RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01156
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090723

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Basic Trainee, medically separated for “chronic left shoulder pain,” with a disability rating of 10%.  

CI CONTENTION:  The CI contends his conditions continue to worsen and have also affected his back.  His 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 - 20090611	VARD – No VA Claim	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Shoulder Pain	8519	10%	N/A				
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Chronic Left Shoulder Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-hand dominant CI injured his left shoulder in February 2006 during basic training.  Nerve conduction study on 6 March 2009 showed evidence of a left long thoracic nerve injury with subsequent weakness of the serratus anterior muscles.  Orthopedic consultation on 23 April 2009 diagnosed long thoracic nerve palsy, with an expected recovery of 6 to 12 months.  Despite treatment, the left shoulder condition could not be adequately rehabilitated to meet the physical requirements of his military specialty and the CI was referred for an MEB.  The MEB forwarded “chronic left shoulder pain due to long thoracic nerve injury” for PEB adjudication.  At the time of the 18 May 2009 physical therapy (PT) clinic appointment, for MEB range of motion (ROM) measurements, 2 months prior to separation, the CI reported left shoulder pain and that he was unable to do push-ups, carry heavy weight, or do any activity that involved his upper body.  He reported a 5-6/10 pain level.  The physical examination revealed a flexion ROM of 179 (normal 180) and abduction of 178 (normal 180) with popping.  The examiner noted that there was no swelling, muscle spasms, muscle atrophy, deformities, or scarring.  According to the MEB NARSUM evaluation on 28 May 2009 (2 months prior to separation) the CI complained of shoulder and neck pain that was present every day.  Physical examination showed a prominent “winging” of the left scapula. There was no bony or soft tissue tenderness, ligamentous laxity, guarding, or muscle spasm.  ROM measurements were recorded from the previous PT examination.  There was pain noted during abduction with weakness in the left serratus anterior muscle.  There was no incoordination or lack of endurance noted.  The CI did not file a VA claim.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under 8519 code (long thoracic nerve, paralysis of), rated as moderate.  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), and the examinations in evidence demonstrated motion above this level.  Although there was no limitation of motion to support a rating under the 5201 code, Board members agreed that 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 (clavicle or scapula, impairment of).  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 left shoulder condition.  

BOARD FINDINGS:  In the matter of the chronic left shoulder pain 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 20150610, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160018461 (PD201501156)

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