RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-05933
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20060425

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Infantryman, medically separated for “chronic left shoulder pain” with a disability rating of 10%.  

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 - 20060407	VARD - 20070330	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Shoulder Pain 	5099-5003	10%	Left Shoulder Injury	5201	0%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Left (Non-Dominant) Shoulder Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent Bankart repair with electrothermal capsular shrinkage on his left shoulder prior to entering military service in March 1999.  He underwent a second surgery for left open inferior capsular shift and Bankart repair on 27 September 2005.  

At the orthopedic follow-up on 1 March 2006, 5 months post-surgery and 2 month prior to separation, the CI reported residual pain and no instability.  On examination, there was no swelling, tenderness, atrophy or weakness in the shoulder, arm or hand.  The range of motion (ROM) was reported as abnormal with flexion to 160 degrees (normal 180) and abduction to 140 degrees (normal 180).  During the orthopedics clinic surgery follow-up visit on 23 March 2006, 6 months post-surgery and 1 month prior to separation, the CI complained of severe left shoulder pain.  The examiner noted no erythema or effusion.  The ROM testing showed flexion of 160 degrees and abduction to 140 degrees.  

The 30 March 2006 MEB NARSUM examination, 1 month prior to separation, noted complaints of chronic left shoulder pain.  The CI stated he had decreased stability of the left shoulder and felt his ROM was mechanically blocked and not just limited by pain.  Physical examination was performed on 31 January 2006 and showed symmetrical shoulders with no evidence of atrophy or sulcus.  The left shoulder was not tender, but the CI had painful ROM with active flexion to 160 degrees and abduction to 135 degrees.  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%, coded 5099-5003, citing pain rated IAW the US Army Physical Disability Agency pain policy.  The VA rated the left shoulder condition 0%, coded 5201 (arm limitation of motion), citing failure to appear for a scheduled examination.  The VASRD §4.71a threshold for rating ROM impairment (code 5201) is “at shoulder level” (approximately 90 degrees from the side), the examinations in evidence demonstrated motion above this level.  Although there was insufficient limitation of motion to support a rating under the 5201 code, panel members agreed that 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 the 5202 code (humerus, other impairment of); and no nonunion with loose movement of the clavicle to warrant the next higher 20% 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 20170707, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180008259, 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