RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01942
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050215

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Military Police, medically separated for “right shoulder injury” with a disability rating of 10%.

CI CONTENTION:  The CI contended both shoulders and back condition.  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 - 20041015	VARD - 20060104	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder Injury	5304	10%	Status Post Right Shoulder Rotator Cuff Repair	5201	20%	20051005	
Chronic LBP	Not Unfitting	Lumbar Spine Osteoarthritis with Degenerative Disc Disease of L4-5	5242	NSC		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Right Shoulder Injury.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right hand dominant CI injured his right shoulder in July 2002 after heavy engaging in unit sports activity.  Radiographic studies showed evidence of a shoulder repair and degenerative arthritis.  The MEB forwarded “chronic right shoulder pain s/p rotator cuff injury with subsequent repair” and “osteoarthritis of the right shoulder” for PEB adjudication.  

DOS 20050215  Date of surgery, June 2003 20 mos pre-sep
Right Shoulder ROM
(Degrees)	PT~16 Mos. Pre-Sep
(20030916) p.291	MEB~5 Mos. Pre-Sep
(20040901) p.37	VA ~8 Mos. Post-Sep
(20051005) p.153	
Flexion (180 Normal)	135	“has full range of motion”	90	
Abduction (180)	55	“	40	
Comments	Pain	Limited by pain	Limited by pain	
§4.71a Rating				

According to the MEB NARSUM evaluation on 1 September 2004 (5 months prior to separation) the examiner noted the CI complained of right shoulder pain that caused his inability to perform his duties.  Shoulder dislocations were not reported.  The physical examination showed no evidence of instability and full range of motion (ROM) limited by pain. 

At the 5 October 2005 VA Compensation and Pension (C&P) evaluation, performed 8 months after separation, the CI reported pain with lifting and laterally stretching his arm.  The physical exam showed ROM limited by pain and decreased abduction.  

The Board directed attention to its rating recommendation based on the above evidence. 

The PEB rated the right shoulder condition 10%, coded 5304 (group IV), citing residual muscle weakness and pain on motion.

The VA rated the right shoulder condition 20% coded 5201 (arm limitation of motion), based on the VA C&P examination 8 months after separation, citing “full forward elevation to 180 degrees and limited  and painful abduction to 90 degrees. 

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 dominant arm requires motion limited to “at shoulder level” and the C&P examination reflected this degree of limitation.  There was no malunion with marked deformity or frequent episodes of recurrent dislocation 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 Board recommends a disability rating of 20% for the right shoulder condition, coded 5201.  

OR

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right shoulder condition.  

Contended PEB Conditions:  Chronic LBP.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the right shoulder condition, the Board unanimously recommends a disability rating of 20%, coded 5201 IAW VASRD §4.71a.  

OR

In the matter of the right shoulder condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  

In the matter of the contended LBP condition, the Board unanimously recommends no change from the PEB determinations as not unfitting.  

Use for dissenting vote:  The single voter for dissent recommended no change / modification / re-characterization and did not elect to submit a minority opinion or The single voter for dissent submitted the appended minority opinion.

There were no other conditions within the Board’s scope of review for consideration.  

The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  (No recommendation chart.)  

OR

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 Injury	5201	20%	
COMBINED	20%	
Voting Options:
1) No Rechat 
2) 5201 @ 20%= Combined 20%
3) #### @ #0% + #### @ #0% = Combined #0%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150714, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	
The Shoulder and Arm
	Rating
	Major	Minor
5200 	Scapulohumeral articulation, ankylosis of:

	Note: The scapula and humerus move as one piece.

		Unfavorable, abduction limited to 25º from side	50	40
		Intermediate between favorable and unfavorable	40	30
		Favorable, abduction to 60°, can reach mouth and head	30	20

5201 	Arm, limitation of motion of:

		To 25° from side	40	30
		Midway between side and shoulder level	30	20
		At shoulder level	20	20

5202 	Humerus, other impairment of:

		Loss of head of (flail shoulder)	80	70
		Nonunion of (false flail joint)	60	50
		Fibrous union of	50	40
		Recurrent dislocation of at scapulohumeral joint.
				With frequent episodes and guarding of 
					all arm movements	30	20
				With infrequent episodes, and guarding of 
					movement only at shoulder level	20	20
		Malunion of:
				Marked deformity	30	20
				Moderate deformity	20	20

5203 	Clavicle or scapula, impairment of:

		Dislocation of	20	20
		Nonunion of:
				With loose movement	20	20
				Without loose movement	10	10
		Malunion of	10	10
		Or rate on impairment of function of contiguous joint.

Appendix A

~90 degrees of abduction is “at shoulder level” (see guidance notes above)
~45 degrees of abduction is “midway between side and shoulder level”

The SCAPULA is composed of:
1.Shoulder blade which rests over the ribs on the back and is stabilized and moved by muscles attached to the thorax – the scapulothoracic articulation  
The scapular blade also serves as the attachment point for muscles that move the arm by attachment to the rotator cuff.
2. Acromion – the bony prominence on top to which the collar bone (clavicle) is attached forming the acromioclavicular joint (AC joint).
3. Coracoid process which is an important attachment point for ligaments.
4. Glenoid fossa – the cup shaped portion into which the ball shaped humeral  head is attached with a flexible joint capsule, the rotator cuff, and muscles / tendons.

Humerus	Acromion	Coracoid Process	Clavicle

	

CLAVICLE - collar bone
Stabilizing strut from the acromion to the upper sternum (sternoclavicular joint).  
Helps maintain orientation of scapula.  
However, the clavicle can be resected with minimal functional impact unless the patient is a gymnast.  Was more important for our ancestral tree living primates.

HUMERUS – upper arm bone
The ball shaped humeral head articulates in the cup shaped glenoid fossa of the scapula.
The joint is most correctly referred to as the glenohumeral joint rather than the shoulder joint.
The glenohumeral joint has the largest range of motion of all joints and is therefore the least stable.   

Key Soft Tissue Concepts
-Joint capsule:  flexible for freedom of motion
-Glenoid labrum: Rim of cartilage around the fossa adding stability to the GH joint
-Rotator cuff: strong sheet shaped tendon attached to the humeral head to which muscles from the scapula attach & produce movement of the humerus in relation to the scapula. 
-Muscles that move the humerus in relation to the scapula: rotator cuff muscles (supraspinatus, infraspinatus, terres min &  subscapularis) and muscles attached directly to the humerus (deltoid, terres maj, coracobrachialis)
-Muscles that move the scapula in relation to the chest (gliding rotation and elevation in a frontal plane, some minimal side to side motion), e.g. rhomboids, trapezius, levator scap., latissimus.
-Muscles attached to both the humerus and scapula / clavicle for combined powerful shoulder girdle motion: pectoralis
-Muscles for combined shoulder / elbow flexion: biceps

Shoulder Motion  (see ROM figures)   
GHJ = glenohumeral joint 
STA = scapulothoracic articulation
Forward flexion: 	All GHJ
Backward extension: 	All GHJ
Internal rotation: 	All GHJ
External rotation: 	All GHJ
Abduction:		Combined GHJ 90° & STA 90° 
Adduction:		Combined GHJ & STA return
With arm level to ground:
     Cross body adduction:   Combined GHJ  >  STA 
     Out and back reach:       Combined GHJ  >> STA 
Upward shrug:    All STA
Downward depress: All STA
Functional motion such as lifting, reaching, pushing, pulling, throwing, push-ups, climbing, pull-ups, ADLs, etc. involved smooth coordinate combined motions.

Shoulder separation

	

DROP v13                                                Enclosure (2) 

Use appropriate chart from the Nine Core Condition Templates

DOS 200#####
Left Hip (Thigh) ROM
(Degrees)	PT ~# Mo. Pre-Sep
(200#####) p.#	MEB ~# Mo. Pre-Sep
(200#####) p.#	VA C&P ~# Mo. Post-Sep
(200#####) p.#	
Flexion (125 Normal)	#	#	#	
Extension (20)	#	#	#	
External Rotation (45)	#	#	#	
Abduction (0-45)	#	#	#	
Adduction (45)	#	#	#	
Comment	AO	AO	AO	
§4.71a Rating	#%	#%	#%	

DOS 200#####
Right Elbow ROM
(Degrees)	PT ~# Mo. Pre-Sep
(200#####) p.#	MEB ~# Mo. Pre-Sep
(200#####) p.#	VA C&P ~# Mo. Post-Sep
(200#####) p.#	
Flexion (145 Normal)	#	#	#	
Extension (0)	#	#	#	
Comment	AO	AO	AO	
§4.71a Rating	#%	#%	#%	

DOS 200#####
Left Wrist ROM
(Degrees)	PT ~# Mo. Pre-Sep
(200#####) p.#	MEB ~# Mo. Pre-Sep
(200#####) p.#	VA C&P ~# Mo. Post-Sep
(200#####) p.#	
Dorsiflexion (70 Normal)	#	#	#	
Palmar Flexion (80)	#	#	#	
Ulnar Deviation (45)	#	#	#	
Radial Deviation (20)	#	#	#	
Comment	AO	AO	AO	
§4.71a Rating	#%	#%	#%	

DOS 200#####
Right Forearm ROM
(Degrees)	PT ~# Mo. Pre-Sep
(200#####) p.#	MEB ~# Mo. Pre-Sep
(200#####) p.#	VA C&P ~# Mo. Post-Sep
(200#####) p.#	
Pronation (80 Normal)	#	#	#	
Supination (85)	#	#	#	
Comment	AO	AO	AO	
§4.71a Rating	#%	#%	#%	

Other Table Examples:  

DOS 200#####
Pulmonary Exam	PT ~# Mo. Pre-Sep
(200#####) p.#	MEB ~# Mo. Pre-Sep
(200#####) p.#	VA C&P ~# Mo. Post-Sep
(200#####) p.#	
FEV1 (% Predicted)	#	#	#	
FEV1/FVC	#	#	#	
Meds				
§4.97 Rating	#%	#%	#%	

DOS 200#####
Right / Left  Hand
(Dominant)	MEB ~# Mo. Pre-Sep
(200#####) p.#	VA C&P ~# Mo. Post-Sep
(200#####) p.#	
Thumb to Fingertips
(Distance, inches)			
Index to Palmar Crease
(Distance, inches)			
Index Extension
(Degrees)			
Middle to Palmar Crease
(Distance, inches)			
Middle Extension
(Degrees)			
Comments	AO	AO	
§4.71a Rating	#%	#%	

DOS 200#####
HEARING	EXAM	MEB  ~5 Mo. Pre Sep	VA C&P ~2 Mo. After Sep	
LEFT EAR	Average Hearing Loss	 dB	 dB	
	Speech Discrimination	%	%	
	Table VI / VIa	  / I	 / I	
RIGHT EAR	Average Hearing  Loss	 dB	 dB	
	Speech Discrimination 	%	%	
	Table VI / VIa	 / I	  /  I	
§4.85 RATING	Table VII	%	%	
(Average hearing loss is the sum of pure tone thresholds at 1000, 2000, 3000, and 4000 Hz divided by four)

Example from case     DOS 200#####
HEARING	EXAM	MEB  ~5 Mo. Pre Sep	VA C&P ~2 Mo. After Sep	
LEFT EAR	Average Hearing Loss	53 dB	48 dB	
	Speech Discrimination	88%	92%	
	Table VI / VIa	II / III	I / II	
RIGHT EAR	Average Hearing  Loss	53 dB	45 dB	
	Speech Discrimination 	88%	94%	
	Table VI / VIa	I / III	I / II	
§4.85 RATING	Table VII	0%	0%	
(Average hearing loss is the sum of pure tone thresholds at 1000, 2000, 3000, and 4000 Hz divided by four)

DROP v13                                                Enclosure (3)

§4.130 Rating:  

70% > Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood 
		1) suicidal ideation 
		2) obsessional rituals which interfere with routine activities
		3) speech intermittently illogical, obscure, or irrelevant
		4) near-continuous panic or depression affecting the ability to function
		independently, appropriately and effectively
		5) impaired impulse control (such as unprovoked irritability with periods of 				violence)
6) spatial disorientation		    7) neglect of personal appearance and hygiene
		8) difficulty in adapting to stressful circumstances (including work or a work like 			setting)
		9) inability to establish and maintain effective relationships

50% > Occupational and social impairment with reduced reliability and productivity
		1) flattened affect
		2) circumstantial, circumlocutory, or stereotyped speech
		3) panic attacks more than once a week
		4) difficulty in understanding complex commands
		5) impairment of short- and long-term memory (e.g., retention of only highly 				learned
		 material, forgetting to complete tasks)
		6) impaired judgment
		7) impaired abstract thinking
		8) disturbances of motivation and mood
		9) difficulty in establishing and maintaining effective work and social 				relationships

30% > Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal)
		1) depressed mood
		2) anxiety
		3) suspiciousness
		4) panic attacks (weekly or less often)
		5) chronic sleep impairment
		6) mild memory loss (such as forgetting names, directions, recent events) 

10%> Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication

DROP v13                                                Enclosure (4)

Awaiting Updates

AR20170015655 , XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.

Sincerely,					      
						      					
Enclosure