RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXX  	CASE:  PD-2017-03879
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090309

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Automated Logistical Specialist, medically separated for “right shoulder pain” with a disability rating of 20%.  

CI CONTENTION:  “More service connected disabilities have been found since discharge.”  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 – 20081212	VARD – 20090520	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Shoulder Pain	5201	20%	Status Post Rotator Cuff Repair, Right Shoulder	5099-5019	10%	20090313	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  10% 	

ANALYSIS SUMMARY:  

Right Shoulder Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s shoulder condition began in December 2003 after falling off a truck and hyperextending his shoulder.  A right shoulder arthroscopy with superior labral repair was conducted on March 2008.  The 29 October 2008 MEB NARSUM examination, 5 months prior to separation, noted complaints of chronic right shoulder pain.  The dull, achy pain was approximately 6/10, and increased to 8-9/10 with motion.  Physical examination revealed right shoulder forward flexion to 160 degrees (normal 180) and abduction to 90 degrees (normal 180) with pain.  There was tenderness at the right biceps tendon area.  Also noted were three surgical scars approximately 15 cm in length located in the right shoulder area.  

At the 13 March 2009 VA Compensation and Pension (C&P) examination, 4 days after separation, the CI reported right shoulder pain that was worse with overhead  range of motion (ROM).  Physical examination revealed no deformity, tenderness, or joint instability.  ROM was 130 degrees forward flexion and 130 degrees abduction with pain on motion.  There was no evidence of any joint effusion, and no swelling, heat, or redness.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the shoulder condition 20%, analogously coded 5201 (arm, limitation of motion), citing loss of (dominant) shoulder mobility at shoulder level.  The VA rated the shoulder condition 10%, analogously coded 5099-5019 (bursitis), based on the C&P examination, citing painful or limited motion of a major joint or group of minor joints.  

The VASRD §4.71a threshold for rating for ROM impairment is “at shoulder level” (approximately 90 degrees from the side).  The 30% rating for the dominant arm requires motion limited to “midway between side and shoulder level” and the MEB NARSUM examination reflected this degree of limitation.  There was no malunion with marked deformity or frequent episodes of recurrent dislocation of the humerus to justify a higher rating under the 5202 code (humerus, other impairment), and no higher rating available under the 5203 code (clavicle or scapula, impairment).  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.  

BOARD FINDINGS:  In the matter of the shoulder condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  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.  

PD-2017-03879

AR20190011646, XXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXX

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.

PD-2017-03879