RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01148
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20071125

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 “bilateral shoulder pain” with a disability rating of 0%.  

CI CONTENTION:  No specific contention made.  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 - 20070820	VARD - 20080129	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Shoulder Pain	5099-5003	0%	Residuals, Surgical Repair of Right Shoulder 	5299-5203	10%	20071113	
			Residuals, Surgical Repair of Left Shoulder 	5299-5203	10%	20071113	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral Shoulder Pain.  The PEB combined the right and left shoulder conditions under a single disability rating, coded analogously to 5003 and rated 0% with application of the US Army Physical Disability Agency pain policy.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The panel noted that “bundling,” the combining of two or more major joints, may be permissible under VASRD code 5003 rating requirements, and this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The panel’s initial charge in this case was therefore directed at determining if combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that adjudicated by the PEB.  

Left Shoulder.  According to the service treatment record and MEB narrative summary (NARSUM), the right hand dominant CI’s MRI arthrogram on 18 January 2006 showed anterior and posterior labral tears (the cartilage lining of the shoulder joint) and he underwent surgical repair on 11 May 2006.  A repeat post-surgical MRI arthrogram on 2 March 2007 showed fraying of the labral cartilage with mild degenerative joint changes.  Formal range of motion (ROM) testing in physical therapy on 22 March 2006 showed flexion of 140 degrees (normal 180) and abduction of 135 degrees (normal 180) after repetition.  The limitation in motion was mechanical (speculated to be post-operative adhesions) rather than due to pain.  During the 29 March 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months prior to separation, the physical examination noted that the ROM and strength of both shoulders was reduced.  

The 15 May 2007 MEB NARSUM examination, 6 months prior to separation, noted ongoing bilateral shoulder pain which precluded full duty.  The physical examination showed one mildly positive test for instability and difficulty being placed in a position of apprehension, but others were negative.  Testing for a rotator cuff injury and for impingement was negative.  The acromio-clavicular joint (ACJ), between the shoulder and collar bone, was unremarkable.  It was anticipated that additional surgery would likely be necessary in the future, and noted that he could not perform overhead work and that there was loss in his ROM.  

At the 13 November 2007 VA Compensation and Pension (C&P) examination, 2 weeks before separation, the CI reported limited ROM with weakness of the left shoulder.  The physical examination showed full ROM with weakness.  Pain was denied.  Atrophy and laxity were absent.  The CI could maintain flexion against resistance.  He was diagnosed with bilateral shoulder weakness.  

The panel directed attention to its rating recommendation based on the above evidence.  The VA rated the left shoulder condition 10%, analogously coded 5299-5203 (impairment of clavicle or scapula), based on the C&P examination, citing weakened movement.  

Panel members first considered if the left and right shoulders were separately unfitting.  Both were profiled, found to be medically unacceptable, and separately addressed by the PEB in the rating discussion.  The panel found sufficient evidence to recommend that each be found separately unfitting, and then considered the appropriate rating and coding options for the left shoulder.  Limited motion was present on the physical therapy examination 8 months prior to separation, but not on the VA examination less than 2 weeks prior to separation.  Regardless, it was not compensable under a code specific for the shoulder (5201).  Weakness was noted on multiple examinations, but not quantified nor accompanied by atrophy.  It was also noted that the CI was able to flex his arm against resistance.  Instability was not present on examination, although testing was suggestive of it.  Nonetheless, an impairment in the performance of his duties was clearly present.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 10% for the left shoulder condition, coded 5299-5203.  The minority voter recommends no change in the PEB adjudication.  

Right Shoulder.  The CI was also evaluated for the less symptomatic right shoulder pain during this period.  An MRI arthrogram on 1 September 2006 noted some degenerative changes of the ACJ and a tear of the posterior labrum.  This and the joint capsule were surgically repaired on 1 November 2006.  It also remained symptomatic and impaired duty, and was referred for MEB along with the left shoulder.  Formal ROM testing in physical therapy on 22 March 2006 showed flexion of 165 degrees and abduction of 150 degrees after repetition.  The limitation in motion was due to pain.  During the MEB examination, the CI reported two shoulder surgeries.  The physical examination noted that the ROM and strength of both shoulders was reduced.  The MEB NARSUM examination noted ongoing bilateral shoulder pain which precluded full duty.  The physical examination was unremarkable.  It was anticipated that he might improve some with reduced activity following separation, and noted that he could not perform overhead work.  At the C&P examination the CI reported instability of the right shoulder.  Full ROM with weakness was noted.  There was no joint laxity or atrophy present.  The CI could maintain flexion against resistance.  Painful motion was not documented.  

The panel directed attention to its rating recommendation based on the above evidence.  The VA rated the right shoulder condition 10%, analogously coded 5299-5203 (impairment of clavicle or scapula), based on the C&P examination, citing weakened movement.  The panel majority concluded there was sufficient evidence of painful motion and functional loss to support a 10% rating for the right shoulder condition IAW §4.59 and §4.40.  In considering other rating options, there was no limitation of motion which attained a higher rating under the diagnostic codes for limitation of motion (5201), or instability for a higher rating under 5202 (humerus, other impairment).  There was therefore no VASRD §4.71a rating higher than 10% for the right shoulder under any applicable code.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 10% for the right shoulder condition, coded 5099-5003.   

BOARD FINDINGS:  In the matter of the bilateral shoulder condition, the panel majority recommends that each shoulder be separately adjudicated as follows: an unfitting left shoulder condition coded 5299-5203, and an unfitting right shoulder condition coded 5099-5003, each rated 10% IAW VASRD §4.71a.  The single voter for dissent recommends no change, but did not elect to submit a minority opinion.  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	
Left Shoulder Pain	5299-5203	10%	
Right Shoulder Pain	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170221, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180010929, 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. 

Sincerely,					      
Enclosure