RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04328
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20051101

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Radiology Specialist, medically separated for “left shoulder pain” with a disability rating of 0%.  

CI CONTENTION:  The CI made no specific contention.  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 - 20051005	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Shoulder Pain	5099-5003	0%	No VA Examination Proximate to Separation in Evidence	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA  	

ANALYSIS SUMMARY:  

Left Shoulder Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI underwent two left (non-dominant) shoulder surgeries with the final one in January 2003 for shoulder chondromatosis and instability.  Eight months prior to separation, an emergency room (ER) visit noted the CI was evaluated for a burning sensation about the left shoulder.  His physical examination (PE) revealed full range of motion (ROM) of the left shoulder.  Upper extremity strength was normal.  The CI was diagnosed with shoulder pain and muscle strain.    

At the 23 August 2005 MEB NARSUM examination, 3 months prior to separation, the CI endorsed complaints of chronic pain and instability in his left shoulder.  His PE revealed well-healed incisions over his left shoulder consistent with his surgical history.  Left shoulder ROM was listed as forward flexion to 120 degrees (normal 180).  There was no comment with regard to abduction of the left shoulder.  Upper extremity strength and sensation were intact.  Eight days after the MEB NARSUM examination, physical therapy measured left shoulder ROM as forward flexion to 157 degrees and abduction to 154 degrees (normal 180).  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 at 0%, analogously coded 5099-5003 (arthritis, degenerative), citing chondromalacia.  The minimum rating under code 5201 (arm, limitation of motion) for the non-dominant arm requires motion limited to “at shoulder level” and the ER and PT ROM evaluations reflected limitation occurring above shoulder level.  Therefore, the limitation of motion evidence of record for the left shoulder did not support a rating under diagnostic code 5201.  Additionally, the pre-separation PT examination did not note findings of swelling, muscle spasm, painful motion or other evidence of functional loss to support a 10% rating IAW VASRD §4.59, §4.40 or §4.45.  There was no malunion, deformity, or recurrent dislocation of the humerus to justify a rating under the 5202 code (humerus, other impairment of); and no nonunion or malunion of the clavicle or scapula to warrant a rating under the 5203 code (clavicle or scapula, impairment of).  After due deliberation, considering all of 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. 

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170502, w/atchs
Exhibit B.  Service Treatment Record

AR20180006274, XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	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.

Sincerely,					      
Enclosure