RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01732
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041208

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Infantryman, medically separated for “left shoulder pain and instability” with a disability rating of 10%.  

CI CONTENTION:  “I could not perform my duties without causing more injury.”  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 Medical Evaluation Board (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 - 20041105	VARD - 20050817	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Shoulder Pain and Instability	5099-5003	10%	Left Shoulder Status Post Reconstructive Surgery	5299-5203 	10% 	20050513 	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Left Shoulder Pain and Instability.  According to the service treatment record and MEB narrative summary (NARSUM), the CI underwent left shoulder surgery in July 2003 for anterior capsular shift and labral repair.  In October 2003, the CI began to report “popping and cracking with pain” and a feeling of instability.  After the pain increased in April 2004, he was evaluated by orthopedics.  Physical examination showed deconditioning with decreased muscle bulk of the left shoulder and minimal scapular winging (secondary to muscle weakness).  Range of motion (ROM) testing showed left shoulder flexion and abduction of 180 degrees (normal for both).  The CI was guarding during instability testing, but in the supine position no instability was appreciated.  Apprehension sign was positive (equivalent to painful motion).  Testing for biceps injury was equivocal with one of two tests “slightly” reproducing the pain, but impingement was negative.  There was no evidence of rotator cuff tendonitis or tear.  An MRI in May 2004 revealed postsurgical changes of the glenoid labrum and re-injury of the glenoid labrum could not be excluded, but was considered unlikely.  The surgical hardware appeared to be in place.  The CI was offered surgical exploration but opted for conservative treatment.  There was improvement with physical therapy, but painful shoulder motion persisted, especially with external rotation and abduction of the arm.  

During the 2 October 2004 MEB NARSUM examination, 2 months prior to separation, the CI complained of left shoulder pain and instability.  Although the CI reported he was able to do everything, he was limited by shoulder pain.  The physical examination cited the orthopedic examination above.  The 13 October 2004 MEB examination (recorded on DD Forms 2807-1 and 2808) showed “marked joint laxity.”  Left shoulder ROM in degrees was flexion of 180 and abduction of 120.  

At the 13 May 2005 VA Compensation and Pension (C&P) examination, 5 months after separation, the CI reported constant left shoulder pain aggravated by use.  He denied current instability or locking.  Physical examination showed tenderness anteriorly (subscapularis muscle).  Testing for labral tears was negative.  There was weakness of the supraspinatus muscle and pain with testing.  There was no effusion, abnormal movement or guarding of movement.  Left shoulder ROM was flexion of 170 degrees and abduction of 180 degrees, with pain in both planes of movement.  The VA examiner noted that functional loss due to pain, weakness or fatigue as a result of repetitive motion was considered in the measurements.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 10%, analogously coded 5003 (arthritis, degenerative), citing moderate instability and slight loss of motion with normal strength and imaging.  The VA also rated the left shoulder condition 10%, analogously coded 5203 (clavicle or scapula, impairment of), based on the C&P examination, citing functional loss due to pain, mild weakness and slight limitation of motion.  

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.  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).  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 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 shoulder condition 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 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 20161010, w/atchs  
Exhibit B.  Service Treatment Record  
Exhibit C.  Department of Veterans Affairs Record  

AR20180016919, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.

Sincerely,				

	       
Enclosure