RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01365
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20031215

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Army Reserve E4, Recruiter Aide, medically separated for “left shoulder partial deltoid tear,” with a disability rating of 20%.  

CI CONTENTION:  The CI contends his conditions warrant a higher rating and continue to affect his daily activities.  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 review of disability ratings assigned 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 or non-compensable.  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 determination 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(s) 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 - 20031103	VARD - 20041115	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Shoulder Partial Deltoid Tear	5303	20%	Status Post Left Shoulder Partial Deltoid Tear	5299-5202	0%	20040818	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Left Shoulder Partial Deltoid Tear.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right hand dominant CI injured his left shoulder in May 2001 during a training accident where he was struck with a heavy object.  Despite treatment including physical therapy, anti-inflammatory treatments, and multiple steroid injections, 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 partial deltoid enterosepsis tear” for PEB adjudication.  

X-rays in June 2001 showed no structural abnormalities, and magnetic resonance imaging (MRI) studies in July 2001 showed a moderate contusion and partial tear of the deltoid muscle at and adjacent to the acromial origin, and rotator cuff tendinitis.  The MEB NARSUM examination on 14 July 2003, 5 months prior to separation, noted complaints of pain with forward flexion and internal rotation posteriorly, and difficulty with heavy lifting activities.  Physical examination showed point tenderness around the left anterior aspect of the acromion in the deltoid region and pain with forward flexion and abduction.  Rotator cuff impingement tests were negative.  

At the 18 August 2004 VA Compensation and Pension (C&P) evaluation, performed 8 months after separation, the CI reported constant pain on a 6/10 scale with weakness, fatigability, and lack of endurance.  He reported no stiffness, swelling, heat, redness, instability, locking, or flare-ups, and no dislocation or recurrent subluxation.  Physical exam showed no objective evidence of painful motion, edema, effusion, instability, or weakness.  There was no guarding or ankylosis and gait was normal.  X-rays showed a normal left shoulder with no significant osseous, joint, or soft tissue abnormality.  The CI did complain of some left deltoid pain with downward pressure of the left arm with the shoulder and arm extended at 90 degrees.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 20%, coded 5303 (group III function:  elevation and abduction of arm).  The VA initially rated the left shoulder condition 0% coded 5299-5202 (analogous to humerus, other impairment), based on the VA C&P examination 8 months after separation, citing no objective evidence of pain on motion.  Two years later, in March 2006, the VA changed the rating to 10% and the code to 5303-5203 (clavicle or scapula, impairment), effective the day after separation, citing clear and unmistakable error but not specifying the reason for the rating increase or code change.  The PEB rated the condition using the VASRD muscle code for the shoulder girdle and arm.  Accordingly, the 5303 Group III code includes rating of injury involving the deltoid.  The non-dominant left shoulder was injured resulting in a partial tear of the deltoid.  The PEB assigned a rating that reflected moderate impairment.  A higher 30% rating would indicate a severe impairment for which there was no evidence.  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 left shoulder condition and IAW VASRD §4.71a/4.73, the panel unanimously recommends no change in the PEB adjudication.  There were 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 20150616, 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 10 May 17

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and 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 USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN

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