RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX		CASE: PD-2017-01251 BRANCH OF SERVICE: MARINE CORPS	SEPARATION DATE: 20090530

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E6, Platoon Sergeant, medically separated for “scapulothoracic dysfunction, post traumatic, right, moderate” and “right posterior tibial tendonosis,” rated 10% each, with a combined disability rating of 20%.

CI CONTENTION: Review requested of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB). 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 - 20090330	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Scapulothoracic Dysfunction Post Traumatic, Right, Moderate	5099-5003	10%	

No VA Examination in Evidence	
Right Posterior Tibial Tendonosis	5099-5003	10%		
Contusion, Humeral Head, Right	Not Unfitting / Cat II		
Posterior Malleolar Fracture Right Ankle, Healed	Not Unfitting / Cat II		
Peroneal Nerve Dysfunction Right Ankle, Recovered	Not Unfitting / Cat II		
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: NA	

ANALYSIS SUMMARY:

Scapulothoracic Dysfunction... According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI sustained a right shoulder dislocation in March 2008 after a motor vehicle accident (MVA). X-rays on 14 March 2008 demonstrated a Hill-Sachs deformity of the humeral head consistent with prior shoulder dislocation and well reduced.

At the 1 April 2008 physical therapy examination the CI reported intermittent 6/10 right shoulder pain, aching, soreness, and stiffness. The pain was aggravated by movement and alleviated by rest. Physical examination showed range of motion of flexion to 124 degrees (normal 180) and abduction to 96 degrees (normal 180) The 22 April 2004 right shoulder MRI showed a possible labral tear and a small tear of the rotator cuff. At the PT examination 2 days later, right shoulder flexion was 157 degrees with  abduction to 158 degrees and pain  with motion  noted.  At the  18 September 2008 orthopedic examination, 8 months prior to separation, the CI reported persistent right shoulder pain. The physical examination showed right shoulder crepitance, pain with internal rotation and apprehension maneuver. The examiner noted a history of shoulder dislocation with labral tear which did not warrant surgery. The 17 November 2008 MEB NARSUM examination, 6 months prior to separation, noted complaints of persistent right shoulder pain. Physical examination showed mild to moderate scapulothoracic dysfunction and mild winging of the scapula.   There was no VA examination proximate to separation in evidence.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the right shoulder condition 10%, analogously coded 5099-5003 (degenerative arthritis). The PEB listed the right humeral head contusion as a related diagnosis (Category II) contributing to the disability in this case. The panel concluded the Category II diagnosis was not a separate condition which could be reasonably justified as separately unfitting; nor would a separate rating be achievable without violation of VASRD §4.14 (avoidance of pyramiding).

Panel members agreed there was evidence of painful motion for a 10% rating analogous to 5003. There was no limitation of forward flexion or abduction at shoulder level for a 20% rating under 5201 (shoulder limitation of motion). There was no malunion or nonunion for a rating under 5202 or 5203. 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.

Right Posterior Tibial Tendonosis. According to the STR and MEB NARSUM, the CI’s right ankle/foot condition began in in March 2008 after the same MVA previously mentioned. The CI sustained a non-displaced fracture of the right posterior malleolus which was treated with casting.  The 28 May 2008 nerve conduction study showed right ankle peroneal neuropathy.

The 1 July 2008 podiatry examination showed tenderness along the peroneal nerve, pain with eversion, and plantar flexion. There were mild sensory deficits, an antalgic gait and guarding of the right foot. The 17 November 2008 MEB NARSUM examination, 6 months prior to separation, noted complaints of persistent right ankle pain. Physical examination showed mild weakness with dorsiflexion and sensory deficits along the superficial branch of the peroneal nerve of the distal lower limb and foot.  There was no VA examination proximate to separation in evidence.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the right ankle/foot condition 10%, analogously coded 5099-5003 (degenerative arthritis). The PEB listed “posterior malleolar fracture right ankle, healed and peroneal nerve dysfunction right ankle, recovered” as related diagnoses (Category II) contributing to the disability in this case. The panel concluded the Category II diagnoses were not separate conditions which could be reasonably justified as separately unfitting; nor would separate ratings be achievable without  violation  of  VASRD §4.14.   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 ankle/foot condition.

BOARD FINDINGS: In the matter of the right shoulder condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. In the matter of the right humeral head contusion condition, the panel recommends no change in the PEB adjudication as a related diagnosis (Category II). In the matter of the right ankle/foot condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. In the matter of the posterior malleolar fracture right ankle, healed and peroneal nerve dysfunction right ankle, recovered, the panel recommends no change in the PEB adjudication as a related diagnosis (Category II). 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.

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 21 Apr 19

1.	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 of no 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.