RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02564
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070110

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an National Guard E6, Wheeled Vehicle Mechanic, medically separated for “right shoulder pain,” with a disability rating of 10%.  

CI CONTENTION:  The CI attached a five page letter to her application indicating her conditions continue to worsen and negatively impact her daily activities.  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 - 20061206	VARD - 20070912	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder Pain	5099-5003	10%	S/P R Shoulder Arthroscopy	5201	10%	20070501	
			Right Shoulder Scar	7805	0%		
Occasional R Sided Neck Pain	Not Unfitting 	Cervical Spondylosis & Strain	5242-5237	10%		
Occasional Headaches	Not Unfitting	Tension Headaches	8100	30%		
Mild R Facial Numbness/Tingling	Not Unfitting	Right Facial Hypoesthesia	8205	10%		
GERD and Hiatal Hernia	Not Unfitting	GERD/Hiatal Hernia	7346	10%		
Hypothyroidism	Not Unfitting	Hypothyroidism	7903	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:  

Right Shoulder (Dominant).  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s underwent right shoulder surgery in January 2006.  

At the time of the Physical Therapy (PT) clinic appointment on 20 April 2006, 9 months prior to separation, right shoulder range of motion (ROM) was flexion of 120 degrees (normal 180 degrees) and abduction of 65 degrees (normal 180 degrees) with painful motion.  At the 19 June 2006 PT evaluation, 7 months prior to separation, right shoulder ROM was flexion of 136 degrees and abduction of 115 degrees.  At the time of the MEB PT ROM evaluation on 7 November 2006, 3 months prior to separation, right shoulder ROMs were flexion of 104, 141 and 142 degrees on repetition (normal 180 degrees) and abduction of 135, 135, and 135 degrees (normal 180 degrees).  Motion was painful.  That same day (7 November 2006) the MEB NARSUM examination noted complaints of chronic right shoulder pain with decreased ROM.  Daily pain was rated 3-4/10 which increased to 6/10 with cold weather.  The CI reported she avoided repetitive pushing, pulling, overhead use, lifting and throwing.  Physical examination showed pain with motion greater than 90 degrees of flexion and abduction, with no gross muscle atrophy.  The examiner stated “she has good range of motion greater than 90 degrees with pain and stiffness” (no specific end measurements were detailed).  “Good” internal/external rotation was recorded.  Grip strength was 4/5 (slight weakness) on the right and 5/5 on the left.  Biceps strength was 5/5 bilaterally.  Deep tendon reflexes 2+ biceps, trace radial.  There was no muscle atrophy of the upper extremities.  Strength was 3/5 on the right.  The remainder of the physical examination was noted to be normal.  

At the 1 May 2007 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI complained of right shoulder weakness, stiffness, swelling, heat, giving way, lack of endurance and locking.  She denied locking or dislocations.  The CI reported constant pain throughout the day that radiated to the neck, head, upper back, and down the arms.  She reported difficulty performing repetitive lifting and carrying, pushing and pulling and reaching overhead.  Physical examination showed no evidence of edema, effusion, redness, heat, abnormal movement or subluxation.  There was tenderness to palpation of the anterior right shoulder with mild weakness and guarding of movement.  ROM was flexion of 150 degrees (180 normal) with pain at 130 degrees.  Abduction was 140 degrees (normal 180 degrees) with pain at 90 degrees.  The ROM of the right shoulder joint was limited by pain, fatigue, weakness and lack of endurance, but not incoordination following repetitive use with pain having the major functional impact.  There was no additional limitation in degrees after repetitive use.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder condition 10%, coded 5099-5003 (arthritis, degenerative), citing “rated for pain as slight and frequent (likely application of the US Army Physical Disability Agency pain policy).  The VA rated the right shoulder condition 10%, coded 5201 (arm, limitation of motion of), based on the C&P examination 3 months after separation, citing painful and limited motion with flexion of 150 degrees and abduction of 140 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), and the examinations in evidence demonstrated motion above this 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).  There was no malunion or recurrent dislocation of the humerus to justify a rating under the 5202 code (humerus, other impairment of); and no nonunion with loose movement of the 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 adjudication for the right shoulder condition.  

Contended PEB Conditions:  Right Sided Neck Pain, Occasional Headaches, Mild Right Facial Numbness/Tingling, Gastroesophageal Reflux Disease (GERD) and Hiatal Hernia, and Hypothyroidism.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled, implicated in the commander’s statement or judged to fail retention standards.  The CI was evaluated by Neurology on 12 September 2006.  The examiner stated “as far as the neck, pains and the headaches go neither prevent her from functioning within the confines of her job or MOS” and Soldier met retention standards.  There was no performance-based evidence from the record that any 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 any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the right shoulder condition and IAW VASRD §4.59, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended right sided neck pain occasional headaches, mild right facial numbness/tingling, GERD, hiatal hernia and hypothyroidism conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  There were 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 20151122, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170013323, 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.

A copy of this decision has been provided to the counsel you listed on your application, XXXXXXXXXXXXXXXXXXX.

Sincerely,					      
						      					
Enclosure