RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02320
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040306

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E8, Finance Senior Sergeant, medically separated for “chronic pain, right shoulder,” with a disability rating of 10%.

CI CONTENTION:  “The rating is too low for my condition, and were low ball.”  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 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 - 20031201	VARD - 20040910	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Right Shoulder	5099-5003	10%	S/P GSW Muscle Group III…	5303	40%	20040517	
			S/P GSW Fractured Humerus Right…	5299-5202	20%		
			S/P GSW Muscle Group I	5301	10%		
			Scar, S/P GSW Wound	7804	10%		
			Scar, S/P GSW Surgery	7802	0%		
			Scar, S/P GSW Right Upper Extremity	7802	0%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Chronic Pain, Right Shoulder.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right hand dominant CI had surgery for rod placement in the humerus (the upper arm bone) in November 2002 after suffering a gunshot wound to his chest and right shoulder.  

The 20 October 2003 MEB NARSUM examination, 5 months prior to separation, noted complaints of pain in the right shoulder and right arm.  The CI reported his pain had improved slightly, but he had some numbness and tingling on and off of the right inner fingers (digits 3-5).  Radiographs of the right shoulder in September 2003 demonstrated the presence of several large pieces of metal and multiple tiny metal fragments about the proximal humerus, with a well-healed fracture.  Physical examination showed the presence of pain on abduction of the right shoulder with no swelling or evidence of motor or sensory deficits.  Grip strength was recorded as 5/5 for the bilateral upper extremities. Range of motion (ROM) measurements from a September 2003 orthopedic examination were quoted, with right shoulder flexion to 50 degrees (normal 180) and abduction to 80 degrees (normal 180).  The physical therapy (PT) examination on the same date as the NARSUM examination (20 October 2003) recorded ROM as flexion to 135 degrees and abduction to 135 degrees.

During the 17 May 2004 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported he had occasional mild tenderness of the scar and he was unable to elevate his right arm above the level of the right clavicle due to pain.  He also reported residual tingling and numbness, with mild weakness, in digits 3-5 of the right hand.  The CI indicated that the right arm had no effect on his occupation or usual daily activities except for limited use.  The examiner noted there had been no episodes of dislocation, recurrent subluxation, or inflammatory arthritis.  Physical examination showed forward flexion and abduction to 90 degrees without pain.  Right upper extremity muscle strength was normal with the exception of mild muscle weakness in the right deltoid and right hand.  Radiographs taken that same day showed deformity of the proximal shaft of the humerus secondary from old healed fracture of the proximal shaft of the humerus.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder condition 10%, analogously coded 5003 (arthritis, degenerative).  The VA did not rate the right shoulder pain, but instead assigned an evaluation of 20% coded 5299- 5202 (analogous to impairment of the humerus).

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 examinations in evidence demonstrated motion above this level.    PT ROM recorded 5 months prior to separation noted forward flexion to 135 degrees.  The C&P examination, 2 months after separation recorded 90 degrees of forward flexion.  A review of the STR showed that ROM testing by PT in the 12 months prior to separation were all (5 examinations) in the non-compensable range with the exception of the September 2003 orthopedic examination that recorded 50 degrees of right shoulder flexion.  All panel members agreed there was insufficient evidence to support a rating under the 5201 code for limitation of motion, and agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion) consistent with the PEB determination.  The panel next considered a rating under the 5301 code (muscle group I, elevation of arm above shoulder) since the CI’s shoulder pain was documented as directly related to the gunshot wound.  IAW VASRD 4.56, “a through and through injury with muscle damage shall be evaluated as no less than a moderate injury for each group of muscles damaged.”  Based on the description alone, the 10% criteria was met.  However, based on the clinical evidence and the CI’s reported signs and symptoms, evidence supporting a rating under a muscle code was limited and offered no advantage to the CI.  

The C&P examiner documented no adhesions or tendon damage, no muscle herniation, and no additional limitation of motion due to pain, lack of endurance, weakness, or excess fatigue following repetitive use of right shoulder.  There was no statement made regarding loss of muscle tone or tissue.  Although, the CI complained of limited ability to elevate his right arm above the level of the right clavicle due to pain, this was inconsistent with multiple ROM examinations in the STR, and may represent post separation worsening.  

Panel members agreed there was no path to a higher rating under any of the muscle codes.  The panel also agreed a higher rating under the 5202 code was not warranted since there was no evidence of malunion, nonunion, or dislocation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded there was insufficient cause to recommend a change in the PEB adjudication for the right shoulder condition.  

BOARD FINDINGS:  In the matter of the chronic pain, right shoulder status post surgery for fracture of right humerus condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  There are no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150904, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170012484, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

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