JAN 1 5 2019
MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
BOARDS
Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
Ref: (a) DoDI 6040. 44
In accordance with reference (a), I have reviewed the cases
listed below and approve the recommendations of the PDBR that the
following individual's records not be corrected to reflect a change
in either characterization of separation or in the disability
rating previously assigned by the Department of the Navy's Physical
Evaluation Board:

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2017-00098
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20041012

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E4, Builder, medically separated for “recurrent left subscapularis tear” with a disability rating of 20%. 

CI CONTENTION:  “I should have received [a] 30% rating for this arm.”  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 - 20040512	VARD - 20050406	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Recurrent Left Subscapularis Tear	5299-5003	20%	Residuals, Left Subscapularis Tear	5201	20%	20050208	
Os Acromiale	Cat II					
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Recurrent Left Subscapularis Tear.  According to the service treatment record and MEB narrative summary (NARSUM), the right-hand dominant CI underwent repair of a subscapularis tendon rupture of his left shoulder in July 2003.  He was evaluated by orthopedics in February 2004 and was diagnosed with recurrent left subscapularis rupture.
  
The 3 February 2004 MEB NARSUM examination, 8 months prior to separation, noted complaints of pain and stiffness of the shoulder with weakness with internal rotation.  Physical examination showed well healed surgical incisions and no muscle atrophy.  There was tenderness to palpation over the anterior joint capsule.  Left shoulder range of motion (ROM) testing showed forward flexion and abduction of 140 degrees each (normal 180).  Load shift testing showed mild anterior instability, but it was symmetrical bilaterally.  Strength testing of the subscapularis (abdominal press and lift off) was graded 0-1/5.  Further surgery was discussed, but the CI declined, which the surgeon considered a reasonable choice.  

At an orthopedic follow-up examination on 15 June 2004, 4 months prior to separation, shoulder ROM was flexion of 180 degrees and abduction of 90 degrees with anterior and inferior instability noted.  The orthopedic surgeon observed the CI would continue to experience weakness with internal rotation and instability given the recurrent subscapularis rupture.  

A physical therapy evaluation on 13 July 2004 noted mild scapular winging and poor scapular control with shoulder movement.  At a follow-up visit on 2 August 2004, 2 months prior to separation, the examiner noted improvement in strength but the CI continued to report difficulty with functional use of the left arm, including overhead use.  Shoulder abduction had improved to 100 degrees.  Internal rotation strength was improved but still decreased (3/5), but there was “excellent return” of scapular control.  

At the 8 February 2005 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported chronic left shoulder pain and fatigue of the left arm.  He reported difficulty abducting his arm and overhead use.  The CI reported he could lift and carry if the arm was “not any higher than about waist level.”  Physical examination showed slight deltoid muscle atrophy and decreased strength with internal rotation (3-4/5).  Left shoulder ROM testing showed flexion of 135 degrees, with pain at extremes of motion, and abduction of 90 degrees, with painful motion and limited internal rotation with pain at the end of motion.  There was no additional limitation of motion with repetitive use.  Left shoulder X-rays showed post-surgical changes, but were otherwise unremarkable.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 20%, coded analogously to 5003 (degenerative arthritis).  The PEB’s Category II diagnosis of os acromiale (a site of failure of fusion of the acromial process which may be asymptomatic or may contribute to shoulder pain due to impingement and/or rotator cuff injury) is intrinsic to the rated condition and a separate rating cannot be supported without pyramiding (VASRD §4.14); thus, it is appropriately subsumed under the same rating.  The VA rated the left shoulder condition 20%, coded 5201, citing 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 limited to this level.  The next higher 30% rating for the non-dominant arm requires motion limited to “25 degrees from the side,” which was not present in this case.  There was no malunion with marked deformity or frequent episodes of recurrent dislocation of the humerus to justify a higher rating under code 5202 (humerus, other impairment of), and no higher rating under code 5203 (clavicle or scapula, impairment of), an analogous code for rotator cuff injury.  The shoulder was not ankylosed for consideration of rating under 5200 (scapulohumeral articulation, ankyloses 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 of the left shoulder condition.  

BOARD FINDINGS:  In the matter of the recurrent 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 20161128, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record