RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00088
BRANCH OF SERVICE:  marine corps 	SEPARATION DATE:  20040415

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Basic Marine, medically separated for a “type II AC injury with rotator cuff tear” with a disability rating of 10%.   

CI CONTENTION:  “Injury resulted in complex regional pain syndrome which took doctors a few years to diagnose.” 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 - 20030306	VARD – 20031006	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Type II AC Injury with Rotator Cuff Tear, Left Shoulder  (Dominant)	5299-5003	10%	Residuals, Left Rotator Cuff Tear	5202	20%	20030912	
Bone Edema Lateral Aspect of the Clavicle c/w Grade II AC Separation Left Shoulder	 
Cat II					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Type II AC Injury with Rotator Cuff Tear (Left Shoulder, Dominant).  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left shoulder condition began in November 2002 after doing a front shoulder roll in martial arts during basic training.  X-rays of the left AC (acromioclavicular) joint on 13 November 2002 revealed a ligamentous injury with superior displacement of the distal end of the left clavicle in relationship to the acromion process.  Axillary view X-rays on 14 November 2002, ordered a history of a type III AC joint separation, demonstrated the humeral head and glenoid process of the scapula were normal.  At the 14 November 2002 orthopedic clinic appointment, the CI reported he injured his left shoulder in combat skills training.  On examination there was edema, positive cephalic (toward the head-upward) elevation of the clavicle and tenderness to palpation at the AC joint and over the coracoid process.  A treatment plan was discussed with the CI; however, he did not desire surgery.  The CI was seen in the sports medicine clinic on 15 November 2002 where he CI refused surgery and an examination was deferred.  However, another note dated 15 November 2002 indicated the CI had a FAROM (full active range of motion) of the upper and lower extremities without limitations.  Reflexes, strength, and sensation were intact.  Pain was 2/10 (10 being the worst pain) with pain being insidious when sleeping on left shoulder and movements early in the morning.  The examiner noted the CI would likely require ongoing therapy and medical follow-up by clinicians familiar with musculoskeletal ailments, continued physical therapy, and regular use of NSAIDs (nonsteroidal anti-inflammatory drugs) to control inflammation.  

During the 6 December 2002 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported a painful left shoulder.  Physical examination showed the left shoulder was raised and oval shaped approximately 4 cm.  Tenderness to palpation was noted, but not erythema (redness).  The CI was able to raise his left arm to approximately 160 degrees (normal 180).  Magnetic resonance imaging (MRI) on 18 December 2002 revealed findings of a type II acromion process with a neutral position, fluid in and surrounding the AC joint, and bone edema involving the internal aspect of the clavicle consistent with AC joint injury and clavicular bone contusion or microfracture. The rotator cuff was intact without evidence of a tear.  

The 11 February 2003 MEB NARSUM examination, 2 months prior to separation, noted complaints of pain with sleeping and active/passive range of motion (ROM) of the CI’s left arm.  Physical examination showed 2 cm winging of the left scapula.  ROM for flexion was 168 degrees and abduction 155 degrees (180 normal).  Muscle strength was 5/5 flexion and 4+/5 abduction.  There was pain with cross arm testing and painful arc at 160 degrees.  Crepitus (grinding sensation) at the AC joint was noted.  Empty can (to determine supraspinatus impingement or integrity of the muscle and tendon) and Neer testing (to determine subacromial impingement) were normal.  

At the 12 September 2003 VA Compensation and Pension (C&P) evaluation, 5 months after separation, the CI reported he injured his left shoulder, was placed in a sling, and was given no physical therapy.  He reportedly wore the sling until about 2 months prior to the examination.  He reported constant pain rated 3/10 increasing to 8/10 with exacerbation. He took Tylenol (acetaminophen, a pain reliever) as many as six to eight a day and aspirin three to four a day.   The CI stated he “basically was not using his shoulder until he was further evaluated.”  Overhead movement and anterior flexion caused his shoulder to flare-up as did even tying his shoes.  With a flare-up the CI reported he had to stop what he was doing, apply ice, and occasionally would go to bed. He had no dislocation or inflammatory arthritis.  Physical examination showed weakness and stiffness.  There was no swelling, heat, redness or locking.  The AC joint was slightly tender with motion in flexion and adduction and had popping with movement.  There was an obvious drop of the shoulder with the distal end of the clavicle being more prominent.  ROMs were flexion of 135 degrees with pain and abduction of 150 degrees with pain.  There was abnormal movement of the AC joint and the CI favored the shoulder while moving through different positions.  X-rays dated 12 September 2003 were consistent with prior acromioclavicular joint separation of the left shoulder with widening of the left acromioclavicular joint which measured just over 2 cm.  There was evidence of prior injury with ossification or calcification at the level of the distal shaft of the clavicle.  The clavicle was positioned more superior than the acromion.  The glenohumeral joint was intact and no fracture of the humerus was seen.  At a PCC visit on 1 November 2004, 7 months after separation, the CI still had left shoulder pain sometimes and took Norco (hydrocodone, a narcotic, and acetaminophen, a pain reliever) with good control.  He stated he could still perform all activities without problems and denied numbness or loss of sensation in the left arm or hand.  Examination of the left shoulder showed no swelling, positive AC joint separation, and left shoulder “ROM.”  Sensation and strength were normal.  Vicodin (hydrocodone, a narcotic, and acetaminophen, a pain reliever) was prescribed for the pain.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left should condition 10%, coded 5299-5003 (arthritis, degenerative).  The Navy PEB also listed bone edema as a related Category II condition (a condition that contributed to the primary unfitting condition but was not separately ratable).  The impairment from the bone edema was properly subsumed under the overall rating for the left shoulder condition IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  The VA rated the left shoulder condition 20%, coded 5202, (humerus, impairment of), based on the C&P examination 5 months after separation, citing infrequent episodes of dislocation of the scapulohumeral joint with guarding of arm movements only at shoulder level.  

Panel members agreed that a 20% rating using code 5203 (clavicle or scapula, impairment of:  dislocation of) was justified for dislocation of the clavicle (grade II or III depending on the report) and 2 cm winging of the scapula noted at the NARSUM examination.  The ROM examinations demonstrated motion above shoulder level which did not support a higher rating under diagnostic code 5201 (arm limitation of motion).   There was no malunion or recurrent dislocation of the humerus to justify a higher rating under the 5202 code (humerus, other impairment of).  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 type II AC injury, dominant left shoulder condition, coded 5203.  

BOARD FINDINGS:  In the matter of the type II AC injury, dominant left shoulder condition, the panel unanimously recommends a disability rating of 20%, coded 5203 IAW VASRD §4.71a.  There are 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	
Type II AC Left Shoulder Injury	5203	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160212, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve Affairs)
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 13 Oct 17 ICO XXXXXXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 20 Sep 17 ICO XXXXXXXXXXXXXXXXXXX  
	(d) PDBR ltr dtd 28 Sep 17 ICO XXXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 28 Sep 17 ICO XXXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 11 Apr 17 ICO XXXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 16 Jun 17 ICO XXXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 25 Sep 17 ICO XXXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 20 Sep 17 ICO XXXXXXXXXXXXXXXXXXX 

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (i) are approved.  The official records of the following individuals are to be corrected as follows:

     a. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     b. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.

     d. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.

     e. XXXXXXXXXXXXXXXXXXX, former USN: Placement on Temporary Disability Retired List with a 60 percent disability rating for six months at time of separation followed by a permanent disability rating of 20 percent.

     f. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 0 percent) effective date of discharge.

     g. XXXXXXXXXXXXXXXXXXX, former USMC: Placement on Temporary Disability Retired List with a 50 percent disability rating for six months at time of separation followed by a permanent disability rating of 10 percent.

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

     h. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 
     
3.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.

                                  XXXXXXXXXXXXXXXXXXX
                                  Principal Deputy, Assistant Secretary
                                  Of the Navy (Manpower and Reserve Affairs)	
                                  Performing the Duties of Assistant 
                                  Secretary of the Navy 
                                  (Manpower and Reserve Affairs)