RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX 	CASE:  PD-2017-02845
BRANCH OF SERVICE:  army	SEPARATION DATE:  20070626

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Wheeled Vehicle Mechanic, medically separated for “chronic left shoulder pain and instability” with a disability rating of 0%.  

CI CONTENTION:  “Review all conditions.”  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 - 20070405	VARD - 20071025	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Shoulder Pain and Instability	5099-5003	0%	Status Post Injury, Left Shoulder	5024-5201	20%	20070807	
Hyperlipidemia	Not Unfitting	Hypercholesterolemia	7099-7005	NSC	20070807	
High Frequency Hearing Loss, Left Ear	Not Unfitting	Bilateral Hearing Loss	6100	NSC	20070815	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Left Shoulder Pain and Instability.  According to the service treatment record and MEB narrative summary (NARSUM), the right-hand dominant CI’s left shoulder condition began during basic training when he dislocated his left shoulder while doing push-ups.  On 9 January 2001, he underwent left shoulder surgery (open posterior capsular shift/horizontal capsulorrhaphy-rotator cuff) for instability.  In April 2002, recurrent posterior instability was noted with laxity of 1-2+, and surgical reconstruction was offered but reasonably declined.  
The 19 September 2006 orthopedic examination, 9 months before separation, noted CI complaints of left shoulder pain and daily subluxation.  On physical examination, the left shoulder had a normal appearance without muscle atrophy.  Active range of motion (ROM) was flexion/extension to 180 degrees (normal) and abduction to 65 degrees (normal 180).  The examiner documented positive test results for antero-glenohumeral laxity, anterior posterior plane push-off, impingement and painful motion and labrum insufficiency; additional surgical intervention was considered.  

At the 1 November 2006 physical therapy evaluation, 8 months before separation, the CI complained of pain and persistent left shoulder instability after failed reconstruction.  Physical examination showed left shoulder active ROM limited due to posterior subluxation past 100 degrees of flexion or abduction with horizontal adduction in the 90-degree position.  Passive ROM was full with positive, mild sulcus and post-subluxation loading tests.  Electrodiagnostic testing was normal.  

The 17 January 2007 orthopedic consult, 5 months before separation, revealed essentially full ROM.  Positive Hawkins posterior load shift for instability (and painful motion) and sulcus sign (instability) tests were recorded.  Strength was slightly decreased (4+/5) from abduction to external rotation.  The CI was unable to bring his arm up over his head with weight secondary to recurrent shoulder instability, and he had subluxation with any type of activity with his arm out in front of his body.  The left upper extremity was neurologically intact.  The specialist stated he was being referred to a PEB “because of his recurrent dislocation.” 

The 12 March 2007 MEB NARSUM examination, 3 months prior to separation, noted CI complaints of left shoulder pain and instability and an inability to perform the heavy physical requirements of a mechanic with his left arm.  Forward flexion and abduction was to 175 degrees in both planes.  The CI demonstrated posterior subluxations which readily self-reduced during forward flexion, external rotation, and internal rotation ROM.  Strength testing was normal (5/5).  

At the 7 August 2007 VA Compensation and Pension (C&P) evaluation, approximately 1 month after separation, the CI reported recurrent left shoulder subluxation with pain, limited ROM and an inability to lift greater than 5 pounds.  He had daily left shoulder subluxation which he reduced himself.  Physical examination showed forward flexion and abduction of 90 degrees in both planes, with pain.  There was no additional loss of motion with repetition, however there was guarding of movement at shoulder level.  The left upper arm, forearm and shoulder strength was slightly decreased (4/5).  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the non-dominant left shoulder condition 0%, analogously coded 5099-5003 (arthritis, degenerative), citing frequent subluxations but no documented dislocations since surgical repair, and full ROM.  The VA rated the left shoulder condition 20%, coded 5024-5201 (tenosynovitis-arm, limitation of), based on the C&P evaluation, citing limitation of arm motion at shoulder level. 
The VASRD §4.71a threshold for a rating for ROM impairment under code 5201 is “at shoulder level” (90 degrees from the side).  Member consensus was that the NARSUM and 17 January 2007 orthopedic consult examinations demonstrated motion above this level.  However, panel members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion) and functional loss.  By consensus, the panel also agreed was no malunion or recurrent dislocation of the humerus and no dislocation or nonunion of the clavicle or scapula to justify a higher rating under the 5202 (humerus, other impairment of) or 5203 (clavicle or scapula, impairment of) codes.  After due deliberation, considering all of 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 5099-5003.  

Contended PEB Conditions:  High Frequency Loss, Left Ear and Hyperlipidemia.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled, implicated in the commander’s statement, nor judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the left shoulder pain and instability condition, the panel majority recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  The single voter for dissent submitted the appended minority opinion.  In the matter of the contended left ear hearing loss and hyperlipidemia conditions, the panel recommends no change from the PEB determinations as not unfitting.  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 as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Shoulder Pain and Instability 	5099-5003	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170427, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record  

MINORITY OPINION.  The minority voter strongly advocates for a 20% rating for the left shoulder condition.  

The table of analogous codes (current proximate to separation) recommended rotator cuff injuries be analogously rated using code 5203 (clavicle or scapula, impairment of).  The CI had undergone rotator cuff surgery (which failed), and instability and recurrent subluxation were a consistent complaint and finding with significant functional loss of the CI’s dominant shoulder.  All of the specialist examinations, as well as the NARSUM, documented easy subluxation of the left shoulder joint (loose movement), clearly supporting a 20% rating coded 5299-5203 IAW VASRD §4.20 (analogous ratings).  

Alternatively, the preponderance of examinations in evidence (19 September 2006 orthopedic examination, 1 November 2006 PT, and 7 August 2007 VA C&P [closest examination to separation]) would reasonably rate the shoulder at 20% for pain-limited motion (analogous to code 5201) or guarded motion (analogous to code 5201) “at shoulder level.”  The only two examinations which documented shoulder motion not limited to shoulder level (17 January 2007 orthopedic and 12 March 2007 NARSUM), clearly described recurrent and easy subluxation during the examinations, warranting a 20% rating under code 5203 as noted above.  

The minority voter strongly recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Shoulder Pain and Instability	5299-5203	20%	

AR20180006112, 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