RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01883
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060914

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E1, Trainee, medically separated for “chronic left (non-dominant shoulder pain,” with a disability rating of 0%.

CI CONTENTION:  “Do not have full abilities in left arm.  Shoulder/neck weak.  Was not able/informed of other options for medical.”  The CI’s 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 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 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 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 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 - 20060817	VARD - None	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Shoulder Pain	5099-5003	0%	No VA Examination in Evidence	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

Left (non-dominant) Shoulder Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-handed CI injured her left shoulder in April 2006 after a fall.  Radiographic studies showed a distal clavicle fracture with some angulation and displacement.  She was treated conservatively and completed 3 months of physical therapy (PT).  Conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “left distal clavicle fracture which is now healed...with persistent pain.”  At the MEB examination (recorded on DD Form 2807) dated June 2006, 3 months prior to separation, the CI reported shoulder pain and impaired use of her left arm with the inability to lift or carry over five pounds.  Radiographic studies on showed post traumatic deformity of the distal left clavicle with evidence of bone callus formation.  The clavicle was in anatomic alignment.  The left acromioclavicular joint space interval measured 8 mm (suggestive of a grade I left AC separation).  
The MEB NARSUM examination on 26 June 2006, 3 months prior to separation, noted complaints of pain in the anterolateral aspect of the shoulder with overhead activity and exertion.  Physical examination showed no gross deformity and the clavicle was not elevated.  There was mild tenderness over the acromioclavicular joint but more tenderness over the anterior aspect of the distal clavicle.  There was no crepitus.  Forward flexion was to 180 degrees (180 normal).  Full symmetric range of motion was noted except for internal rotation.  Rotator cuff strength and sensation were both normal.  At the 5 July 2006 PT ROM evaluation, the left shoulder ROM following repetitive movement showed flexion of 165 degrees (normal 180 degrees) and abduction of 153 degrees (normal 180 degrees).  Pain was noted in all planes.  There was no VA Compensation and Pension evaluation proximate to separation in evidence.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 0%, coded 5099-5003 (arthritis, degenerative), citing application of the US Army Physical Disability Agency (USAPDA) pain policy rating for pain slight/occasional.  The CI does not have a VA disability rating.  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, panel members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion).   There was no mal union 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 panel recommends a disability rating of 10% for the left shoulder condition, coded 5099-5003.  

BOARD FINDINGS:  In the matter of the left shoulder condition, the panel unanimously recommends a disability rating of 10%, coded 5099-5003 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	
Left Shoulder Pain	5099-5003	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150708, w/atchs
Exhibit B.  Service Treatment Record

AR20170009236, 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