RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXX	CASE: PD-2017-04001
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20070321

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E7, Combat Engineer, medically separated for “right (dominant) shoulder pain” with a 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 - 20070116	VARD - 20071022	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right (Dominant) Shoulder Pain	5099-5003	10%	Right Rotator Cuff Injury	5201	20%	20070828	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 30%	

ANALYSIS SUMMARY:

Right (Dominant) Shoulder Pain. According to the service treatment record and MEB narrative summary (NARSUM), the CI underwent a right shoulder rotator cuff repair with distal clavicle excision and debridement of a superior labral anterior to posterior tear in January 2006. A post- surgical MRI showed a small amount of fluid within the subacromial bursa, and he had a second procedure in May 2006 with debridement of the biceps tendon and labrum, and a biceps tendon transfer.  Shoulder X-rays in December 2006 showed acromioclavicular joint widening.

During the 6 December 2006 MEB NARSUM examination, 4 months prior to separation, the CI complained of right shoulder pain when washing his hair or abducting his arm over 90 degrees; he also had subjective numbness in the right hand. The examiner noted he had “regained good motion, but continue[d] to have chronic right shoulder pain…especially with repetitive motion.” Measured flexion was to 150 degrees (normal 180) and abduction to 140 degrees (normal 180).

At the 28 August 2007 VA Compensation and Pension (C&P) examination, 5 months after separation, the CI complained of right shoulder pain and stiffness, but denied dislocation, subluxation, locking, inflammation or effusion.  He also had weekly flare-ups which caused pain

and decreased endurance. Physical examination showed flexion to 180 degrees, with pain starting at 170 degrees, and abduction to180 degrees with pain starting at 90 degrees. There was no evidence of recurrent shoulder dislocations, inflammatory arthritis or joint ankylosis.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the right shoulder condition 10%, analogously coded 5099-5003 (degenerative arthritis), citing slight and frequent pain IAW the US Army Physical Disability Agency pain policy. The VA rated the right shoulder condition 20%, coded 5201 (limitation of arm motion), based on the C&P examination, citing “arm motion limited at shoulder level.” Panel members noted that the VASRD §4.71a threshold for rating for ROM impairment under code 5201 is “at shoulder level” (approximately 90 degrees from the side), and the examinations in evidence demonstrated motion above this level. However, a 10% rating was justified with application of VASRD §4.59 (painful motion). There was no malunion or recurrent dislocation of the humerus to justify a rating under code 5202 code (humerus impairment); and no nonunion with loose movement of the clavicle to warrant the next higher 20% rating under code 5203 (impairment of the clavicle or scapula). 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 right 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-2017-04001

DEPARTMENT OF THE ARMY
ARMY REVIEW BOARDS AGENCY
251 18TH STREET SOUTH, SUITE
385
ARLINGTON, VA 22202-3531

AR20200000301, 

Dear XXXXXXXXXXXXXX
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.

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