RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00730
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20040529

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E6, Fire Control Man First Class, medically separated for “failed right shoulder arthroscopic assisted sub-acromial decompression for sub-acromial impingement” with a disability rating of 10%.

CI CONTENTION:  Current condition supports a higher rating.  Additional unfitting conditions were not considered.  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.

RATING COMPARISON:

SERVICE PEB - 20040401	VARD - 20040903	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Failed Right Shoulder…Decompression…	5099-5003	10%	S/P Right Shoulder Arthroscopic Surgery…	5099-5024	10%	20040108	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Failed Right Shoulder Decompression.  According to the service treatment record and MEB narrative summary (NARSUM), the right dominant CI was evaluated in November 2002 for long standing right shoulder pain without specific injury, but aggravated by combative training.  Non-surgical treatment, including physical therapy (PT), was unsuccessful.  He underwent surgery on 2 September 2003 for decompression of an impingement, but despite subsequent PT rehabilitation, he was not able to regain full right shoulder function.
The 2 December 2003 MEB NARSUM examination, 6 months prior to separation, noted complaints of right shoulder difficulty with overhead work and sleep.  Physical examination showed the CI in mild distress with right shoulder tenderness and signs of impingement.  Strength was normal and instability absent.  Right shoulder flexion and abduction were both 170 degrees (normal 180) with painful motion.  

At the 8 January 2004 VA Compensation and Pension (C&P) general evaluation, 5 months before separation, the CI reported ongoing right shoulder pain which limited activity.  Physical examination showed right shoulder flexion and abduction to 120 degrees limited by pain; strength was not addressed.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder condition 10%, analogously coded 5099-5003 (arthritis, degenerative).  The VA also rated the right shoulder condition 10%, analogously coded 5099-5024 (tenosynovitis), based on the C&P evaluation, citing painful, limited motion.  The VASRD §4.71a threshold for rating ROM impairment (code 5201, arm limitation of motion) is “at shoulder level” (approximately 90 degrees from the side), and the examinations in evidence did not demonstrate motion limited to this level.  However, there was painful  motion recorded on both the MEB NARSUM and VA examinations to support a 10% rating under the codes 5201, 5203 (clavicle, impairment), 5003, or 5024.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel 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 failed right shoulder decompression condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends 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 20160914, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44

      In accordance with reference (a), I have reviewed the cases listed below and approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN