RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX 	CASE:  PD-2016-01763
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20040413

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Signal Support Systems Specialist, medically separated for “right shoulder pain” with a disability rating of 0%.  

CI CONTENTION:  “Daily pain in predominant right arm which was neglected over numerous attempts to get it fixed while in the military.”  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 - 20040122	VARD - 20040512	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder Pain	5099-5003	0%	Right Rotator Cuff Impingement	5299-5203	10%	20040318	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Right Shoulder Pain.  According to the service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-hand dominant CI injured his right shoulder in October 2002 after lifting a rucksack onto his right shoulder.  He was initially diagnosed with a strained muscle and treated with anti-inflammatory medications and exercises to perform.  X-rays at that time revealed a normal right shoulder.  The CI was referred to orthopedics to rule out right shoulder impingement syndrome.  He transferred duty stations prior to this consult but was seen by orthopedics in April and June 2003 and diagnosed with right shoulder rotator cuff syndrome.  

At the time of the sports medicine (University of Buffalo Sports Medicine) clinic appointment on 18 August 2003, 8 months prior to separation, the examiner reviewed a recent MRI arthrogram and determined the CI had a tendinopathy of the right supraspinatus tendon and some irregularity of the anterior glenoid labrum.  The examiner noted right shoulder range of motion (ROM) was “full” with a positive impingement sign and O’Brien test consistent with injury to both the supraspinatus and the glenoid labrum.  The examiner recommended a full course of aggressive physical therapy followed by diagnostic arthroscopy should the physical therapy fail to improve the CI’s right shoulder pain.  

According to the 17 November 2003 MEB NARSUM evaluation, 5 months prior to separation, the CI complained of chronic, sharp, 6/10 right shoulder pain.  He reported that the pain often radiated to the right upper back shoulder and neck and sometimes caused headaches due to spasms.  He reported the pain was worse with lifting, carrying, overuse, push-ups, running and ROM measurements.  He also complained of popping and clicking and a feeling of instability in his right shoulder, occasional tingling, and subjective weakness.  Shoulder dislocations were not reported.  He was unable to ruck march, lift heavy objects, run or take his physical fitness test or fire a weapon.  Physical examination showed increased laxity in both shoulder joints with a positive sulcus sign.  There was mild point tenderness over the right anterior shoulder just inferior to the acromioclavicular joint.  His right shoulder ROM, performed by physical therapy, was considered by the examiner to be “full,” averaging 115 degrees flexion (normal 180) and 115 degrees abduction (normal 180).  He had a positive NEER’s test (test for shoulder impingement) and Hawkin’s impingement sign.  There was decreased subscapularis strength with the lift off test of the right side, otherwise full strength at 5/5 in all muscle groups.  

At the 18 March 2004 VA Compensation and Pension (C&P) examination, 1 month before separation, the CI reported continuing right shoulder pain.  Physical examination showed no joint instability and decreased ROM; overhead extension at 160 degrees and 150 degrees abduction.  His internal and external rotation “appeared normal.”  The examiner noted that the CI held his shoulders in a normal anatomical position and also noted shoulder pain with motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder pain condition 0%, coded analogously as 5003 (degenerative arthritis), citing the US Army Physical Disability Agency pain policy. The VA rated the right shoulder pain condition 10%, coded analogously as 5203, (clavicle or scapular impairment of), based on the C&P examination 1 month before separation, citing evidence of a right rotator cuff impingement.  

Panel members agreed that a 10% rating was justified with application of VASRD §4.59 (painful 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.  There was no malunion or recurrent dislocation of the humerus and no dislocation or nonunion of the clavicle or scapula to justify a higher rating under the 5202 (humerus, other impairment of) or 5203 (clavicle or scapula, impairment of) codes.  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 right shoulder condition, coded 5299-5203.  

BOARD FINDINGS:  In the matter of the right 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 the CI’s prior determination be modified as follows, effective the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Shoulder Pain	5299-5203	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160913, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180003271, 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.