RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX 	CASE:  PD-2016-01351
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20040612

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Infantry Gun Crew and Seamanship Specialist, medically separated for “secondary left shoulder impingement” and “syncope,” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  Requested review of left shoulder and additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 – 20040309	VARD - 20040623	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Shoulder Impingement	5024-5003	10%	Impingement Syndrome of Left Shoulder (Non-Dominant)  	5201	20%	20040405	
Syncope	8299-8210	10%	Syncope	8210-6204	10%	20040405	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Left Shoulder Impingement.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the right-dominant CI was first seen for left shoulder pain on 12 August 2003 for several months without specific antecedent trauma.  He was thought to have a possible rotator cuff injury and referred for physical therapy (PT), where range of motion (ROM) measurements showed flexion limited to 90 degrees and abduction to 60 degrees (normal 180 for both) and signs of impingement.  He continued PT without pain resolution. 

The 19 December 2003 MEB NARSUM examination, 6 months prior to separation, noted a history of multi-directional instability with secondary impingement.  The physical examination was thought to be consistent with impingement likely attributed to micro-instability.  Specific testing for instability was normal and a referenced MRI (not in evidence) was normal.  During the 13 January 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months before separation, the CI reported shoulder pain.  The physical examination was significant for a tender shoulder with reduced ROM (not quantified). 

At the 5 April 2004 VA Compensation and Pension (C&P) evaluation, 2 months before separation, the CI reported that he had been diagnosed with an impingement syndrome.  The physical examination showed flexion of 120 degrees and abduction of 90 degrees with painful motion. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder impingement condition 10%, analogously coded 5024-5003 (tenosynovitis-arthritis, degenerative).  The VA rated the left shoulder condition 20%, coded 5201 (arm, limitation of motion of), based on the C&P examination, citing limitation of arm motion midway between side and shoulder level or for limitation of arm motion at shoulder level.  Panel members noted that the two ROM measurements in evidence prior to separation supported a 20% rating, but no higher, for limited motion of the non-dominant arm under code 5201.  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 left shoulder condition, coded 5201.  

Syncope.  According to the STR, the CI initially had an episode of syncope (fainting) in 1993 accompanied by chest pain and palpitations, and was thought to have dehydration for which he was treated.  On a periodic examination on 7 August 2002, the CI denied a history of LOC or fainting.  On 12 December 2002, he experienced syncope associated with chest pain and palpitations while swimming, and was taken to the emergency room (ER) with little memory of the episode.  The evaluation was unremarkable and he was placed on limited duty until cleared by cardiology.  In primary care on 6 January 2003, the CI recalled another syncopal episode while aboard a ship when he was looking up a ladder.  Review of the STR showed that he fell down a ladder on 11 July 2001 and had a laceration to the chin which required sutures.  There was no loss of consciousness (LOC) with this event and no other similar episode was found in the record.  At the cardiology evaluation on 6 January 2003, the CI recounted the December 2002 episode and one 10 years earlier, but the ship board incident was not reported.  The physical examination was normal.  On 14 January 2003, the CI was taken by ambulance to the ER after he “passed out” while waxing a floor.  His evaluation was unremarkable and documentation from the ambulance crew was not in evidence.  Subsequent testing, which included a tilt table test, stress test, Holter monitoring, and echocardiogram, were all normal.  

In cardiology on 2 April 2003, the CI reported two episodes of syncope without any premonition, but no cardiac cause was found.  At the neurology evaluation on 2 October 2003, he recounted a total of four episodes, with the first onboard a ship about 18 months previously, and then two more 8 months earlier, and another 1 month after those.  He described a prodromal period of nausea and visual changes followed by a headache, and then the LOC, which lasted 30 minutes, and was followed by confusion.  Neurological findings were normal, and the examiner opined that the episodes could be seizures, syncope, or (complicated) migraine headaches.  Subsequent electroencephalogram (EEG) and MRI tests were normal, and the CI was referred back to cardiology with a note that an EEG should be accomplished if another episode occurred.  On 26 December 2003, the CI was seen in the ER for dizziness and headache, but syncope was not recorded.  No further episodes of syncope were documented prior to separation.  
The 19 December 2003 NARSUM examination did address the syncope condition (it was added by the PEB), but on the 13 January 2004  DD Form 2807-1, the CI reported a total of two episodes, and the DD Form 2808 recorded normal cardiac and neurological examination.  Two weeks later, the commander cited the shoulder and back issues as duty limiting, but did not mention syncope. 

At the 5 April 2004 VA Compensation and Pension (C&P) evaluation, 2 months before separation, the CI reported two episodes of syncope.  The first was at the pool and the second while waxing floors in January 2003.  In both cases, the CI noted that he woke up in the ER.  The cardiac and neurological examinations were normal.  On 21 September 2004, at an initial VA primary care intake appointment, the CI reported “3 episodes of syncope a year and a half ago” and the examiner document “last episode of syncope 8 months ago.”  A VA primary care entry on 21 December 2006 noted a “remote history of syncope while in the Navy.”  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the syncope condition 10%, analogously coded 8299-8210 (incomplete moderate paralysis of the tenth cranial nerve).  The VA also rated the syncope condition 10%, analogously coded 8210-6204 (incomplete moderate paralysis of the tenth cranial nerve-peripheral vestibular disorders) based on the C&P examination, citing symptoms involving occasional dizziness.  Members observed that the CI’s history of syncopal episodes had multiple inconsistencies and varied over time and between examiners.  Regardless, no etiology was found, and neurological and cardiac evaluations were negative with treatment records indicating the CI had no syncopal episode for over 5 months at separation and remained symptom-free following separation.  The panel majority agreed the evidence does not support a compensable rating under either code 8210 or 6204,  but noted that  changing the rating of the shoulder to 20% and reducing the syncope to 0% provided no advantage to the CI.  Accordingly, no change was recommended for either condition.  The minority voter recommended retirement at 30% for the shoulder and syncope conditions.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority concluded there was insufficient cause to recommend a change in the PEB adjudication for either unfitting condition.  

BOARD FINDINGS:  In the matter of the left shoulder condition and IAW VASRD §4.71a, the panel majority recommends no change in the PEB adjudication.  The single voter for dissent recommends a disability rating of 20%, but did not elect to submit a minority opinion. In the matter of the syncope condition and IAW VASRD §4.124a, 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 20161002, 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