RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01474
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20040930

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Indirect Fire Infantryman, medically separated for “left shoulder pain” with a disability rating of 0%.  

CI CONTENTION:  “Review all conditions.”  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 - 20040614	VARD - 20041202	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Shoulder Pain	5099-5003	0%	Residuals…Distal Clavicle Excision Left Shoulder	5299-5203	20%	20040513	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Left Shoulder Pain.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-handed CI underwent left shoulder arthroscopy and open acromioplasty and distal clavicle excision on 29 April 2003.  During the 8 April 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported left shoulder impingement.  Physical examination showed pain with abduction at 50 degrees, and decreased range of motion (ROM).  Specific measurements were not listed.  The 10 May 2004 MEB NARSUM examination, 5 months prior to separation, noted complaints of continued left shoulder pain and inability to ruck-march.  Physical examination showed tenderness over the scar at the acromioclavicular (AC) joint.  There was good stability and the CI was neurovascularly intact.  ROM testing showed forward flexion of 110 degrees (180 normal) and abduction of 110 degrees (180 normal).  Painful motion was not mentioned.  

At the 13 May 2004 VA Compensation and Pension (C&P) evaluation, 5 months before separation, the CI reported continued left shoulder pain despite surgical intervention.  Physical examination showed overhead extension of 170 degrees and abduction of 170 degrees with pain at the uppermost reaches of the motions.  The examiner stated: “I did not repeat these (measurements) since he has a lot of discomfort with these and this does give him a moderate amount of physical impairment.”  At the 27 May 2004 physical therapy appointment, 4 months prior to separation, the CI reported 5/10 left shoulder pain.  After repetitive testing, forward flexion was 137 degrees and abduction was 133 degrees.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 0%, coded 5099-5003 (analogous to arthritis, degenerative).  The VA rated the left shoulder condition 20%, coded 5299-5203, (analogous to clavicle or scapula, impairment of), based on the C&P examination 5 months before separation, citing (slight) decreased ROM with a moderate amount of physical impairment.

The panel agreed that the distal clavicle excision was analogous to a clavicle malunion and warranted a 10% rating under code 5203 (clavicle or scapula, impairment of).  The panel deliberated if the pre-separation VA examiner’s statement of “moderate amount of physical impairment,” with no evidence of loose movement or ratable limitation of ROM warranted a 20% rating for the CI’s non-dominant shoulder condition.  There was no dislocation or nonunion of the clavicle or scapula with loose movement to justify a rating higher than 10% under the 5203 code.  There was no malunion or recurrent dislocation of the humerus to justify a higher rating under code 5202 (humerus, other impairment of).  The VASRD §4.71a threshold for rating for shoulder 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.  Panel members noted that a 10% rating was justified with application of VASRD §4.59 (painful motion), but agreed the distal clavicle excision coding was predominant.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left shoulder condition, coded 5299-5203.  

BOARD FINDINGS:  In the matter of the left shoulder condition, the panel unanimously recommends a disability rating of 10%, coded 5299-5203 IAW VASRD §4.71a.  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	
Left Shoulder Pain	5299-5203	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161010, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20180003267, XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

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