RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02113
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061115

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Infantry, medically separated for “chronic pain and instability, left shoulder” with a disability rating of 10%.

CI CONTENTION:  The CI made no specific contention.  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 - 20061020	VARD - 20070412	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain and Instability Left Shoulder	5099-5003	10%	Left Shoulder Dislocation	5203	20%	20060725	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Pain and Instability Left Shoulder (Left Shoulder).  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left (non- dominant) shoulder condition began on 25 February 2006 during boxing training while undergoing basic training.  The CI endured a blow which dislocated his left shoulder, after which he was taken to the Emergency Room where his anteriorly dislocated humerus, subcoracoid type, of the shoulder was reduced under local anesthesia and an immobilizer was placed.  The CI underwent physical therapy, where he reported one dislocation of his left shoulder 2 years earlier.  During physical therapy sessions he reported an additional episode of dislocating and his left shoulder after falling.  Thereafter, he avoided activities which could cause his shoulder to dislocate, but he still felt pain, grinding, and instability.  In June 2006 magnetic resonance imaging (MRI) showed a possible tear of the anterior labrum with mild tendinosis of the rotator cuff.  At the time of the orthopedic clinic appointment on 20 June 2006, 5 months prior to separation, the CI reported pain with overhead use of his arm with apprehension/instability with external rotation and abduction.  On examination, the CI had a normal muscle bulk and tone about the shoulder girdle with no atrophy noted.  He was neurovascularly intact.  There were positive apprehension (possible instability) and O’Brien’s (superior labrum anterior to posterior functionality) tests.  Range of motion (ROM) measurements were flexion 110 degrees (normal 180) and abduction 120 degrees (normal 180).  Surgery was an option, but the CI refused since he felt it “would not make him 100% mission capable to full his duties.”  The orthopedic surgeon noted that “declining surgery at this point is very reasonable given his status as a basic trainee and the prolonged recovery time in this environment.”  Continued physical therapy was recommended.  Despite further 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 MEB.  The MEB forwarded “chronic left shoulder instability, subluxations” for PEB adjudication.     

During the 22 June 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported his left shoulder had been dislocated in the past.  Physical examination showed painful and limited ROM.  The 18 July 2006 the MEB NARSUM examination, 4 months prior to separation, noted complaints of continued problems with his left shoulder including chronic pain and recurrent dislocations when subjected to any stress.  The CI had a total of about six dislocations of the left shoulder, but he was able to reduce them himself due to laxity of the shoulder ligaments.  Pain was recorded as 4/10 (10 being the worst pain).  Physical examination showed tenderness over the superior and anterior aspect of the left shoulder along with grinding and crepitus with movement.  Pain and discomfort on movement were also noted.  ROM measurements were flexion 130 degrees and abduction 130 degrees.  The examiner’s impression was that the CI had left shoulder chronic subluxation with chronic pain consistent with joint instability of the left shoulder region.  

At the 25 July 2006 VA Compensation and Pension (C&P) examination, 4 months before separation, the right hand dominant CI reported suffering for the prior 5 months from left shoulder pain, which occurred constantly and was localized.  The pain was sharp in nature and was 4/10 in intensity.  The left shoulder pain was elicited by physical activity and relieved by rest.  The CI could function without medication and the condition did not cause incapacitation.  The CI’s functional impairment was listed as loss of motion and difficulty lifting.  Physical examination showed signs of tenderness about the left shoulder and guarding of movement.  Flexion and abduction were 165 degrees each.  DeLuca testing revealed a loss of 8 degrees of motion after repetitive use due to pain, fatigue, weakness, and lack of endurance.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 10%, analogously coded 5099-5003 (arthritis, degenerative), citing the US Army Physical Disability Agency (USAPDA) pain policy.  The VA rated the left shoulder condition 20% coded 5203 (clavicle or scapula, impairment of, non-union of: with loose movement), based on the C&P examination 4 months before separation, citing dislocation of the clavicle or scapula, or nonunion of the clavicle or scapula with loose movement.

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 all probative examinations in evidence demonstrated motion above that level.  Although there was insufficient  limitation of motion to support a rating under the 5201 code, panel members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion).  However, although there was no malunion of the humerus, there was dislocation of the humerus as evidenced by initial X-rays that required reduction under local anesthesia and multiple subsequent dislocations due to ligamentous laxity, which the CI self-reduced.  Panel members discussed a 20% rating using code 5202 (with infrequent episodes, and guarding of movement only at shoulder level) for the CI’s non-dominant arm or a 20% rating using code 5203 (clavicle or scapula, impairment-dislocation), which was less likely since it was a humerus dislocation rather than clavicle or scapula dislocation, was justified for multiple recurrent dislocations of the shoulder in response to any stress as documented by the MEB examiner.  The record is silent on guarding; nevertheless, the CI limited himself from activities that would invoke a shoulder dislocation thereby implying voluntary guarding was taking place, although it was not explicitly addressed by an examiner, but was alluded to as chronic instability.  Furthermore, the CI was given the option for surgery to correct his shoulder instability; however, he refused surgery, a not unreasonable decision, given an uncertain surgical outcome and a possibility of losing his ability to perform in his MOS postoperatively.  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 left shoulder condition, coded 5202.  

BOARD FINDINGS:  In the matter of the chronic pain and instability of the left shoulder condition, the panel unanimously recommends a disability rating of 20%, coded 5202 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	
Chronic Pain and Instability of the Left Shoulder	5202 	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150724, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170011086, 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