RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01030
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040208

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Hospital Food Service Specialist, medically separated for “left shoulder pain,” with a disability rating of 0%.  

CI CONTENTION:  Contends left shoulder and PTSD conditions.  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 - 20031103	VARD – N/A	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Shoulder Pain	5099-5003	0%	No VA Examination in Evidence	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS: N/A	

ANALYSIS SUMMARY:  

Left Shoulder.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left shoulder condition began in August 2002 (18 months prior to separation) while lifting an automobile transmission.  Radiographic imaging (X-ray) revealed no bony left shoulder abnormalities.  Despite treatment, the left shoulder condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “left shoulder pain” for PEB adjudication.  

At an orthopedic examination in September 2002 (17 months prior to separation), the physical examination showed full range of motion, with crepitus, and a positive test for a rotator cuff injury (O’Brien sign).  An August 2003 (6 months prior to separation) family practice consultation note described a reinjured shoulder, with physical examination findings of tenderness over the anterolateral shoulder (glenohumeral joint), and pain with abduction and internal rotation (‘empty can’ sign) indicative of a rotator cuff injury.  At a physical therapy consultation in September 2003, the CI reported chronic pain, pain with more than 20 push-ups, and with overhead reaching.  Physical examination showed tenderness of left biceps and decreased (4/5) strength of flexion.  Flexion was to 160 degrees and abduction was greater than 110 (normal 180); both with pain.  The examiner suspected a biceps tendon sprain vs a rotator cuff (superior labral) injury.  The MEB NARSUM examination on 8 September 2003 (5 months prior to separation) noted complaints of chronic left shoulder pain.  Physical examination showed a normal neurologic examination, normal strength (flexion/extension), abduction of 180 degrees (normal) and evidence of painful motion.  

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

The Board directed attention to the rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 0%, analogously coded 5099-5003 (degenerative arthritis), citing painful motion and the US Army Physical Disability Agency pain policy.  The Board considered the evidence for a higher rating.  There was evidence of tenderness, crepitation, painful motion and clinical findings of a rotator cuff injury for a 10% rating analogously coded 5299-5201 (tenosynovitis; arm, limitation of motion).  The Board agreed there was no ROM limitation which would achieve a rating higher than 10%.  There was no ankylosis, fracture (nonunion/malunion) or subluxation/instability that would support a higher rating under any other joint code.  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 pain condition, analogously coded 5299-5201.  

BOARD FINDINGS:  In the matter of the left shoulder pain condition, the Board unanimously or majority recommends a disability rating of 10%, coded 5299-5201 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 Pain	5299-5201	10%	

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

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, AR20170001072 (PD201501030)

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