RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02181
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20020124

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty O3, Infantry, medically separated for “chronic left shoulder pain,” with a disability rating of 0%.

CI CONTENTION:  The left shoulder injury.  The 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 - 20011203	VARD - 20020208	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Shoulder Pain	5099-5003	0%	Bicipital Tendinitis and Mild Ligamentous Instability, Left Shoulder	5024	10%	20011016	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:

Chronic Left Shoulder Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-handed CI’s left shoulder condition began after weight lifting.  He underwent arthroscopic surgery (thermal capsule shrinkage) for instability in March 2001.  The MEB forwarded “left shoulder pain with probable pseudo instability” for PEB adjudication.  During a Physical Therapy examination on 16 August 2001, 5 months prior to separation, the physical examination revealed normal manual muscle testing (5/5) for left shoulder deltoid, eternal rotation and internal rotation.  Range of motion (ROM) of flexion was to 150 degrees and abduction to 170 (both normal 180) with painful motion.  The MEB NARSUM examination on 07 November 2001, 3 months prior to separation, noted complaints of continued post-operative pain with activity.  Physical examination showed no atrophy.  Rotator cuff motor strength was 5/5 with abduction and adduction.  Active ROM was symmetric bilaterally with an ability to touch T6 with abduction, adduction, external rotation and internal rotation.  The left shoulder had positive tests for painful motion and instability (positive Neer, Hawkins, O’Brien’s, Speed, and biceps load, and apprehension testing).  At the 16 October 2001 VA Compensation and Pension (C&P) evaluation, performed 3 months before separation, the CI reported left shoulder pain aggravated when he swung his arm attempting to run, and a pop when he attempted to lift anything; unable to lift objects over 30 pounds and could not perform upper body physical activities.  Physical examination of the left shoulder showed no atrophy, deformity, abnormal movement or weakness.  There was tenderness over the biceps tendon.  ROM was flexion to 180 degrees and abduction to 160 with painful motion.  The physician’s diagnosis was “left shoulder glenoid labral tear and mild ligamentous instability S/P arthroscopic surgery with residuals of pain and bicipital tendonitis.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 0%, analogously coded 5099-5003 (degenerative arthritis), citing the US Army Physical Disability Agency pain policy for minimal/frequent pain.  The VA rated the left shoulder condition 10%, coded 5024 (tenosynovitis), based on the C&P examination 3 months before separation, citing painful motion and slight instability or pseudo-instability.  The VASRD §4.71a threshold for rating for ROM impairment (code 5201, arm limitation of motion) is “at shoulder level,” and the examinations in evidence demonstrated motion above this level.  However there was evidence of painful motion and instability causing functional loss supporting the 10% rating (based on §4.59, §4.40 and §4.45).  There was no malunion or recurrent dislocation of the humerus at the time of separation and no dislocation or nonunion of the clavicle or scapula to justify a higher rating under the 5202 (humerus, other impairment) or 5203 (clavicle or scapula, impairment) codes.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left shoulder condition, coded 5299-5024.

BOARD FINDINGS:  In the matter of the left shoulder condition, the Board unanimously recommends a disability rating of 10%, coded 5299-5024 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 Pain	5299-5024	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150706, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170005398, XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	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