RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00962
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20040331

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Avenger Crewmember, medically separated for “chronic pain right shoulder” with a disability rating of 10%.  

CI CONTENTION:  “Pain level and condition is worsening.  Condition is also causing other health issues.”  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 - 20040226	VARD -  NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain Right Shoulder	5009-5003	10%	No VA Examination Proximate to Separation in Evidence	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Chronic Right Shoulder Pain.  According to the service treatment record) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right (non-dominant) shoulder pain began after a clavicle fracture resulted in a nonunion in 2000.  He underwent right shoulder arthroscopic subacromial decompression and distal clavicle resection in June 2002.  Then in January 2003, he had a right clavicle open reduction and internal fixation (ORIF) with an iliac crest bone graft.  In May 2003 hardware was removed and X-rays showed a well-healed clavicle.  

During the 3 September 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, the CI reported right shoulder pain and numbness, and that he could not raise his right arm over his head or lift heavy weight without severe pain.  Physical examination showed right arm numbness, and range of motion (ROM) testing showed flexion to 70 degrees (normal 180) and abduction to 70 degrees (normal 180).  The examiner noted he “could not get right forearm even level…”  

The 12 December 2003 MEB NARSUM examination, 3 months before separation and 7 months post-ORIF, noted CI complaints of pain aggravated by lifting overhead.  Physical examination showed slight AC joint tenderness with some mild crepitus, but no tenderness over the previous clavicle malunion site.  Right shoulder ROM measurements (active or passive ROM not noted) showed flexion to 160 degrees (normal 180) and abduction to 150 degrees (normal 180).  

At a 12 January 2004 primary care clinic examination, 2 months prior to separation, the CI reported pulsating pain extending from behind the right ear to his fingertips.  Physical examination showed a positive drop arm test (pain with returning from abduction to 90 degrees).  ROM evaluation showed flexion to 89 degrees and abduction to 175 degrees.  There was no VA examination in evidence proximate to separation.  

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), citing the US Army Physical Disability Agency pain policy.  The VASRD §4.71a threshold for rating for ROM impairment (code 5201, arm limitation of motion) is “at shoulder level” (approximately 90 degrees from side).  The panel majority agreed the MEB examination and primary care clinic evaluations both demonstrated ROM at that level and justify a 20% rating for a non-dominant arm.  There was no fibrous union or nonunion of the humerus to justify a higher rating under the 5202 code (humerus, other impairment of), and no higher rating available 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 recommends a disability rating of 20% for the right shoulder condition, coded 5201.  

BOARD FINDINGS:  In the matter of the right shoulder condition, the panel majority recommends a disability rating of 20%, coded 5201 IAW VASRD §4.71a.  The single voter for dissent recommends no change and elected not to submit a minority opinion.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Pain Right Shoulder	5201	20%	

The following documentary evidence was considered:  

Exhibit A.  DD Form 294, received 20160927, w/atchs  
Exhibit B.  Service Treatment Record  

AR20170019688, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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 also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure