RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX		CASE: PD-2017-00414 BRANCH OF SERVICE: MARINE CORPS	SEPARATION DATE: 20070115

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E-4, Helicopter/Tiltrotor Dynamic Components Mechanic, medically separated for “chronic right shoulder pain s/p [status post] revision right shoulder arthroscopy with arthroscopic labral repair and capsular shift” with a disability rating of 20%.

CI CONTENTION: “Medical records lost had evidence of other issues with shoulder, neck and spine.” Review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB) was requested.  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20061106	VARD - 20080122	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Shoulder Pain…	5201	20%	Pain Syndrome with Bony Degenerative Changes, Right Shoulder	5201	10%	20070709	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 10%	

ANALYSIS SUMMARY:

Chronic Right Shoulder Pain. According to the service treatment record and MEB narrative summary (NARSUM), the CI underwent a right (dominant) shoulder arthroscopic superior labral and anterior labrum repair on 28 July 2004. Four weeks later, he was instructed to do a pull-up and felt a painful popping in the right shoulder along with immediate pain and stiffness thereafter. On 8 June 2006, he underwent a right shoulder revision arthroscopy with labral repair (Bankart procedure).  At a physical therapy visit on 18 September 2006, forward flexion was   0-

170 (normal 180) with poor rhythm, wing and tip. Abduction with “thumb up” was 0-95 degrees (normal 180), with poor rhythm wing and tip.

At the 15 September 2006 MEB NARSUM examination, 4 months prior to separation, the CI complained of instability, posterior capsular pain, and light stiffness with extremes of motion. The examiner documented “range of motion of his right shoulder is 145 degrees flexion and adduction with 30 degrees external rotation.” During the MEB examination (recorded on DD Forms 2807-1 and 2808) a week later, the examiner noted right shoulder instability and decreased range of motion (ROM). At an orthopedic visit on 11 October 2006, flexion from “9/15” was recorded as “ROM: flex to 150.”

At the 9 July 2007 VA Compensation and Pension (C&P) examination, 6 months after separation, the CI complained of constant sharp pain, tightness and popping of the right shoulder especially, with external rotation and abduction. Physical examination showed anterior tenderness, but no swelling or erythema. Goniometrically measured ROM showed forward flexion of 170 degrees, with crepitus and snapping; no measurements for abduction were provided. There was increased pain after repetition, with fatigability secondary to pain, no loss of motion.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the right shoulder condition 20%, coded 5201 (arm, limitation of motion). The VA rated the right shoulder condition 10%, coded 5201, based on the C&P examination, citing pain and some limitation of motion. Panel members noted that the VASRD §4.71a threshold for rating for ROM impairment under code 5201 is “at shoulder level” (approximately 90 degrees from the side), and only one examination in evidence (18 September 2005) demonstrated motion close to this level. The next higher 30% rating for the dominant arm requires motion limited to “midway between side and shoulder level,” but this degree of limitation was note reflected in any of the , examinations. 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 ratings available under code 5203 (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 right shoulder condition.

BOARD FINDINGS: In the matter of the right shoulder condition and IAW VASRD §4.71, 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.

	

2	PD-2017-00414

DEPARTMENT OF THE NAVY
SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309
WASHINGTON NAVY YARD, DC 20374-5023

IN   REPLY  REFER  TO,
1850
CORB: 003 20May20

From: 

Director, Secretary of the Navy Council of Review Boards 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW  (PDBR)

Ref:	(a) DoDI 6040.44
(b) PDBR ltr dtd 29 Mar 19

I.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation (reference (b)) to the Department of the Navy on 5 Mar 2020 for appropriate action.

2.	On 20 March 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) accepted the recommendation of the PDBR ofno change to your characterization of separation or disability rating assigned by the Department of the Navy's Physical Evaluation  Board.

3.	The Secretary's decision on your PDBR application is final and is not subject to appeal or additional review by the Board for Correction of Naval Records.