RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX  	CASE:  PD-2017-04400
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050802

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Indirect Fire Infantryman, medically separated for “chronic pain/instability, left shoulder” 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’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 20050621	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain/Instability, Left Shoulder 	5099-5003	10%	No VA Examination Proximate to Separation in Evidence	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA 	

ANALYSIS SUMMARY:  

Left Shoulder Pain/Instability.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the right-handed CI underwent left shoulder surgery in October 2004 for joint stabilization and ligament repair.  The 18 May 2005 MEB NARSUM examination, 3 months prior to separation, noted complaints of persistent left shoulder pain and limited range of motion (ROM).  Physical examination (PE) revealed decreased and painful ROM of the left shoulder with flexion of 137 degrees (normal 180) and abduction of 76 degrees (normal 180).  There was 3/5 weakness in the left upper extremity.  Increased neurologic sensation was present about the left shoulder muscle mass.  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 10%, analogously coded 5099-5003 (degenerative arthritis), citing the US Army Physical Disability Agency pain policy.  Panel members agreed the limitation of left shoulder abduction to 76 degrees supported a 20% rating under VASRD code 5201 (limitation of arm motion).  Additionally, members agreed that an alternate rating could be supported under a VASRD muscle code of either Group I or III as “moderately severe” due to the 3/5 strength measurement; however, such coding would not be of any additional benefit to the CI in comparison to the limitation of motion code.  There was no clinical evidence of ankylosis or nonunion/malunion of any component of the shoulder girdle.  Therefore, after due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a rating of 20% for the left shoulder condition. 

BOARD FINDINGS:  In the matter of the left shoulder condition, the panel recommends a disability rating of 20%, coded 5201 IAW VASRD §4.71a.  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	
Chronic Pain/Instability, Left Non-Dominant Shoulder 	5201	20%	

The following documentary evidence was considered:

AR20190004418, XXXXXXXX

XXXXXXXXX
Dear XXXXXXXXX:
The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability. I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation. This will not result in any change to your separation document or the amount of severance pay. A copy of this decision will be filed with your Physical Evaluation Board records. I regret that the facts of the case did not provide you with the outcome you may have desired.

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 also been provided to the Department of Veterans Affairs.