RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX 	CASE:  PD-2016-01440
BRANCH OF SERVICE:  marine corps 	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, Finance Technician, medically separated for “posterior left shoulder instability, status post (S/P) multiple surgical procedures” with a disability rating of 10%.  

CI CONTENTION:  “At the time of discharge I had already had (4) four surgeries and no success fixing the injury, I have had several more surgeries since discharge to include total replacement of the left shoulder that I was discharged and med. boarded for.  It is more than half of my 100% permanent & total rating with VA as well…”  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 - 20040204	VARD - 20040825	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Posterior Left Shoulder Instability…	5299-5003	10%	Left Shoulder Arthritis, S/P Multiple Surgeries	5202-5201	20%	20040304	
Instability of the Tendon of the Long End of the Biceps Left Shoulder…	Cat II					
Permanent Musculocutaneous Nerve Lateral Antebrachial Cutaneous Nerve Palsy…	Cat II					
Superficial Cervical Plexus Injury…	Cat II					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY

Posterior Left Shoulder Instability, S/P Multiple Surgical Procedures.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the left-hand dominant CI underwent multiple left shoulder surgeries with the last being a diagnostic arthroscopy followed by open biceps tenodesis of the left shoulder on September 2003.  As part of the surgical procedure he had a nerve block placed by anesthesia.  During the recovery period a superficial cervical plexus injury occurred due to the block, leaving him with numbness on the anterior, superior, and posterior aspects of the shoulder, as well as the neck and pre-ear areas on the left face and head.  

The 5 December 2003 MEB NARSUM examination, 4 months prior to separation, noted complaints of limited range of motion (ROM) and continued pain in the left shoulder with improvement in previous popping and snapping.  Physical examination of the left shoulder showed good biceps contour as compared to the right shoulder with 5/5 supination strength.  He had permanent numbness along the radio volar aspect of the left forearm in the distribution of the lateral antebrachial nerve, a permanent injury due to a surgical procedure in May 2002.  He also had decreased sensation along the neck, anterior chest wall; and anterior, superior and posterior aspect of the shoulder.  ROM showed flexion to 135 degrees (normal 180).  He had excellent anterior and posterior stability with almost normal translation in both directions.  

At the 4 March 2004 VA Compensation and Pension (C&P) Joint evaluation, less than 1 month before separation, the CI reported severe pain with severe restriction in his ROM.  He could no longer do push-ups, pull-ups, or any lifting or handling, especially overhead, with respect to the left shoulder.  He also reported decreased strength in the left shoulder.  Physical examination showed 90 degrees of flexion (normal 180) and abduction of 90 degrees (normal 180).  Rotator cuff strength on the left was 4/5 to external rotation and 5/5 to internal.  

At the 22 March 2004 C&P Peripheral Nerve examination, 9 days prior to separation, the CI reported numbness on the left side of his neck, up to and behind the ear and down over the top of his torso, extending about 12 cm above the nipple line, up to and including the shoulder itself.  Occasionally he felt the arm “jumping as though out of control, it jerks.”  He had little pain, but the persistent numbness bothered him “quite a bit.”  Physical examination showed 5/5 strength, normal reflexes, and sensory examination intact to pinprick, touch, and position sense.  The examiner noted his examination was “totally normal” and he did not appear for his electro myelogram.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 10%, coded 5299-5003.  The PEB also listed instability of the tendon of the long end of the biceps; permanent musculocutaneous nerve palsy; and superficial cervical plexus injury as related Category II conditions (conditions that contributed to the primary unfitting condition but are not separately ratable).  The impairment from these related conditions was properly subsumed under the overall rating for the left shoulder instability IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  The VA rated the left shoulder condition 20%, coded 5202-5201, (humerus, other impairment of, with limitation of motion of the arm), based on the C&P examination 1 month before separation, citing severe limitation of motion; flexion and abduction to 90 degrees.  

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 VA examination proximate to separation demonstrated motion limited to this level.  The panel considered this examination as having the highest probative value given it was the closest to date of separation, was the most VASRD compliant, and was the most thorough examination in evidence.  The next higher 30% rating for the dominant arm requires motion limited to “midway between side and shoulder level.” However, examinations did not reflect this degree of limitation.  There was no malunion with marked deformity or frequent episodes of recurrent dislocation of the dominant humerus to justify a higher rating under the 5202 code (humerus, other impairment of), and no higher ratings 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 left shoulder instability condition, coded 5201.  

BOARD FINDINGS:  In the matter of the posterior shoulder instability condition, the panel unanimously recommends a disability rating of 20%, coded 5201 IAW VASRD §4.71a.  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 the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Posterior Left Shoulder Instability, S/P Multiple Surgical Procedures	5201	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161012, 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 13 Oct 17 ICO XXXXXXXXXXXXXXXXXX  
	(c) PDBR ltr dtd 08 Mar 18 ICO XXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 06 Mar 18 ICO XXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 07 Mar 18 ICO XXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 07 Mar 18 ICO XXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 06 Mar 18 ICO XXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 07 Mar 18 ICO XXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 08 Mar 18 ICO XXXXXXXXXXXXXXXXXX
	(j) PDBR ltr dtd 08 Mar 18 ICO XXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (j) 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 USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     c. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 40 percent rating (increased from 20 percent) effective date of discharge. 

     d. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 40 percent rating (increased from 10 percent) effective date of discharge.       

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

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

     g. XXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.   

     h. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge.
	
     i. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 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.