetic resonance imaging (MRI) of the right shoulder demonstrated a possible labral injury, for which he underwent an arthroscopic Bankart surgical repair (to reattach and tighten the torn labrum (fibrocartilaginous rim attached around the margin of the glenoid cavity in the scapula (shoulder blade)) and ligaments of the shoulder.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “right shoulder pain status-post arthroscopic Bankart repair” for PEB adjudication.

At the MEB examination (recorded on DD Forms 2807-1 and 2808) dated 31 October 2006 and 9 November 2006, 13 months prior to separation, the CI reported he dislocated [his shoulder] five times in basic combat training, had right arm numbness around the shoulder/forearm, and noted swelling after use with pain.  Examination of the right shoulder was recorded in the MEB NARSUM.  At the NARSUM MEB examination performed on 23 October 2006, almost 2 months prior to separation, the CI reported right shoulder pain which prevented him from performing the physical requirements of basic training, particularly push-ups.  The CI had ROM measurements 0-180 degrees abduction with pain at the extreme ROMs, 45 degrees of adduction, 45 degrees of external rotation, and to T-10 for internal rotation.  He had negative instability with load-shift testing, normal motor function, and no sensory deficits. 

At a VA examination on 11 January 2007 the CI said he had mild pain in the right shoulder post right shoulder rotator cuff surgery, although the MEB noted a Bankart repair, on 8 August 2006.  On examination the CI had mild pain on the superior aspect of the right shoulder with abduction.  An MRI dated 13 February 2007 showed no evidence of a tear of the supraspinatus tendon and there was a small cortical cyst in the region of the humeral tuberosity.  At the 11 June 2007 VA Compensation and Pension (C&P) examination, performed 6 months after separation, the CI reported a right shoulder injury with a constant pulling sensation, worse when he lifted a gallon of milk, and pain of the shoulder with stiffness in the morning, which was worse with forward flexion or abduction greater than 120 degrees.  The CI also reported instability of the right shoulder.  Physical examination showed well healed surgical scars of the right shoulder.  The examiner noted guarding and some instability of the right shoulder.  When the examiner pulled the humerus directly down, there was approximately a 1/2-inch slippage noted.  Forward flexion/abduction was 0-120 degrees with pain, but the CI was able to extend to 145 degrees.  

The range of motion (ROM) evaluations 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
(Degrees)	MEB ~2 Mos. Pre-Sep
	PT ~1 Mos. Pre-Sep
	VA ~6 Mos. Post-Sep
	
Flexion (180 Normal)		142/138/139	0-120	
Abduction (180)	0-180	136/140/142	0-120	
Comments	Pain at ROM extremes; negative instability testing	ROM limited by pain and muscle contracture	Guarding; instability present; pain on motion; no loss of motion with repetition	
§4.71a Rating	0%	10% (PEB 0%)	VA 20%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under the analogous 5099-5003 code (Arthritis, degenerative (hypertrophic or osteoarthritis)), citing the US Army Physical Disability Agency Pain Policy.  The VA assigned a 20% rating for residuals, status post trauma, right shoulder injury under the 5203 code (Clavicle or scapula, impairment of:) for dislocation of the clavicle or scapula, or nonunion of the clavicle or scapula with loose movement.
  
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).  The 20% rating requires motion limited to “at shoulder level” and only the VA examination, 6 months post-separation came close to that level at 120 degrees for both flexion and abduction, whereas the pre-separation examinations were well beyond 90 degrees of flexion and abduction, although no flexion measurement was recorded for MEB NARSUM examination.  Board members discussed whether flexion and abduction to 120 degrees was close enough to 90 degrees to warrant a 20% rating.  However, the VA examination was 6 months after separation and its measurements were disparate from those at the pre-separation examinations without an explanation whether there was an interval injury or whether the limitation of motion was as a result of post-operative mechanical causes or scarring.  There was no supporting medical evidence prior to separation to justify a higher rating under the 5202 code (Humerus, other impairment of:), although the CI did have a half inch of laxity and guarding at the VA C&P examination 6 months post-separation to raise consideration of a 20% rating based on “recurrent dislocation at the scapulohumeral joint with infrequent episodes, and guarding of movement only at shoulder level.” However, there was no evidence for a higher rating using code 5202 in the absence of frequent episodes and guarding of all arm movements.  Furthermore, there was no dislocation of the clavicle or scapula, to warrant a rating using code 5203 code, although an analogous code 5299-5203 warrants consideration (Clavicle or scapula, impairment of: Nonunion of: with loose movement) since the surgical procedure was to repair the torn labrum of the glenoid, which is part of the scapula and there was loose movement marked by a half inch of slippage that supported the CI’s report of shoulder laxity.  IAW VASRD §4.21 not all cases will show all the findings specified, but clearly there is coordination of the rating with impairment of function.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 20% for the right shoulder condition.   

BOARD FINDINGS:  In the matter of the right shoulder injury condition, the Board unanimously or majority recommends a disability rating of 20%, coded 5299-5203 IAW VASRD §4.71a.  The single voter for dissent recommended a 10% rating and elected not to submit a minority opinion.  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	
Right Shoulder Injury Condition	5299-5203	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150602, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170011690, XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and recommended that your percent of disability be increased to 20% but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s record of proceedings and majority recommendation (copy enclosed).  I regret to inform you that I reject the Board’s majority recommendation and accept the Board’s dissent recommendation that your disability rating should be modified to 10%.  There is insufficient justification to support the Board’s recommendation in accordance with Army and Department of Defense regulations.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,

						      					
Enclosure