RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXX	CASE: PD-2017-00005
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20041223

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Indirect Fire Infantryman, medically separated for “right 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 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 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 - 20041018	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Shoulder Pain	5099-5003	0%	No VA Examination Proximate to Separation in Evidence	
Hypertension	Not Unfitting		
Seasonal Allergies	Not Unfitting		
COMBINED RATING: 0%	COMBINED RATING OF ALL VA CONDITIONS: NA	
	
ANALYSIS SUMMARY:

Right Shoulder Pain. According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent right shoulder surgery in January 2004 for arthroscopy with anterior plication after a fall on his outstretched hand that caused a subluxation injury. Following surgery there was no residual instability but the CI had persistent pain while working in the overhead position and was unable to perform the duties of his MOS. The 19 August 2004 commander’s statement, 4 months prior to separation, noted that following surgery and rehabilitation, the CI continued to have pain and lack of right shoulder mobility which impaired the successful performance of his duties. The 15 September 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of right shoulder pain with push- ups, pull-ups, and overhead activities and denied recurrent instability. Physical examination showed well-healed surgical incisions. Right shoulder range of motion (ROM) showed flexion of 170 degrees (normal 180). There was pain with extremes of external rotation. The CI did not have signs of impingement or instability.  There was no tenderness along the  acromioclavicular

joint. Shoulder X-rays were normal without evidence of degenerative changes. There was no VA examination proximate to separation in evidence.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the right shoulder condition 0%, analogously coded 5003 (degenerative arthritis), citing no residual instability, full ROM with marked pain while working in the overhead position, and unable to accomplish primary MOS and other strenuous tasks. The condition was rated as analogous to degenerative arthritis without  significant loss of  shoulder 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. However, panel members agreed that a 10% rating was justified with application of VASRD §4.59 for painful motion noted in the MEB NARSUM examination proximate to separation. 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) or 5203 (clavicle or scapula, impairment) codes. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the right shoulder condition, coded 5099-5003.

Contended PEB Conditions: Hypertension and Seasonal Allergies. The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting. The contended conditions were not profiled or implicated in the commander’s statement, and did not fail retention standards. There was no performance-based evidence from the record that either of the conditions significantly interfered with satisfactory duty performance at separation. After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions, so no additional disability ratings are recommended.

BOARD FINDINGS: In the matter of the right shoulder condition, the panel recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a. In the matter of the contended conditions, the panel recommends no change from the PEB determinations as not unfitting. 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 medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Right Shoulder Pain	5099-5003	10%	

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20170104, w/atchs Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

PD-2017-00005

AR20190014190, XXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXX

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

PD-2017-00005

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