RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME: XXXXXXXXXXXXXXXX

CASE: PD-2017-03999

BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20051028

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E5, Military Intelligence Analyst, medically separated for “adhesive capsulitis, left (non-dominant) shoulder” with a disability rating of 20%.

CI CONTENTION: Review requested of additional conditions (mood disorder) 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 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 – 20050922	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Shoulder Adhesive Capsulitis	5201	20%	No VA Examination Proximate to Separation in Evidence	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: NA	

ANALYSIS SUMMARY:

Left Shoulder Pain. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI sustained a partial tear of the left (non-dominant) rotator cuff after a motor vehicle accident in 2001, and after recovering through rehabilitation for a year, he re-injured the shoulder during a fitness test. He again underwent physical therapy (PT) and took pain medications without relief, and was diagnosed with left shoulder adhesive capsulitis by orthopedics in May 2005. At the 1 May 2005 occupational therapy visit, 5 months prior to separation, the CI reported decreased range of motion (ROM) and a high level of left shoulder pain. The physical examination (PE) revealed flexion to 85 degrees (normal 180) and abduction to 45 degrees (normal 180), with pain limited motion. A clinical encounter on 17 May 2005 documented both flexion and abduction were to 45 degrees.

The 20 July 2005 MEB NARSUM examination, 2 months before separation, noted complaints of left shoulder pain, and the examiner documented normal bilateral grip strength and left upper arm strength “slightly less” than the right.       There were no left shoulder or arm neurovascular

changes, and reflexes were 2+ and equal in both upper extremities. A left shoulder MRI done on 16 August 2005 was normal. 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 left shoulder condition 20%, coded 5201 (arm, limitation of motion), citing limitation of motion. The VASRD §4.71a threshold for rating ROM impairment under this code is 20% where ROM is “at shoulder level” (approximately 90 degrees from the side), or when abduction is “midway between side and shoulder level” (approximately 45 degrees from the side). The highest 30% rating for a non-dominant arm requires motion limited to “25 degrees from side,” but examinations did not reflect this degree of limitation. Therefore, absent any degree of fibrous union or nonunion of the humerus to justify a higher rating under code 5202 (humerus, other impairment of), and no higher ratings available under code 5203 (clavicle or scapula, impairment of), the ROM measurements clearly supported the PEB’s 20% 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 left shoulder condition.

BOARD FINDINGS: In the matter of the left 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.

2	PD-2017-03999

AR20200000232,

Dear

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.

A copy of this decision has been provided to the counsel you listed on your application, XXXXXXXXXXX.

Printed on	Recycled Paper