RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00957
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050418

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Infantryman, medically separated for “right shoulder (dominant) pain with recurrent superior labral lesion” with a disability rating of 20%.   

CI CONTENTION:  “I would like a full review of medical evaluation to ensure I received a fair decision.”  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 - 20050112	VARD - 20050520	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder Pain…	5202	20%	Residual of a Right Shoulder Injury, Postoperative (Dominant)	5299-5202	20%	20050120	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Right Shoulder Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s right shoulder condition began in March 2003 when he slipped and fell while carrying a heavy load.  An MRI on 22 March 2004 showed a grade IV superior labrum anterior posterior (SLAP) lesion and a probable low grade partial tear of the supraspinatus tendon.  He underwent an arthroscopic repair on 9 April 2004, and although he initially did well, he developed recurrent instability and popping.  At a physical therapy examination on 18 August 2004, he had a full range of motion (ROM) with internal rotation to T12.  
During the 16 December 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported he was unable to lift his arm above his shoulder.  Physical examination revealed decreased ROM secondary to apprehension for dislocation but no measurements were provided.  The 29 November 2004 MEB NARSUM examination, 5 months prior to separation, noted CI complaints of a sensation of impending dislocation with overhead reaching or lifting, but he denied any frank dislocations.  Physical examination showed symmetric shoulder bulk and tone, and negative Hawkin’s (subacromial impingement), O’Brien’s (glenohumeral labral tear), cross-body adduction (acromioclavicular joint injury), drop-arm (rotator cuff tears) and lift-off (to determine a tear in the subscapularis tendon or subscapularis tendonitis) tests.  He had a positive apprehension test (for possible torn labrum or anterior instability), but was nontender about the shoulder and cervical spine.  The 16 December 2004 MEB addendum noted active flexion of 150 degrees (normal 180) and abduction of 130 degrees (normal 180) after repetition and with significant guarding and apprehension at ROM endpoints.
	
At the 20 January 2005 VA Compensation and Pension (C&P) examination, 3 months before separation, the CI reported mild instability and popping despite surgery.  Physical examination showed normal shoulder bulk, muscle tone, and neurovascular findings.  On examination, right shoulder ROM after repetition showed flexion of 101 degrees and abduction of 126 degrees, with painful motion in both planes and range limited by pain and apprehension. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder condition 20%, coded 5202 (humerus, other impairment of), citing significant guarding and apprehension.  The VA also rated the right shoulder condition 20%, analogously coded 5299-5202, based on the C&P examination, citing recurrent episodes of instability and popping with decreased ROM and painful motion.  Panel members noted there was no arm limitation of motion sufficient to warrant a rating using code 5201; and no malunion with marked deformity of the humerus, or frequent episodes of recurrent dislocation with guarding of all arm movements, to warrant the next higher 30% rating under code 5202.  Additionally, there was no higher rating available under code 5203 (clavicle or scapula, impairment of) or code 5200 (scapulohumeral articulation, ankylosis of) in the absence of ankylosis.  After due deliberation, considering all of 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 pain 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 20170217, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180010081, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.

Sincerely,					      
Enclosure