RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01229
BRANCH OF SERVICE:  NAVY 	SEPARATION DATE:  20041006

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Vocalist/Auxiliary Percussionist, medically separated for “impingement syndrome” rated 10% for the left shoulder and 0%, for the right shoulder, with a combined disability rating of 10%.  

CI CONTENTION:  The CI contends the rating be changed for the gastroesophageal reflux disease (GERD).  She also requested a condition not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB) be reviewed.  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 - 20040617	VARD - 20050516	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Impingement Syndrome, [Left Shoulder]	5299-5003	10%	Impingement Syndrome of Left Shoulder	5201	0%	20050414	
Impingement Syndrome, [Right Shoulder]	5299-5003	0%	Impingement Syndrome of Right Shoulder	5201	0%	20050414	
Mild Postoperative Dysphagia	Not Unfitting	GERD, Status Post Laparoscopic Nissen Fundoplication with Mild Postoperative Dysphagia	7346-8210	0%	20050414	
GERD	Not Unfitting					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Impingement Syndrome of the Left and Right Shoulder.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI first reported shoulder pain, left greater than right, in May 2004 without injury or trauma.  X-rays showed a type II acromion with a small anterior spur on the inferior surface of the acromion.  

The 18 May 2004 orthopedic MEB NARSUM addendum, 5 months prior to separation, noted complaints of left greater than right shoulder pain, aggravated by lifting musical instruments and other musical gear.  There were no complaints of dislocation.  Physical examination showed generalized ligamentous laxity in both upper extremities.  Both shoulders had a positive Sulcus sign, indicating inferior subluxation of the glenohumeral joint, and at least grade one anterior and posterior subluxation of the glenohumeral joint.  Neer and Hawkins impingement signs were both positive, but more dramatic on the left than the right.  She had a negative cross arm adduction sign and a negative Speeds test but did have tenderness over the bicipital tendon in the groove over the anterior aspect of the left humerus.  There was no sign of rotator cuff pathology.  Range of motion (ROM) measurements showed each shoulder had flexion of 180 degrees (normal) and abduction of “at least 90 degrees” (normal 180) before experiencing pain.  

Physical therapy (PT) sessions on 24 May and 18 June 2004, documented active ROM of the bilateral shoulders within normal limits and “full AROM” with weakness on external rotation and abduction, with pain on abduction on the left.  At the time of her 24 June 2004 orthopedic clinic appointment, 4 months before separation, she reported left shoulder pain.  Physical examination of the left shoulder revealed no scapular winging and no other obvious abnormalities.  ROM measurements showed flexion of 170 degrees but abduction measurements were not provided.  The examiner noted that internal rotation caused shoulder pain.  

The 24 June 2004 orthopedic summary assessment indicated left shoulder diagnoses of impingement syndrome, bursitis, and multidirectional instability.  Examination of the left shoulder had no scapular winging.  The surgeon documented that the CI had “symmetric ROM, forward flexion to 170 degrees, external rotation to 90, and internal rotation to T7 bilaterally.  Internal rotation causes shoulder pain.”  

At the 14 April 2005 VA Compensation and Pension (C&P) evaluation, 6 months after separation, the CI reported pain in both shoulders, left worse than right.  She had difficulty picking items off of high shelfs and lifting things at home.  Physical examination showed mild tenderness in the left shoulder with no deformity, dislocation, or instability.  The ROM of the shoulders on abduction and flexion was from zero to 160 degrees bilaterally, with mild pain bilaterally with the ROM.  There was no additional loss following repetitive use.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated one shoulder condition 10%, and the other shoulder condition 0%, each coded 5299-5003 (analogous to degenerative arthritis).  Although the PEB findings did not specifically delineate which shoulder was rated at 10% and which one was rated at 0%, it is clear from the language in the MEB NARSUM addendum that the left shoulder was more painful and symptomatic.  The VA rated each shoulder condition 0%, coded 5201 (limitation of motion of the arm), based on the C&P examination 6 months after separation, citing a non-compensable evaluation was assigned because arm motion was not limited at shoulder level.  

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 for each shoulder.  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) for each shoulder condition as documented on the orthopedic addendum and VA examinations.  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 there was insufficient cause to recommend a change in the PEB adjudication (10%) for the left shoulder condition, but recommends a disability rating of 10% for the right shoulder condition, coded 5299-5003.  

Contended PEB Condition:  Mild Postoperative Dysphagia and GERD.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  The contended conditions were not noted on any limited duty instrument.  The 25 May 2004 NARSUM addendum indicated she had mild postoperative symptoms from her Nissen fundoplication (surgery for GERD) which contributed to her dysphagia and questionable regurgitation, which sometimes interfered with her singing.  However, the examiner noted that these symptoms might last up to 6 months to a year after surgery and improve.  The non-medical assessment did not implicate any aspect of singing or vocal performance as interfering with or limiting duty performance.  There was no performance-based evidence from the record that either condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determinations for the either of the contended conditions and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the left shoulder condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the right shoulder condition, the panel unanimously recommends a disability rating of 10%, coded 5299-5003 IAW VASRD §4.71a.  In the matter of the contended mild postoperative dysphagia and GERD conditions, the panel unanimously agrees that it cannot recommend either for additional disability rating.  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	
Impingement Syndrome, Left Shoulder	5299-5003	10%	
Impingement Syndrome, Right Shoulder	5299-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160926, 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 11 Mar 18 ICO XXXXXXXXXXXXXXXXXX 
	 (c) PDBR ltr dtd 11 Mar 18 ICO XXXXXXXXXXXXXXXXXX 
	 (d) PDBR ltr dtd 12 Mar 18 ICO XXXXXXXXXXXXXXXXXX
	 (e) PDBR ltr dtd 11 Mar 18 ICO XXXXXXXXXXXXXXXXXX
	 (f) PDBR ltr dtd 12 Mar 18 ICO XXXXXXXXXXXXXXXXXX

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

     a. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.       

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

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

     d. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 50 percent rating (increased from 10 percent) effective date of discharge.  

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