RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00932
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20091214

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Security Forces Apprentice, medically separated for “chronic left shoulder pain” with a disability rating of 20%.  

CI CONTENTION:  “Review all conditions.”  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’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 panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’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 panel 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 panel 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 - 20091124	No VA Claim in Evidence	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Shoulder Pain secondary to Labral Tear	5399-5304	20%	NO VA Rating in Evidence	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  	

ANALYSIS SUMMARY:  

Chronic Left (Non-dominant) Shoulder Pain secondary to Labral Tear.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left shoulder condition began in February 2009 after obstacle course training.  Magnetic resonance imaging (MRI) performed in May 2009 showed a left shoulder superior labral tear with extension into the biceps tendon.  There were no rotator cuff tears and no evidence of injury due to shoulder instability.  Surgery was recommended but the CI declined.  

The 14 June 2009 MEB NARSUM examination, 6 months prior to separation, noted complaints of symptomatic labral tear of the non-dominant left shoulder.  
Physical examination showed left shoulder forward flexion of 160 degrees and abduction of 120 degrees (normal 180 for each).  There was tenderness to palpation over the biceps tendon and acromioclavicular joint.  Clinical testing for shoulder joint pathology and biceps tendon injury was positive. There was no evidence of instability.  Rotator cuff strength was graded 4/5.  Physical therapy measured left shoulder ROM on 19 August 2009.  Flexion was 143 degrees and abduction was 61 degrees after three repetitions.  There was no VA disability claim in evidence.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 20%, coded analogously to 5304 (Group IV muscle injury – shoulder rotator cuff muscles), citing chronic left shoulder pain secondary to labral tear.  

The PEB rated the chronic left shoulder pain 20% IAW VASRD §4.73 (muscle injuries) analogous to moderately severe muscle injury and the panel agreed that the shoulder disability could not be characterized as severe for a higher rating under 5304 based on the CI’s overall shoulder ROM and mildly decreased strength at the MEB NARSUM examination.  The panel next reviewed to see if a higher rating was supported with any applicable code IAW VARSD §4.71a (musculoskeletal system).  The 30% rating for limitation of arm motion (5201) for a non-dominant arm requires motion limited to “25 degrees from side,” but the MEB NARSUM and PT examinations did not reflect this degree of limitation.  There was no shoulder ankylosis or impairment of the humerus or to justify a higher rating under the respective codes. (5200, 5202) code, and no higher rating than 20% 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 panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left shoulder condition.  

BOARD FINDINGS:  In the matter of the chronic left shoulder pain condition and IAW VASRD §4.73, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, 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 20150608, with attachments
Exhibit B.  Service Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-00932.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

XXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings