RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01772
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050503

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Trainee, medically separated for “left shoulder instability…,” with a disability rating of 0%.

CI CONTENTION:  His shoulder condition continues to worsen.  He also contends for a condition not identified by either the MEB or PEB.  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 - 20050412	VARD - None	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Shoulder Instability…	5201	0%	No VA Examination in Evidence	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Left Shoulder.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the left hand dominant CI’s left shoulder condition began in November 2004 after performing basic training.  Magnetic resonance imaging (MRI) study was not considered a good one; however, radiographic studies did not reveal any gross anomaly. There was no surgical indication. 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 a MEB.  The MEB forwarded “left shoulder instability” for PEB adjudication.  The range of motion (ROM) evaluations 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 ~4 Mos. Pre-Sep	MEB ~2 Mos. Pre-Sep	PT ~2 Mos. Pre-Sep	
Flexion (180 Normal)	“Full AROM with pain”	120	159,160,160	
Abduction (180)	“	0-180	164,170,170	
Comments	Painful motion	-	Painful motion	
§4.71a Rating	10%	10%	10%	

A physical therapy (PT) exam of the left shoulder, dated 21 January 2005, 3 months before separation, documented motor strength 4/5.  The MEB NARSUM examination on 2 March 2005, 2 months prior to separation, noted complaints of dislocation or popping out of socket.  The physical examination showed a positive sign for instability (apprehension test.)  

There was no VA examination in evidence.  A PT exam of the left shoulder, on 18 March 2005, 2 months prior to separation, noted motion limited by pain and apprehension.  

The Board directed attention to its rating recommendation based on the above evidence.                                                                                                      The PEB rated the left shoulder condition 0%, coded 5201 (arm, limitation of motion), citing 180 degrees of abduction.  There was no VA rating in evidence.  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.  However, 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 and no dislocation or nonunion of the clavicle or scapula to justify a higher rating under the 5202 (humerus, other impairment of) or 5203 (clavicle or scapula, impairment of) codes.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommended a disability rating of 10% for the left shoulder condition, coded 5099-5003.  

BOARD FINDINGS:  In the matter of the left shoulder condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  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	
Left Shoulder Instability	5099-5003	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150701, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB										

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

20 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170001946 (PD201501772)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 10% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:  

CF: 
(  ) DoD PDBR
(  ) DVA