DEPARTMENT  OF  THE NAVY
SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309
WASHINGTON NAVY YARD, DC 20374

IN   REPLY   REFER TO:
1850
CORB:003
20 Feb 20

From: To:

Subj: Ref:

Director, Secretary of the Navy Council of Review Boards 
PD-2016-01645

PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)

(a) DoDI 6040.44
(b)	PDBR ltr dtd 29 Oct 18

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation (reference (b)) to the Department of the Navy.

2.	On 12 February 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) accepted the recommendation of the PDBR of no change to your characterization of separation or disability rating assigned by the Department of the Navy's Physical Evaluation Board.

3.	The Secretary's decision on your PDBR application is final and is not subject to appeal or additional review by the Board for Correction of Naval Records.

RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX		CASE: PD-2016-01645 BRANCH OF SERVICE: MARINE CORPS	SEPARATION DATE: 20020831

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E2, Basic Marine, medically separated for “left scapulothoracic articulation bursitis” with a disability rating of 10%.

CI CONTENTION: Review requested of left shoulder, which has significantly worsened, and an additional condition (neck) 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 - 20080423	VARD - 20030827	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Scapulothoracic Articulation Bursitis	5299-5003	10%	Left Shoulder with Hill-Sach’s Deformity, Recurrent Dislocation	
5299-5203	
20%	
20030807	
Bilateral Shoulder Multidirectional Instability, Left Symptomatic	Category II					
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 20%	
	
ANALYSIS SUMMARY:

Left Scapulothoracic Articulation Bursitis. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI suffered a left (non-dominant) shoulder dislocation during basic training in February 2002 and dislocated the same shoulder during a fall 6 weeks later. He was diagnosed with bilateral multidirectional instability, which was determined to be a congenital  laxity  of  shoulder  joint  attachments  in  all  planes;  but,  he  denied  any   injuries,

dislocations, or complaints for either shoulder before enlistment. There was no evidence of any further right shoulder injuries or symptoms during the CI’s remaining 6 months of service, and an MRI demonstrated intact joint attachments and no pathology except an incidental Hill-Sachs lesion (chip fracture typical for dislocation). Surgery not indicated, but rehabilitation was unsuccessful.

A review of the STR showed evidence of a nerve injury (long thoracic) associated with the initial dislocation, resulting in muscle dysfunction and scapular winging. There were multiple treatment entries that showed normal motor strength (5/5 all groups) with no contrary evidence, and no left arm intermittent sensory complaints or objective sensory deficits; electrodiagnostic testing (EMG) was normal. There was ample STR documentation of grossly normal shoulder range of motion (ROM) measurements with flexion and abduction to 180 degrees. There was evidence of painful motion and positive signs of instability (apprehension, load shift, sulcus, etc.) for the left but not right shoulder. Although there was documentation of positive apprehension with physical examination stress maneuvers, there was no record of guarding with routine activity.

The 5 April 2002 MEB NARSUM orthopedic examination, 5 months prior to separation, was supplemented by a MEB addendum on 30 May 2002 that addressed issues raised by the CI’s rebuttal. The examiner noted a non-specific “sensation of left shoulder subluxation and pain” that had not improved with treatment, and rendered the CI “unable to perform pullups, pushups, or engage in other activities necessary for Recruit training.” There were no neurological symptoms or guarding. Physical examination recorded “Grade II instability ... anterior, posterior, and with sulcus testing” of both shoulders, but apprehension and relocation tests were positive on the left only. Left shoulder flexion and abduction were 160 degrees (compared to 180 degrees on the right), with painful motion and scapular winging. Motor strength testing was not documented. The orthopedist opined that the bilateral multidirectional instability had existed prior to service (EPTS) with service aggravation of the left shoulder, but not the right.
The earliest VA evidence was a Compensation and Pension (C&P) examination on 7 August 2003,
12 months after separation, which provided marginal probative value for the panel’s recommendation. It only addressed the left shoulder and documented flexion and abduction limited to 90 degrees “at which [point] there is severe pain and marked weakness.” Guarding of shoulder movement with routine activities was not documented.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the left shoulder condition 10%, coded “5299-5003” (arthritis, degenerative), without citing VASRD criteria. The PEB did specify a left shoulder EPTS condition with a 0% deduction, and also listed “bilateral, multidirectional instability of the shoulders, symptomatic on left” as a related Category II condition (contributes to the primary unfitting condition but not separately ratable). The VA rated the left shoulder condition 20%, analogously coded 5299-5203 (clavicle or scapula, impairment), based on the C&P examination, citing ROM limitation, but did not mention scapula or clavicle impairment.

The panel directed attention to its rating recommendation based on the above evidence. Members first considered the Category II adjudication and determined that while the CI’s bilateral shoulder condition existed prior to service, only the left shoulder instability was symptomatic and permanently service aggravated, and thus could be considered for a higher rating. Although the C&P ROM examination supported the minimum 20% rating for flexion or abduction “at shoulder level” (approximately 90 degrees), the panel determined that the preponderance of STR ROM evidence did not meet this criteria. Additionally, there was no evidence to support a clavicle or scapula impairment (5203) even analogously.

The panel extensively deliberated whether the left shoulder joint instability justified a higher rating under code 5202 (humerus, other impairment), and determined that the STR and VA

evidence did not support a 20% rating without evidence of “recurrent dislocation at scapulohumeral joint” that requires “guarding of all arm movements” or “guarding of movement only at shoulder level.” While a positive apprehension test was noted, this is not a substitute for the “guarding” required by the code.

The panel also considered rating recommendations under a nerve or analogous muscle code based on the CI’s nerve injury with scapular winging, but the preponderance of evidence recorded normal left shoulder strength, slightly limited ROM, and a normal EMG which were not supportive of a separate rating. Members agreed that there was no separately unfitting impairment that would justify additional rating for nerve or muscle disability, and that to do so would also raise a serious question of pyramiding based on VASRD §4.14 (prohibits more than one rating based on the same impairment). After due deliberation, considering all 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 for the left shoulder condition.

BOARD FINDINGS:  In the matter of the left scapulothoracic articulation bursitis and IAW VASRD
§4.71a, 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 that there be 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 20161025, w/atchs Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record