RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00304
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080830

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Metal Worker, medically separated for “right dominant shoulder dislocation” with a disability rating of 20%.

CI CONTENTION:  “Did not include PTSD. Condition has worsened since discharge.” 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 - 20080603	VARD - 20150116	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Dominant Shoulder Dislocation	5202	20%	Right Labral Tear Including Slap	5202	30%	20141027	
			Right Labral Tear including SLAP with Painful Motion	5201-5019	10%	20141027	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Right Dominant Shoulder Dislocation.  According to the service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-hand dominant CI initially injured his right shoulder in 2003 prior to enlistment as the result of a snowboarding accident.  Subsequently, he was able to pass the military enlistment physical (MEPS) to enter active duty service in March 2005.  In April 2005 during basic training, the CI dislocated his right shoulder during a grenade throwing exercise.  He completed training, however in October 2005, he dislocated his right shoulder again.  After a closed reduction, he experienced four more dislocations but recovered sufficiently to deploy to Iraq in July 2006.  During this deployment, he suffered approximately nine anterior dislocations of his right shoulder.  Although his right shoulder became progressively weaker and more painful, the CI completed the Iraq tour, redeploying in June 2007.  An MRI (arthrogram) performed on 21 February 2008 showed a torn anterior/inferior labrum (cartilage rim of shoulder) and a sub-acute Hill-Sachs lesion (injury to the head of the humerus due to dislocations).  At the 29 February 2008 orthopedics evaluation, 6 months before separation, the CI reported greater than a dozen right shoulder dislocations.  The most recent dislocation had occurred on 3 February 2008, the CI reported that while throwing a ping pong ball, he felt his shoulder pop out.  Physical examination showed shoulder range of motion (ROM) described as forward flexion of “about 100 degrees” with positive testing for instability (positive sulcus test and pain with abduction and external rotation).  There was tenderness to palpation (TTP) of the shoulder and painful motion with all ROM.  The Ci was offered surgery to stabilize the shoulder, but he opted for a permanent profile.  

At the 7 April 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported recurrent right shoulder dislocations with pain on lifting or doing exercises.  Physical examination showed tenderness with right shoulder ROM.  The 29 April 2008 MEB NARSUM examination, 4 months prior to separation, noted complaints of right shoulder pain and recurrent dislocations, the most recent dislocation in the last 3 months.  The CI reported pain exacerbations were caused by abduction of the arm once, by lifting five pounds of weight once, performing five pushups, carrying 20 pounds or any throwing motion.  Pain during flare-ups (occurring daily) was described as sharp.  Pain was alleviated with rest and ice, attempting to reduce his own shoulder, or going to the Acute Care clinic if he was unable to reduce it.  Following a dislocation the pain would take 3-4 days to return to baseline.  The CI reported he overcompensated for his right shoulder by using his left shoulder for most activities of daily living, including lifting his child, throwing any object, dressing himself or reaching overhead.  Physical examination showed marked TTP over the anterior shoulder.  There was minimal muscle spasm noted, with normal muscle bulk.  Sensation and reflexes were normal.  Ligamentous laxity was noted in the glenohumeral joint and testing for instability was positive. Shoulder ROM after three repetitions was forward flexion of 90 degrees and abduction of 114 degrees, with painful motion.  The examiner noted that ROM was limited in all planes of motion, especially with overhead motion and became, successively more limited with successive trials (positive DeLuca).  

At the 27 October 2014 VA Compensation and Pension (C&P) evaluation, performed over 6 years after separation, the CI reported chronic right shoulder pain and inability to raise his right arm above 90 degrees.  The CI had not had any surgery on the right shoulder.  Physical examination showed localized tenderness about the right shoulder.  The CI used no brace or assistive device.  There examiner noted a history of frequent dislocations and guarding of movements only at shoulder level.  Muscle strength testing was 4/5 in abduction and flexion (active movement against some resistance) with normal reflexes and sensation.  Shoulder ROM was flexion and abduction, both 95 degrees, with painful motion.  Shoulder MRI performed on 2 June 2014 showed supraspinatus tendinopathy and degenerated anterior labrum, most likely torn and a healed Bankart lesion (injury from dislocation).  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder dislocation 20%, coded 5202 (humerus impairment of), citing infrequent dislocations of the scapulohumerus joint.  The PEB determined the condition existed prior to service (EPTS) with permanent service aggravation and an undetermined EPTS factor.  In addition, the PEB combined the right shoulder Hill-Sachs lesion (additional right shoulder condition referred by the MEB) with the right dominant shoulder dislocation condition.  The Hill-Sachs lesion was a consequence of the shoulder dislocations and both conditions referred to the same disability and cannot be separated as to their fitness and disability effects.  The panel therefore supports this combination as appropriate under VASRD §4.14 (avoidance of pyramiding).  The VA rated the right dominant shoulder dislocation 30% coded 5202 (humerus impairment of), based on the remote C&P examination over 6 years after separation, citing recurrent dislocation of the scapulohumeral joint with frequent episodes and guarding of all arm movements.  

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.  The C&P examination performed more than 6 years after separation, was well beyond the panel’s normal 12 month window for consideration, and provided no probative information for the panel’s rating recommendation at separation.  

There were 15 or more right shoulder dislocations documented from April 2005 to approximately February 2008, 3 months before the NARSUM and 7 months before separation.  Additionally, at the MEB NARSUM examination, the CI reported frequent exacerbations of right shoulder pain, at times relieved by reducing his own shoulder and that he relied on his left shoulder for most routine daily activities.  A 30% rating is supported based on “frequent episodes of recurrent dislocation of the dominant upper extremity with guarding of all arm movements” under 5202.  There was no fibrous union, nonunion or loss of the head of the humerus for a higher rating under 5202.  There was no evidence of dominant arm limitation of motion midway between the side and shoulder level (5201) and there was no ankylosis (5200) for higher rating with these codes.  There was therefore no higher rating than 30% available with any alternative VASRD code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.7 (higher of two ratings) and VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the right dominant shoulder dislocation condition, coded 5202.  

BOARD FINDINGS:  In the matter of the right dominant shoulder dislocation condition, the panel unanimously recommends a disability rating of 30%, coded 5202 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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Dominant Shoulder Dislocation	5202	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160524, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170015259, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,					      
Enclosure