RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02401
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090821

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an E3, Trainee, medically separated for “bilateral shoulder instability and pain” rated 10% each with a combined disability rating of 20%.

CI CONTENTION:  “Review all conditions.”  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 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 - 20090811	No VA claim in evidence	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Shoulder Instability and Pain (Right) 	5099-5003	10%		 	 

Bilateral Shoulder Instability and Pain (Left)	5099-5003	10%					
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:   	

ANALYSIS SUMMARY:  

Right Shoulder Instability and Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-handed CI underwent right shoulder surgery on 8 January 2009 for shoulder instability.  At the time of the orthopedic clinic appointment on 6 April 2009, 3 months after surgery and 5 months prior to separation, the CI reported that his right shoulder felt better, “but the soreness was somewhat bothersome to him.”  On examination he had “near full symmetrical range of motion (ROM),” with tenderness along the posterior glenohumeral joint line.  His motor strength was 5/5 in all directions. 

At the 6 May 2009 physical therapy examination, 4 months before separation, the CI reported “intermittent sharp pain in right shoulder with radiation down into right arm and hand, and upwards into upper back.”  On examination the CI’s flexion after repetition was 156 degrees (normal 180) and his abduction after repetition was 169 degrees (normal 180), with painful motion noted.  The examiner noted painful motion in all planes of movement.  

During the 27 May 2009 MEB examination (recorded on DD Forms 2807 and 2808), 3 months prior to separation, the CI reported that his right shoulder had been swollen and painful since the first dislocation in July 2008 and he could not lift weight with it.  Physical examination showed decreased ROM and pain throughout ROM testing without weakness or deformity.  The examiner did not specify right, left or both. 

The 14 July 2009 MEB NARSUM examination, 1 month before separation, noted complaints of bilateral shoulder instability with pain.  The physical examination noted full symmetric shoulder ROM bilaterally.  The physical therapy measured ROM evaluation noted above was cited.  There was no VA Compensation and Pension examination in record 

Left Shoulder Instability and Pain.  According to STRs and the MEB NARSUM, the CI reported the same symptoms of the left shoulder as the right shoulder before surgery at an orthopedic visit in April 2009 (3 months after the right shoulder surgery), without specific injury.  At the time of the orthopedic clinic appointment on 6 April 2009, 5 months prior to separation, the CI complained of left shoulder pain and crepitus on motion.  On examination he had near full symmetrical ROM and palpable crepitus with testing for labral (cartilage rim of the shoulder) tear.  Left shoulder MRI on 29 April 2009 showed a small labral tear.  

At the 6 May 2009 physical therapy examination, 4 months before separation, showed left shoulder flexion after repetition was 165 degrees (normal 180) and his abduction after repetition was 179 degrees (normal 180), with painful motion.  

During the 27 May 2009 MEB examination (recorded on DD Forms 2807 and 2808), 3 months prior to separation, the CI was noted to have decreased ROM and pain throughout ROM testing without weakness or deformity.  The examiner did not specify right, left or both.  

The 14 July 2009 MEB NARSUM examination, 1 month before separation, noted complaints of shoulder instability and pain.  The symptoms of the left shoulder at the 6 April 2009 orthopedic visit above were noted and the MEB NARSUM examiner indicated that in pre-operative evaluations the CI was unable to do push-ups due to pain and weakness.  The physical examination noted full symmetric shoulder ROM bilaterally.  Exam testing maneuvers were consistent with a labral tear and showed posterior instability of the left shoulder.  The physical therapy measured ROM evaluation noted above was cited.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating for the right shoulder and a 10% rating for the left shoulder, coded 5099-5003 (analogous to degenerative arthritis), citing “satisfactory evidence of painful motion.”  

The relevant clinical evidence for rating both shoulders was similar and therefore the ratings of the shoulders are discussed together.  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 for both shoulders.  Although there was insufficient limitation of motion to support a rating under the 5201 code, panel members agreed that a 10% ratings for the right and left shoulders was justified for painful, limited motion of a single major joint with imaging evidence of pathology under 5099-5003.  
There was no malunion or recurrent dislocation of either humerus to justify a rating under the 5202 code (humerus, other impairment of); and no nonunion with loose movement of the either clavicle to warrant the next higher 20% rating 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 panel concluded that there was insufficient cause to recommend a change in the PEB adjudications for the the right or left shoulder conditions.

Contended PEB Conditions:  Visual Impairment and Pes Planus.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  Neither of the conditions were profiled, implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that either of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for either of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the right and left shoulder instability and pain conditions IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudications.  In the matter of the contended visual impairment and pes planus conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  

The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150828, with attachments
Exhibit B.  Service Treatment Record

AR20170012631, 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