RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03498
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20080311

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Aerospace Propulsion Craftsman, medically separated for “right shoulder pain” and “dysthymic disorder,” rated 10% and 0%, respectively, with a combined disability rating of 10%.  

CI CONTENTION:  No specific contention was 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 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 - 20080111	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder Pain	5003	10%	No VA Examination Proximate to Separation in Evidence	
Dysthymic Disorder	9433	0%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Right Shoulder Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the right-handed CI underwent multiple right shoulder surgeries during the period April 1995 to July 2005 with the last procedure being a Bankart repair.  Post-surgical radiographic studies in September 2007 revealed glenohumeral joint changes.  The 1 October 2007 MEB NARSUM examination, 5 months prior to separation, noted complaints of right shoulder pain that worsened with work and changes in weather.  Physical examination showed normal right shoulder strength without evidence of instability, but there was mild tenderness of the deltoid head.  The neurology ROM study, after three repetitions, showed 167 degrees of flexion (normal 180) and 180 degrees of abduction (normal), with pain on external and internal rotation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder condition 10%, coded 5003 (arthritis, degenerative).  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 the examination in evidence demonstrated motion above this level.  Although there was no compensable limitation of motion to support a rating under the LOM code, panel members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion), and §4.40 (functional loss).  Panel members considered other arm and analogous codes, but all were less applicable and/or not advantageous to rating.  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.  

Dysthymic Disorder.  According to the STR and MEB psychiatric addendum, the CI’s dysthymic disorder began in September 2006 when he complained of an inability to regulate his mood.  He denied periods of depressed or elated moods, but noted irritability, low frustration tolerance, and frequent feelings of anger without provocation.  The CI described explosive outburst and reported a childhood history of difficult moods and behavioral problems.   Although the STR noted a history of transient passive suicidal ideation, the CI was never treated in the emergency room (ER) or inpatient psychiatry unit.

The 18 December 2006 MEB psychiatry addendum, 15 months prior to separation, noted complaints of mood instability.  The CI was prescribed antidepressant medication that helped his mood.  He had decreased his alcohol intake, but still underwent an inpatient alcohol dependence rehabilitation program.  During the mental status examination (MSE) the CI was angry and agitated, but cooperated with the examiner. The remainder of the examination was unremarkable with the exception of poor judgment and insight.

The STR going forward demonstrated minimal mental health (MH) treatment.  The CI either cancelled appointments or did not present.  The single MH encounter on 26 November 2007, 3 months prior to separation, noted the CI was still drinking alcohol and was no longer taking his antidepressant medication.  He denied changes in his mood, had no symptoms of depression, but reported chronic feelings of low mood, episodic impulsivity and irritability.  The CI denied a history of panic attacks, anxiety symptoms or symptoms of PTSD.  The MSE was unremarkable with the exception of dysthymic affect, and poor insight/judgment.  The examiner assessed a Global Assessment of Functioning score in the mild range (65).

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the dysthymic disorder 10%, with a 10% deduction for contributing factors of personality disorder and alcohol dependence, for a final rating of 0%, coded 9433 (dysthymic disorder).  Panel members first agreed that the provision of VASRD§ 4.129 for a “mental disorder that develops in service as a result of a highly stressful event” were not applicable. 

Panel members noted a GAF score in the mild range for mild symptoms or impairment due to a MH disorder that also included alcohol dependence and a personality disorder.  Therefore, the panel was unable to justify a rating higher than 10% based on the evidence at the time of separation.  There were no hospitalizations or ER visits, and the CI had no suicidal or homicidal ideations.  There was no report of anxiety, panic attacks, problems with sleep or lack of energy.  In regards to the deduction taken by the PEB, a directed opinion from the examiner addressing the degree of contribution from each diagnosis was not in evidence.  Thus the panel could not fairly apportion a deduction.  Having concluded that no deduction should be applied, members turned to deliberation of a fair rating (IAW VASRD §4.130) of the overall psychiatric disability in evidence at separation.  The panel agreed that a 10% rating and no higher was warranted for mild social and industrial impairment.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the dysthymic disorder, coded 9433.  

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 dysthymic disorder, the panel recommends a disability rating of 10%, coded 9433 IAW VASRD §4.130.  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	
Dysthymic Disorder	9433	10%	
Right Shoulder Pain	5033	10%	
COMBINED	20%	

SAF/MRB
3351 Celmers Lane
JBA NAF Washington, MD 20762-6435

Dear XXXXXXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-03498.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not in accordance with the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay. 

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept the recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  This will not result in any change to your separation documents or the amount of severance pay you are entitled to.  Disability severance pay is computed the same regardless of a rating of 0, 10 or 20 percent.