RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXXXX	CASE: PD-2017-05787
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20050526

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Light Wheeled Vehicle Mechanic, medically separated for “right shoulder pain” with a disability rating of 10%.

CI CONTENTION: In addition to the right shoulder, the CI requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB) was requested.  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’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 - 20050315	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Shoulder Pain	5099-5003	10%	No VA Examination Proximate to Separation in Evidence	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: NA	

ANALYSIS SUMMARY:

Chronic Right Shoulder Pain. According to the service treatment record and MEB narrative summary (NARSUM), the right-hand dominant CI’s right shoulder condition began in January 2004 after a 5-ton truck tailgate fell on him. He continued to have decreased range of motion (ROM) in abduction and external rotation and with any elevation or swinging motion of the right arm. An MRI in June 2004 showed mild supraspinatus tendinosis, mild acromioclavicular arthrosis and questionable degenerative changes of the anterior superior labrum without discrete tear. Electrodiagnostic studies were normal. Orthopedics found no focal lesion that could be surgically corrected.

During the physical therapy (PT) clinic examination on 10 December 2004, 5 months prior to separation, the CI complained of constant 3-6/10 pain in the shoulder joint and upper trapezius region. Physical examination showed mild guarded positioning of the right upper extremity without muscle atrophy, bony deformity or gross asymmetry of scapulohumeral tracking through active flexion and abduction. The ROM evaluation showed painful active flexion of 150 degrees (normal 180) and abduction of 90 degrees (normal 180).

The 4 February 2005 MEB NARSUM examination, 3 months prior to separation, noted complaints of right shoulder pain located in the anterior and posterior aspects of the shoulder to include the glenohumeral joint. He characterized the pain as achy to sharp pain, rated a 6/10, and varied in intensity with activity. The symptoms were constant and worsened with overhead work or with swinging, rotating or lifting the right arm. Physical examination of the right shoulder revealed no focal tenderness over the rotator cuff, but there was mild tenderness over the AC joint. The ROM evaluation by PT on 31 January 2005 showed painful flexion of 138 degrees and abduction of 85 degrees after repetitive motion. Provocative testing for rotator cuff impingement signs was negative. His motor strength was 5/5 with some cogwheel weakness on abduction. Distally he was fully neurovascularly intact. 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 right shoulder condition 10%, analogously coded 5099-5003 (arthritis, degenerative), citing degenerative joint disease with slight loss of motion. The VASRD §4.71a threshold for rating for ROM impairment (code 5201, arm limitation of motion) is “at shoulder level” (approximately 90 degrees from the side). The 20% rating for the dominant arm requires motion limited to “at shoulder level” and PT ROM evaluations reflected this degree of limitation. There was no malunion with marked deformity or frequent episodes of recurrent dislocation of the humerus to justify a higher rating under the 5202 code (humerus, other impairment of) and no higher rating available under the 5203 code (clavicle or scapula, impairment of). After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the right shoulder condition, coded 5201.

BOARD FINDINGS: In the matter of the right 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 Right Shoulder Pain	5201	20%	

ARXXXXXXXXXXX

Dear XXXXXXXXXXXXXXX:

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.

Sincerely,

Enclosure