RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01808
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090629

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E4, Infantryman, medically separated for “right (non-dominant) shoulder pain,” with a disability rating of 10%.

CI CONTENTION:  The CI did not submit a contention in the application.  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 - 20090306	VARD - None	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right (Non-Dominant) Shoulder Pain…	5099-5003	10%	No VA Examination in Evidence	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Right (Non-Dominant) Shoulder Pain.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right shoulder pain condition began following a shoulder dislocation in August 2007 during combatives.  X-rays dated 7 August 2007 revealed an unremarkable shoulder series.  At a physical therapy visit on 29 August 2007 the CI reported having a labral tear based on magnetic resonance imaging (MRI) at a clinic.  On examination the CI had 100 degrees of flexion and 60 degrees of abduction of the right shoulder.  Physical therapy was commenced and continued for 2 months; however, at an orthopedic visit on 5 November 2007 there were clinical signs of both posterior injury and anterior instability with concurrent inflammation of the subacromial space.  X-rays showed “no significant degenerative changes, bone, or soft tissue apparently identified.”  MRI findings reported at an orthopedic visit on 30 November 2007 revealed an apparent type III SLAP (superior labrum anterior and posterior) tear and an extensive abnormal signal throughout the anterior/superior labrum, as well as a partial detachment of the poster labrum from the glenoid.  On 21 December 2007 the CI underwent right shoulder arthroscopy and had a right shoulder SLAP repair, an infraspinatus rotator cuff repair, a subacromial decompression, and placement of a pain pump.  Postoperative physical therapy was carried out and on 31 January 2008 the CI reported continued pain, but no pain to forward flexion and abduction to 90 degrees.  Despite continued physical therapy right shoulder pain over the biceps persisted.  On 20 June 2008 the CI underwent right shoulder arthroscopy for a failed SLAP repair, which was debrided with suture removal, and an open biceps tenodesis (movement of the long head of the biceps) for biceps tendinitis.  At a physical therapy clinic appointment on 7 July 2008, 11 months prior to separation, the CI reported he continued to have “elevated pain levels.”  The examiner noted there was no swelling, no edema and no erythema of the shoulders and there were well-healed surgical scars.  Right shoulder flexion was 90 degrees (normal 180 degrees) and abduction was 90 degrees (normal 180 degrees).  Pain was elicited by motion of the shoulder at end range of movement.  

In August 2008 the CI reported pain in the biceps area proximally and distally consistent with tenodesis failure.  A pain management specialist assessed the CI’s condition as adhesive capsulitis of the right shoulder secondary to trauma and surgery.  Treatment consisted of Celebrex (celecoxib, a nonsteroidal anti-inflammatory drug (NSAID)) and a Flector (diclofenac epolamine, an NSAID) patch on the right shoulder along with Percocet (oxycodone, a narcotic, and acetaminophen, a pain reliever).  At the end of October 2008 the CI had “a kind of lytic shot of the right shoulder” consisting of Novocaine (procaine, an anesthetic), cortisone (a steroid), and glucose to treat the scarring around the joint with “a pretty good 10 days” afterward.  X-rays of the right shoulder on 4 December 2008 were normal.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “right shoulder pain” for PEB adjudication.

At physical therapy on 8 December 2008, 6 months prior to separation, the examiner recorded MEB range of motion measurements as right shoulder flexion 110 degrees and abduction 115 degrees following repetition and noted the limitation of motion was due to pain/mechanical causes.  During the 17 December 2008 and 9 January 2009 MEB examination (recorded on DD Forms 2807-1 and 2808) 5 months prior to separation, the CI reported a dislocated right shoulder and surgeries on 21 December 2007 and 21 June 2008.  Physical examination showed decreased ROM/deformity left biceps.  

At an orthopedic evaluation on 9 February 2009, 5 months prior to separation, the examiner noted there was no swelling of the shoulder joint, but there was right shoulder joint stiffness, which felt unstable and was able to be dislocated voluntarily.  On examination of the right shoulder there was tenderness with a long head biceps deformity.  Flexion and abduction were “abnormal” with painful motion, laxity, and weakness.  The 27 February 2008 MEB NARSUM examination, 4 months prior to separation, noted complaints that the CI was unable to perform activities as an infantryman.  Physical examination showed well-healed surgical scars.  He was neurovascularly intact distally and had no significant neck pathology and no radicular symptoms.  Right shoulder flexion was 90 degrees and abduction was 90 degrees.  There was no VA examination in evidence proximate to separation

The ROM examinations in evidence which the panel weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Right Shoulder ROM
(Degrees)	PT ~11 Mos. Pre-Sep
	MEB PT ~6 Mos. Pre-Sep
	MEB NARSUM ~4 Mos. Pre-Sep
	
Flexion (180 Normal)	90	110, 110, 110	90	
Abduction (180)	90	115, 115, 115	90	
Comments		Painful motion		
§4.71a Rating	20%	10%	20%	

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right (non-dominant) shoulder pain condition 10%, coded 5099-5003 (arthritis, degenerative), citing painful limitation of motion in a major joint.  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).  The 20% rating for the non-dominant arm requires motion limited to “at shoulder level” and the July 2008 physical therapy and NARSUM examinations reflected this degree of limitation, while the MEB PT examination, performed between the aforementioned examinations, flexion and abduction measurements were relatively close to the shoulder level.  Nevertheless, the MEB NARSUM examination in February 2009 was most proximate to separation and best reflected the CI’s disability at separation.  There was no fibrous union or nonunion of the humerus to justify a higher rating under the 5202 code (humerus, other impairment of), and no higher rating available 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 panel recommends a disability rating of 20% for the right (non-dominant shoulder pain condition, coded 5201.

BOARD FINDINGS:  In the matter of the right (non-dominant) shoulder pain condition, the panel unanimously recommends a disability rating of 20%, coded 5201 IAW VASRD §4.71a.  
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	
Right (Non-Dominant) Shoulder Pain	5201	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150705, w/atchs
Exhibit B.  Service Treatment Record

AR20170009323, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure