RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00142
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041111

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Human Resources Specialist, medically separated for “right (dominant) shoulder pain” with a disability rating of 0%.  

CI CONTENTION:  “My medical records show that my shoulder and other claimed disabilities were inaccurately rated at less than 10% and I would like for my rating to be updated and reflect my actual medical condition.”  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 - 20040722	VARD - 20041130	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder Pain	5099-5003	0%	Right Shoulder Pain	5299-5024	NSC	20040922	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:

Right Shoulder Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s right shoulder condition began in June 2002 after playing racquetball.  He was treated by physical therapy on multiple occasions but his pain persisted.  X-rays were normal.  An MRI revealed a normal right shoulder.  There was no surgical indication.

The 4 June 2004 MEB NARSUM examination, 5 months prior to separation, noted complaints of right shoulder pain that was dull and aching with activity.  Physical examination revealed symmetric deltoid and pectoralis muscle bulk and tone.  Rotator cuff (muscles and tendons) and shoulder joint tear and impingement tests were negative.  Right shoulder external rotation and abduction elicited painful motion.  The 28 June 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, documented that right shoulder range of motion (ROM) testing elicited pain.  At the primary care examination on 1 September 2004, 2 months prior to separation,  repetitive goniometric ROM measurements showed right shoulder flexion to 180 degrees (normal) and abduction to 180 degrees (normal); painful motion was present.  

At the 22 September 2004 VA Compensation and Pension (C&P) examination, 2 months before separation, the CI reported right shoulder pain and stiffness in the morning with some difficulty lifting extremely heavy items which required some shifting of tasks to his left non dominant hand.  Physical examination showed “full” right shoulder ROM; painful motion was not addressed.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder condition 0%, analogously coded 5099-5003 (arthritis, degenerative), citing the US Army Physical Disability Agency pain policy.  The VA did not service connect the right shoulder condition, analogously coded 5099-5024 (tenosynovitis), based on the C&P examination, citing a noncompensable examination.  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 STR and VA examinations in evidence demonstrated motion above this level.  However, panel members agreed that there was sufficient evidence of painful motion to support a 10% rating IAW VASRD §4.59 (painful motion), as recorded on the MEB NARSUM, MEB, and primary care ROM examinations proximate to separation.  There was no fibrous union or nonunion of the humerus (5202), nor nonunion or malunion of the clavicle or scapula (5203), to support a higher rating.  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, analogously coded 5299-5201.

BOARD FINDINGS:  In the matter of the right shoulder condition, the panel recommends a disability rating of 10%, coded 5299-5201 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 medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Shoulder Pain	5299-5201	10%	

The following documentary evidence was considered:  

Exhibit A.  DD Form 294, dated 20161217, w/atchs  
Exhibit B.  Service Treatment Record  
Exhibit C.  Department of Veterans Affairs Record  

AR20180012021, 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 and to the counsel you listed on your application, Mr. Stan Claridy, Disabled
American Veterans (DAV) Hinesville GA, 1113 Oglethorpe Highway, Hinesville, GA
31313-1200.
Sincerely,

Enclosure