RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01570
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20080211

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Submarine nuclear Propulsion Plant Supervisor-Electrical, Submarine Nuclear Propulsion Plant Operator-Electrical, medically for “bilateral shoulder instability, attention deficit hyperactivity disorder (ADHD), sleep disorder due to pain, right shoulder superior labral tear,” for a combined overall effect (OE), disability rating of 0%.

CI CONTENTION:  The CI contends his bilateral shoulder instability, ADHD, and right shoulder labral tear and seeks a higher rating as indicated by the VA ratings.  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 - 20071109	VARD - 20080317	
Condition	Code	Rating	Condition	Code	Rating	
Bilateral Shoulder Instability	Overall Effect	0%	Left Shoulder Condition	5201	NSC	
Right Shoulder Labral tear			Right Shoulder Labral Tear	5299-5203	10%	
ADHD			Adjustment Disorder w/Anxious Mood	9440	10%	
Sleep Disorder due to Pain			Obstructive Sleep Apnea	6847	Voc rehab*	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

The PEB combined the left and right shoulder instability, right shoulder superior labral tear, ADHD, and sleep disorder due to pain conditions as a single unfitting condition due to overall effect and rated 0%.  The combination of multiple conditions as a single Service disability reflects the PEB’s determination that each condition was not separately unfit, but the functional impairment resulting from the conditions was unfitting.  Fitness determinations are intrinsic to the Services and outside of the scope of the VASRD; therefore, recommendations for separate VASRD codes and ratings can only be rendered if Board members determine by the preponderance of evidence that the condition(s) would have independently resulted in MEB referral and a PEB finding that the member was unfit due to physical disability.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s single overall effect rating was justified in lieu of separate unfit determinations and ratings.  The evidence for the left and right shoulder instability, right shoulder superior labral tear, ADHD, and sleep disorder due to pain conditions are presented separately; with separate fitness determinations and rating recommendations if indicated. 

Right Shoulder Instability.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right shoulder symptoms began approximately in 1998 before enlisting into the Navy and worsened in 2003 without specific injury.  Magnetic resonance imaging (MRI) studies 22 January 2007 showed a SLAP lesion (a tear in the joint lip, or labrum).  A right shoulder arthroscopic SLAP repair surgery was performed in May 2007.  Despite physical therapy treatment, the right shoulder pain and stiffness condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for a MEB.  The MEB forwarded “superior glenoid labrum lesions (SLAP) and other joint derangement, shoulder region” for PEB adjudication.  

At the MEB NARSUM examination on 18 September 2007, 5 months prior to separation, the examiner noted that the CI was unable to lift greater than 10 lbs. or work overhead without developing pain.  Physical examination of his right shoulder showed 180 degrees of forward flexion (normal), 180 degrees of abduction (normal), internal rotation to T7 vertebra and 40 degrees of external rotation.  He had a 1+ sulcus sign test for inferior (downward) instability.  The examiner noted the CI had well-healed arthroscopy portals scars.  There was no shoulder swelling. There was 5/5 motor strength.  Shoulder impingement (Neer impingement sign, Hawkins sign) and capsular laxity (load-and-shift test) tests were negative.  At the 11 February 2008 VA Compensation and Pension (C&P) evaluation, performed 1 day after separation, the CI reported constant soreness and could not do heavy lifting.  Physical examination showed the right shoulder was positioned 2 cm lower than the opposite shoulder.  There was pain on palpation anteriorly.  The right shoulder range of motion (ROM) was noted as forward flexion to 180 degrees, abduction to 170 degrees, external rotation to 90 degrees, internal rotation to T7, adduction 45 degrees, and extension posteriorly to 70 degrees.  All planes of motion were without pain except for internal rotation.  There was no additional loss of joint function because of pain, fatigue, weakness, lack of endurance, or in coordination with repetitive ·motion.  At the time of the family practice clinic appointment on 6 December 2007, the CI reported a sudden onset of increased 8/10 right shoulder pain with no relief with Mobic or the use of a sling.  On examination the CI had normal full range of motion but noted pain with motion.  The Board first considered if the right shoulder instability condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Board members agreed that the preponderance of evidence showed that the functional limitations of the condition contributed to the CI’s inability to perform his military rating, and accordingly a separate disability rating is recommended.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder 0%, and included as part of the OE.  The VA rated the right shoulder condition 10% coded analogously 5299-5203 (Clavicle or scapula, impairment of), based on the VA C&P examination 1 day after separation, citing right shoulder superior labral tear.  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 recommends a disability rating of 10% for the right shoulder instability condition.  

Right Shoulder Superior Labral Tear.  
The Board first considered if the right shoulder labral tear condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The diagnosis of right shoulder labral tear is intrinsic to the right shoulder instability and a separate rating cannot be supported without pyramiding (VASRD §4.14); thus, it is appropriately subsumed in the same rating.

Left Shoulder Instability.  
According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-hand dominant CI’s right shoulder condition symptoms began approximately in 1998 before enlisting into the Navy without specific injury.  MRI studies in July 2007 revealed a small recess in the superior anterior labrum and a large axillary pouch.  No evidence of any rotator cuff tear.  There was a small fraying of his supraspinatus (a rotator cuff muscle) and a normal biceps tendon.  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 “other joint derangement, shoulder region” for PEB adjudication.  

At the physical therapy clinic on 25 June 2007, the examiner recorded that the CI was to have a MRA on left shoulder soon.  On examination the left shoulder was completely normal and without evidence of painful motion.  The MEB NARSUM examination on 18 September 2007, 5 months prior to separation, noted that he was unable to lift greater than 10 lbs. or work overhead without developing pain.  The left shoulder ROM was noted as forward flexion to 180 degrees, abduction to 180 degrees, external rotation to 60 degrees, and internal rotation to T-7 vertebra.  All planes of motion were without pain.  There was no additional loss of joint function because of pain, fatigue, weakness, lack of endurance, or in coordination with repetitive ·motion.    There was no shoulder swelling. The CI had 5/5 motor strength.  Shoulder impingement (Neer impingement sign, Hawkins sign) testing was negative. Capsular laxity (load-and-shift test) testing was a positive load-and-shift test.  At the 11 February 2008 VA Compensation and Pension (C&P) evaluation, performed 1 day after separation, the CI reported constant soreness and could not do heavy lifting.  Physical examination showed no deformity, edema, effusion; increased heat or redness.  There was pain on palpation anteriorly over the short head of the biceps.  The left shoulder ROM was noted as forward flexion  to 180 degrees, abduction to 180 degrees, extension to 90 degrees internal rotation to 90 degrees, external rotation 90 degrees, adduction  to 45 degrees, and extension 70 degrees.  All planes of motion were without pain and there was no additional loss of joint function because of pain, fatigue, weakness, lack of endurance, or incoordination with repetitive motion.  The range of motion (ROM) examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Left Shoulder ROM
(Degrees)	PT 7 Mos Pre-Sep 	MEB ~5 Mos. Pre-Sep
	VA ~1 day. Post-Sep
	
Flexion (180 Normal)	180	180	180	
Abduction (180)	180	180	180 	
Comments	no pain with any motion 		no pain with motion noted	
§4.71a Rating	0%	0%	0%	

The Board first considered if the left shoulder instability condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The Board could not find evidence in the commander’s statement or elsewhere in the STR that indicated any significant interference of left shoulder pain with the performance of duties, nor were any physical findings documented by the MEB or VA examiners which would logically be associated with significant disability.  Therefore, the Board concluded that the preponderance of evidence showed the left shoulder instability condition would not reasonably have caused the CI to be referred into the DES or be found unfit due to the left shoulder instability condition.

Sleep Disorder Due To Pain.  
The Board first considered if the sleep disorder condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The diagnosis of sleep disorder due to pain in his shoulder was intrinsic to the right shoulder instability and a separate rating cannot be supported without pyramiding (VASRD §4.14); thus, it is appropriately subsumed in the same rating.

ADHD.   
The PEB rated the ADHD condition 0%, coded as part of the OE.  The VA rated the Adjustment Disorder With Anxious Mood condition 10% coded 9440 (Chronic adjustment disorder), based on the VA C&P examination 1 day after separation, citing the CI’s mental disorder could cause an occasional decrease in work efficiency or intermittent periods of inability to perform occupational tasks.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), ADHD condition symptoms began before enlisting into the Navy.  After several mental health sessions in July and August 2007 the CI was diagnosed with both ADHD and Adjustment Disorder with anxiety.  Despite treatment, the ADHD 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 as part of his OE.  The MEB forwarded ADHD for PEB adjudication.  At the physical therapy clinic on 25 June 2007, the examiner recorded that the CI had symptoms of anger, general feeling of discouragement, trouble concentrating, and restlessness. He was diagnosed with Adjustment Disorder with anxiety.  The MEB NARSUM addendum examination on 25 October 2007, 4 months prior to separation, reported a longstanding history which predated naval service, of classic symptoms of ADHD.  The CI also reported difficulty finishing tasks and had difficulty getting organized to complete complex tasks.  At times he did not listen when addressed by others, sometimes fidgeted and paced, and was noted to be impatient.  His inattentive symptoms resulted in the CI forgetting appointments or losing things.  His mental status exam was normal.  There were no duty limitations noted that were specifically due to the ADHD.  According to the commander’s statement dated 2 October 2007 the CI could no longer perform his duties as an instructor.  He was not permitted to be on podium instructing students due to the potential risk of injury or harm to a student (assumed due to physical limitations).  The CI’s performance evaluation report for the period 25 October 2006 to 15 November 2007 documented that he was a Dynamic Instructor and that his pleasant and cheerful demeanor made it easy for students to understand and associate with his method of instruction, creating an open atmosphere in the classroom allowing him to successfully impart knowledge to his students.  

The Board first considered if the ADHD condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The Board determined that the evidence did not demonstrate any significant interference of ADHD with the performance of duties, nor were any findings documented by the MEB or VA examiners which would logically be associated with significant disability.  Therefore, the Board concluded that the preponderance of evidence showed the ADHD would not reasonably have caused the CI to be referred into the DES or be found unfit due to the ADHD condition.  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 right shoulder instability condition, coded analogously 5299-5203 (Clavicle or scapula, impairment of).  

BOARD FINDINGS:  In the matter of the right shoulder instability, the Board unanimously determined that it was unfitting and recommends a disability rating of 10% for the right shoulder instability condition, coded analogously 5299-5203 IAW VASRD §4.71a.  In the matter of the left shoulder instability, sleep disorder due to pain, and ADHD, the Board unanimously determined these conditions were not unfitting.  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	
Right Shoulder instability	5299-5203	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150623, 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 31 Jan 17 ICO XXXXXXXXXXXXXXXXXX      
	(c) PDBR ltr dtd 31 Mar 17 ICO XXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 30 Jan 17 ICO XXXXXXXXXXXXXXXXXX 
	(e) PDBR ltr dtd 04 Apr 17 ICO XXXXXXXXXXXXXXXXXX 
	(f) PDBR ltr dtd 31 Jan 17 ICO XXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 30 Jan 17 ICO XXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 27 Feb 17 ICO XXXXXXXXXXXXXXXXXX
      (i) PDBR ltr dtd 17 Jan 17 ICO XXXXXXXXXXXXXXXXXX 

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

     a. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.

     b. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.

     d. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 0 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.

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

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

     h. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.   
     
3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.

	XXXXXXXXXXXXXXXXXX
	Assistant General Counsel
	(Manpower & Reserve Affairs)