RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01535
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061019

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E5, Recovery Operator and Mechanic, medically separated for “limitation of motion, right (dominant) arm” with a disability rating of 20%.  

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 -20060929	VARD - 20080607	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Limitation of Motion, Right (Dominant) Arm 	5201	20%	Aseptic Necrosis S/P Hemiarthroplasty and Adhesive Capsulitis, Right Shoulder	5201-5051	60%	20080213	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Limitation of Motion, Right (Dominant) Arm.  According to the service treatment record and MEB narrative summary (NARSUM), the CI had blunt trauma to his right shoulder (struck by the hook of a five ton crane), developed avascular necrosis of the humeral head, and underwent right shoulder hemiarthroplasty (humeral head prosthesis) on 5 August 2005.  Post-operative X-rays demonstrated a right shoulder prosthesis in good position.  The CI had continued shoulder pain and limited motion (adhesive capsulitis) and underwent manipulation under anesthesia on 15 March 2006, which did not resolve the CI’s shoulder symptoms.  

The May 2006 MEB NARSUM examination (approved 6 July 2006), and the 10 May 2006 occupational therapy MEB evaluation, 5 months prior to separation, noted complaints of right shoulder pain with decreased grip strength.  The CI indicated he was right-handed, but was using his left hand for jar opening, door knob turning, brushing his teeth and hair and any activities above the shoulder.  Physical examination showed tenderness to the anterior shoulder with painful range of motion (ROM) of abduction to 55 degrees (normal 180) and flexion of 55 degrees (normal 180).  Right hand grip strength was significantly diminished to 19.7% of normal.  The 22 August 2006 orthopedic NARSUM addendum agreed with the NARSUM physician and clarified that limited right shoulder ROM was due to adhesive capsulitis and pain.  

At the 13 February 2008 VA Compensation and Pension (C&P) evaluation, 16 months after separation, the CI reported right shoulder pain, limited motion, inability to work overhead and decreased right grip strength.  He sometimes used a right arm sling and brace.  Physical examination showed the right shoulder was slightly smaller, with slight decrease in the size of the deltoid muscle (lifts arm), and there was decreased (4/5) motor function in the deltoid area. The anterior joint was painful to palpation.  ROM was painful with abduction to 48 degrees, and flexion to 54 degrees, both with increase after repetition.  The examiner was unable to achieve 90 degrees of passive abduction for complete ROM measurements.  There was no right forearm atrophy.  

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 of), citing 55 degrees of abduction and flexion.  The VA rated the right shoulder condition 60%, analogously coded 5201-5051 (arm, limitation of motion - shoulder replacement (prosthesis)), based on the C&P examination, citing a prosthetic right humeral head with chronic residuals consisting of severe painful motion or weakness in the affected extremity.  

The panel discussed that the VASRD code 5051 makes no distinction between partial or total replacement of the shoulder joint and the CI had placement of a prosthesis in the right shoulder (hemiarthroplasty).  The 5051 60% rating criteria is “with chronic residuals consisting of severe, painful motion or weakness in the affected extremity.”  Code 5051 indicates that “with intermediate degrees of residual weakness, pain or limitation of motion, rate by analogy to diagnostic codes 5200 and 5203.”  The minimum rating for a shoulder with a prosthesis is 30%.  

The NARSUM and orthopedic examinations were closest to separation and had the highest probative value for rating at separation.  The CI had a hemiarthroplasty or “partial shoulder replacement” (humeral head prosthesis) and not a total shoulder joint replacement.  The VA historically (2004-2008) applied code 5051 for shoulder hemiarthroplasty, although informal VA communication in 2009-2010 indicated that codes 5051-5056 (excluding 5054-hip) were for total joint replacement.  Although analogous coding to 5051 was considered, the panel adjudged that rating analogous to code 5021 was predominant.  

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 all examinations documented at least that level of limitation.  The next higher 30% rating for the dominant arm requires motion limited to “midway between side and shoulder level.”  The panel deliberated if the CI’s disability picture at separation warranted the 30% rating analogous to code 5201 considering CI’s abduction and flexion ROMs more closely approached “midway between side and shoulder level” and the CI had decreased grip strength causing additional functional loss (based on §4.59, §4.40 and §4.45).  Alternative rating analogous to 5051 would not rate higher than 30%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the right shoulder condition, coded 5299-5201.  
BOARD FINDINGS:  In the matter of the right shoulder condition, the panel recommends a disability rating of 30%, 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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Limitation of Motion, Right (Dominant) Arm 	5299-5201	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170227, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180007943, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs. 

Sincerely,					      
Enclosure