RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04496
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061101

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Combat Engineer, medically separated for “limitation of motion of right (dominant) shoulder” with a disability rating of 20%.  

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 - 20060927	VARD - 20070419	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Limitation of Motion of Right (Dominant) Shoulder…	5201	20%	Impingement Syndrome, Right Shoulder	5201	30%	20061227	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Right Shoulder Limitation of Motion.  According to the service treatment record and MEB narrative summary (NARSUM), the CI underwent a Bankart repair in July 2005 for right shoulder anterior instability. His recovery was complicated by adhesive capsulitis, and in October 2005 he had a second procedure for manipulation under anesthesia to increase shoulder range of motion (ROM).  He was improving until he experienced pain and subluxation after lifting his child.  He also complained of right upper extremity numbness, and electrodiagnostic studies in December 2005 showed mild C6-7 radiculopathy.  However, a cervical spine MRI on 17 February 2006 was normal and the numbness was thought to be related to nerve impingement due to scarring in the shoulder.  In March 2006, he underwent a third arthroscopic repair for inferior instability, but post-operatively, he continued to have chronic right shoulder pain and decreasing ROM.  

The CI was referred for a second opinion, and on 19 June 2006, the orthopedic specialist noted complaints of significant pain with any lifting and daily activities.  On examination, he had a grade I shift (laxity) with a sensation of occasional popping and pain (although this was not reproducible every time).  Right shoulder ROM testing showed flexion of 80 degrees (normal 180) and abduction of 80 degrees (normal 180).  There was significant pain with ROM and also with impingement testing.  A shoulder MRI on 17 July 2006 revealed irregularity of the anterior right labrum, joint capsule, glenohumeral articular cartilage and humeral head consistent with a prior Bankart lesion repair.  There was also fraying of the intact supraspinatus tendon and a posterior glenoid articular cartilage abnormality.  At the second opinion orthopedic follow-up visit on 2 August 2006, both flexion and abduction were to 120 degrees, with painful motion.  The provider noted the CI was actively resisting the examination, possibly secondary to pain at the extremes of motion.  A shoulder fusion was considered the only surgical option, however, it was not recommended as it would not return the CI to a level of function to allow continued service.  

At the 21 August MEB physical therapy ROM evaluation, 2 months prior to separation, shoulder flexion and abduction (after three repetitions) were to 55 degrees, with pain.  During the 15 September 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), the CI reported right shoulder pain, and the examiner noted decreased ROM and sensation on the lateral aspect of the right arm and hand.  The MEB NARSUM examination on the same day, noted complaints of moderate and constant right shoulder pain rated at 5/10, which increased to 8/10 when “outside his comfort zone.”  The CI also reported needing assistance with bathing and dressing due to pain and decreased ROM.  The examiner referenced the MEB PT ROM measurements, and was unable to test right shoulder strength due to decreased ROM.  Sensation of the lateral aspect of right hand was decreased compared to left.  At a 29 September 2006 orthopedic appointment, the CI complained of continued shoulder pain, and the provider noted “abnormal” shoulder motion based on the PT ROM evaluation.  There was no shoulder tenderness or muscle atrophy.  

At the 3 January 2007 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported chronic right shoulder pain, rated at 9/10, and decreased ROM and stiffness, but denied instability, recurrent subluxation, dislocation, or flare-ups.  Physical examination showed tenderness and guarding of movement, but no swelling or instability.  Right shoulder ROM showed flexion to 60 degrees and abduction to 45 degrees.  Painful motion was noted, but there was no additional loss of ROM with repetition.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder condition 20%, coded 5201 (arm, limitation of motion of), citing abduction and flexion to 55 degrees and that this was “past midway” and therefore rated as “at shoulder level” since pain was an element of the limited motion.  The VA rated the right shoulder condition 30%, coded 5201, based on the C&P examination, citing limitation of motion with abduction to 45 degrees.  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).  The 30% rating for the dominant arm requires motion limited to “midway between side and shoulder level” (approximately 45 degrees from the side), and the evidence reflected a degree of limitation that was between these two levels.  Right shoulder flexion and abduction ranged between 45 and 60 degrees at both the PT ROM and C&P examinations.  The CI consistently reported right shoulder pain aggravated by daily use and limiting his ability to lift anything or bath and dress himself.   The panel noted his subjective symptoms were supported by objective findings during physical examinations as well as imaging of residual shoulder laxity and joint damage from prior dislocations/subluxations.  Residual nerve related pain due to post-operative scarring was also supported by electrodiagnostic studies.  Although ROM of 55 or 60 degrees is literally above the midway point from the side to the shoulder, the panel majority agreed it was far closer to midway than “at shoulder level,” and given the functional impact of chronic pain and this degree of limitation of arm motion, concluded the CI’s disability is more appropriately rated at midway to the shoulder IAW VASRD §4.71a with consideration of §4.40 (functional loss).  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the right shoulder condition, coded 5201.  

BOARD FINDINGS:  In the matter of the right shoulder condition, the panel majority recommends a disability rating of 30%, coded 5201 IAW VASRD §4.71a.  The single voter for dissent recommends no change and did not elect to submit a minority opinion.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Limitation of Motion of Right (Dominant) Shoulder	5201	30%	

The following documentary evidence was considered:  

AR20190006906, XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiries concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX

	A copy of this decision has also been provided to the Department of Veterans Affairs.