RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00797
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20070518

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Machinist Mate, medically separated for “right shoulder dysfunction…,” with a disability rating of 10%.

CI CONTENTION:  The CI contends he was not able to complete a full career in the Navy, due to his shoulder 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 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 - 20070412	VARD - 20081003	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder Dysfunction…	5099-5003	10%	Traumatic Tear, Supraspinatus Tendon, Right Shoulder,
with Hill-Sachs Deformity	5203	0%	20080605	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Right Shoulder Dysfunction.  According to service treatment record and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent right (dominant) shoulder arthroscopic capsular labral reconstruction in October 2006 due to recurrent dislocations.  Following surgery, further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “other joint derangement, not elsewhere classified, shoulder region” for PEB adjudication.  According to the MEB NARSUM evaluation on 15 March 2007, 2 months prior to separation, the CI complained of fatigue causing shoulder pain rated 5/10.  Other than “occasional popping,” shoulder dislocations were denied.  Physical examination showed no evidence of instability (negative sulcus and negative apprehension).  The CI felt pressure within the shoulder but there was a negative Hawkins sign and negative Neer (both tested for rotator cuff impingement).  Right shoulder range of motion (ROM) showed flexion of 160 degrees (normal 180) and abduction was 160 degrees (normal 180); however, painful motion was not addressed.  At the 5 June 2008 VA C&P examination, performed 13 months after separation, the CI reported a flare of shoulder pain every week, lasting 12 hours, and manifested by numbness of the right shoulder after “sleeping on the shoulder the wrong way.”  Physical examination showed no evidence of tenderness or laxity.  Right shoulder flexion was 180 degrees and abduction was 180 degrees without pain or apprehension.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5099-5003 code (degenerative arthritis).  The VA assigned a 0% rating using the 5203 code (impairment of clavicle or scapula), citing no evidence of malunion or nonunion of the clavicle or scapula, or evidence of an additional disability manifested by limitation of motion, or restriction of activity, or functional impairment caused by pain during periods of flare-up, or when the body part is used repeatedly over a period of time.  The VASRD §4.71a threshold for rating for shoulder 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 a 10% rating was justified with application of VASRD §4.59 (painful motion).  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.  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 dysfunction 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 20150602, w/atchs
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 14 Nov 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:

		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXXX, former USN

						  XXXXXXXXXXXXXXXXXXXXX
	     				  Assistant General Counsel
						  (Manpower & Reserve Affairs)