RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01256
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20030228

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an E4, Helicopter Aircraft Mechanic, medically separated for “anterior posterior tear right shoulder” with a disability rating of 10%.  

CI CONTENTION:  The CI contended for his right 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 - 20030107	VARD - 20030710	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Anterior Posterior Tear, Right Shoulder	5299-5003	10%	Right Shoulder Rotator Cuff Debridement	5299-5203	10%	20030507	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Surgical Residuals, Right Shoulder.  There was a paucity of source clinical notes in the available service treatment record (STR) for this case, and the Board’s recommendation was derived primarily from the Medical Evaluation Board (MEB) narrative summary (NARSUM), core military Disability Evaluation System documents, and probative VA evidence as elaborated below.  The CI developed atraumatic right (dominant) shoulder pain in 2000 (basic training).  Magnetic resonance imaging (MRI) demonstrated a partial rotator cuff tear, and in December 2001 (16 months before separation) he underwent arthroscopic surgical repair.  The pain persisted and a repeat MRI raised “questionable” new findings (a labral tear and/or glenoid avulsion).  There was no STR indication of ligamental injury by history or imaging, nor was there any suggestion of instability, subluxation, or dislocations.  A surgical option was offered and reasonably declined; conservative treatment did not result in sufficient improvement to allow unrestricted duty; and, the CI was referred for a MEB.  The MEB forwarded “anterior posterior tear right shoulder” for PEB adjudication.  The MEB NARSUM examination on 31 October 2001, 4 months before separation, documented that the CI “continued to note pain particularly with any overhead motion.”  The physical examination recorded the absence of atrophy or deformity, “mildly positive” impingement signs, 5/5 strength at the shoulder girdle, and no documentation of instability or apprehension.  Range of motion (ROM) was documented as “full” with pain on resisted abduction, but noted forward flexion to 170 degrees (normal 180, 90 for minimum 20%).  

The 7 May 2003 VA Compensation and Pension (C&P) evaluation, 5 weeks after separation, documented that “the shoulder does not bother him on a daily basis ... [but there is an] ... inability to lift or carry anything above 10-15 pounds.”  The CI reported multiple dislocations that had been self-reduced, but the VA examiner specified, “None of this was noted in the chart.”  The physical examination recorded tenderness of the acromioclavicular joint and posterior shoulder, “no locking,” and did not note any instability or apprehension.  Measured ROM was forward flexion to 155 degrees and abduction to 130 degrees (normal 180, 90 for minimum 20%), specifying painful motion.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder condition 10% analogously coded 5299-5003 (analogous to degenerative arthritis; presumptive error since the prefix is properly 5099) was compliant with VASRD §4.71a criteria for the STR evidence.  The VA rated the right shoulder condition 10% analogously coded 5299-5203 (impairment of clavicle or scapula), based on the VA C&P examination 5 weeks after separation, citing decrease range of motion.  There was no ROM limitation supporting a rating higher than 10%; and, no ankylosis, fracture (nonunion/malunion) or sufficient evidence of recurrent dislocation or instability that would support a rating higher than 10% under any alternate 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 of the right shoulder condition.  

BOARD FINDINGS:  In the matter of the right shoulder 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

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 7 Dec 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:

		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC