RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01445
BRANCH OF SERVICE:  Navy	SEPARATION DATE:  20030501

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Steel Worker, medically separated for “recurrent instability, left shoulder” with a disability rating of 10%.

CI CONTENTION:  Current condition supports a higher rating.  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 - 20030313	VARD - 20040803	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Recurrent Instability, Left Shoulder	5299-5003	10%	Left Shoulder Dislocation	5203	10%	20040429	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:

Recurrent Instability, Left Shoulder.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), this right-hand dominant CI underwent left shoulder surgery in June 2001 to tighten the shoulder joint socket following a motor vehicle accident in October 2000.  Following surgery the CI initially recovered, but had another left shoulder injury with subluxation in May 2002.  Additional surgery was not recommended and further treatment did not result in improvement sufficient to allow unrestricted duty.

The 24 September 2002 orthopedic appointment, 7 months before  separation, noted complaints of repetitive left shoulder subluxation (temporary or partial dislocation with movement back into normal joint position), with increasing pain.  The CI indicated he had experienced 4-6 left shoulder subluxations (self-reduced) since the surgery 15 months earlier.  The CI could voluntarily sublux his left shoulder posteriorly.  Physical examination reported left shoulder range of motion (ROM) as flexion and abduction (lifting the arm laterally to the side) at each at 170 degrees (normal 180 for each), with guarding on abduction past 90 degrees.  Testing for impingement (Jobe’s test) was positive.  One test for instability of the shoulder towards the back (posterior load shift) was positive, while another (apprehension test) was negative.

At the 18 October 2002 MEB NARSUM examination, 6 months before separation, the CI reported left shoulder pain rated 4-5/10, with periodic shoulder subluxations that caused numbness and tingling to his left arm when they occurred.  Physical examination revealed “full active ROM” with pain at the extremes of all planes of motion.  The examiner noted 2+ posterior instability (on a scale of 1-3, with 3 being the most unstable; basically, 2+ is a shoulder joint that can be moved to dislocation but returns to proper position when force is removed) and no anterior instability (instability towards the front of the body).  Three tests for instability (Neers, Hawkins, and jerk tests) were positive, while a fourth (apprehension test) was negative.  Neurologic examination was normal.  Radiographic studies revealed minimal osteophyte formation at the inferior glenoid (degenerative changes).  The 11 December 2002 MEB examination (recorded on DD Form 2808) documented left shoulder tenderness and 4/5 weakness.

At the 29 April 2004 VA Compensation and Pension (C&P) examination, performed 12 months after separation, the CI reported continued left shoulder subluxation caused by lifting or moving the arm above shoulder level, with pain caused by subluxation.  Physical examination reported ROM as “anterior abduction” (flexion) at 88 degrees and abduction at 132 degrees (normal 180 for each).  The examiner indicated the CI “would not attempt to move (his arm) past these levels because he was fearful of the shoulder being dislocated.”  The left scapula protruded more than the right with abduction of the arm (‘winging’).  Strength of the left shoulder was reduced by repetitive abduction to 40% less than right shoulder strength.  Radiographic studies revealed a normal left shoulder.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 10%, analogously coded 5299-5003 (degenerative arthritis).  The VA also rated the left shoulder condition 10%, coded 5203 (clavicle or scapula, impairment).

The panel noted the disparity between the orthopedic evaluation (7 months before separation), the MEB NARSUM (6 before separation), and the C&P evaluation (12 months after separation) and carefully reviewed the evidence proximate to separation to determine the probative value of each examination.

The orthopedic evaluation was adjudged to have the highest probative value as it was most specific on testing for instability.  The VASRD §4.71a threshold for rating under the 5202 code (other impairment of the humerus) indicates 20% for recurrent dislocation of the scapulohumeral joint with infrequent episodes and guarding of movement only at shoulder level, which the CI demonstrated at the orthopedic and C&P examinations.  There was no fibrous union or nonunion of the humerus to justify the next higher 40% or 50% rating.  There was likewise no route to a higher rating for limitation of motion (5201), and no higher ratings available under the 5203 code (clavicle or scapula, impairment).

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 20% for the left shoulder instability, coded 5299-5202.

BOARD FINDINGS:  In the matter of the recurrent instability, left shoulder, the panel majority recommends a disability rating of 20%, coded 5299-5202 IAW VASRD §4.71a.  The single voter for dissent recommended no change did not elect to submit a minority opinion.  There were no other conditions within the panel’s scope of review for consideration.  The panel 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	
Recurrent Instability, Left Shoulder	5299-5202	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150615, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 23 May 17 XXXXXXXXXXXXXXXXXX 
	(c) PDBR ltr dtd 26 May 17 XXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 15 Jun 17 XXXXXXXXXXXXXXXXXX 
	(e) PDBR ltr dtd 08 Jun 17 XXXXXXXXXXXXXXXXXX
      (f) PDBR ltr dtd 16 May 17 XXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (f) are approved.  The official records of the following individuals are to be corrected to reflect the stated disposition below:

     a. XXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.

     b. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     d. XXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.

     e. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.   
     
3.  Please ensure all necessary actions are taken to implement these decisions including notification to the former members once those actions are complete.

	XXXXXXXXXXXXXXXXXX
	Acting,