RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2017-06153
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20070105

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Courier, medically separated for “left shoulder adhesive capsulitis” with a disability rating of 0%.  

CI CONTENTION:  The VA provided a higher rating.  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 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 - 20061213	VARD - 20070524	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Shoulder Adhesive Capsulitis	5201	0%	Adhesive Capsulitis, Left Shoulder	5201	20%	20070226	
Left Shoulder Ectopic Calcification with Restricted Elbow Extension	
Cat II
	Left Elbow Ankylosis and Sprain	5205	30%	20070226	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Left Shoulder Adhesive Capsulitis.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the right-hand dominant CI traumatically injured his left shoulder in February 2005.  In July 2005, he underwent an open Bankart and arthroscopic reconstruction to repair superior and anterior labrum tears, and after a delay in physical therapy (PT) for over 3 months, he had a second surgery in October 2005 due to pain and stiffness.  The CI underwent a third surgery on 31 July 2006 (capsular release and manipulation under anesthesia) after continued left shoulder limited range of motion (ROM) and pain (adhesive capsulitis).  

The 31 August 2006 MEB NARSUM examination, 4 months prior to separation and 1 month after surgery, noted complaints of left shoulder stiffness and pain.  Physical findings documented forward flexion to 170 degrees (normal 180), and discomfort at the end of abduction (ROM not quantified).  An X-ray revealed surgical changes and osteoarthritis, and the examiner stated that despite possible improvements, the CI would “most likely be left with a residual functional deficit in his left shoulder limiting his ability to do lifting and overhead work.”  

At the 26 February 2007 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported left shoulder pain, stiffness, weakness and giving way.  Physical examination revealed left shoulder flexion to 130 degrees and abduction to 90 degrees, with painful motion in both planes, and increased pain on repetition without further ROM loss.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 0%, coded 5201 (arm, limitation of motion).  The VA rated the left shoulder condition 20%, also coded 5201, based on the C&P examination, citing abduction limited to 90 degrees.  Panel members deliberated over the probative value of the PT and VA examinations, which were similarly close to the date of separation.  However, the VA examination was more detailed, considered repetition and DeLuca criteria and was further from the last in-service left shoulder surgery accounting for any honeymoon period or post-surgical scarring.  Given the CI’s multiple left shoulder surgeries, recurrent post-operative capsulitis and manipulation under anesthesia within 1 month of the PT ROMs, the panel adjudged that the VA examination had the highest probative value for rating.  A 20% VASRD §4.71a rating for the non-dominant arm (code 5201) requires motion limited to “at shoulder level,” and the VA examination reflected this degree of limitation.  A 30% rating was not warranted since arm motion was not limited to 25 degrees from the side.  The panel considered other VASRD shoulder and analogous codes, but all were less applicable and/or not advantageous for rating.  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 left shoulder condition, coded 5201.  

Contended PEB Condition:  Left Shoulder Ectopic Calcification with Restricted Elbow Extension.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  According to the STR and MEB NARSUM, the CI injured his left elbow and shoulder at the same time, and developed an ectopic elbow calcification (confirmed by X-rays) that caused pain and stiffness.  The NARSUM physical examination revealed a tender mobile firm mass in the posterolateral aspect of the elbow and restricted ROM “from 20 degrees short of full extension (normal 0) to 135 degrees of flexion (normal 145),” with full pronation and supination.  The contended condition was profiled 4T per the commander’s statement, and it was noted that the CI’s medical conditions affected his ability to fulfill primary duty requirements.  The 31 August 2006 orthopedic NARSUM examiner stated the left shoulder and elbow prevented overhead work and heavy lifting, and recommended the left elbow condition be addressed by the MEB in addition to the left shoulder.  The MEB indicated the left “left elbow ectopic calcification with restricted elbow extension” did not meet retention standards.  After the NARSUM was completed, the CI underwent left elbow arthroscopy on 28 November 2006, 1 month prior to separation, with excision of a painful lateral olecranon (ulnar) osteophyte and correction of a 20-degree flexion contracture with burring in the joint to smooth the articular cartilage.  He continued to complain of left elbow pain, stiffness and painful motion.  The C&P examination documented an ankylosed left elbow in favorable condition, however subsequent VA treatment notes documented painful left elbow motion with full ROM or lacking 15 degrees of extension, without painful motion.  

The panel noted the PEB changed the MEB diagnosis from “left elbow ectopic calcification with restricted elbow extension” to “left shoulder ectopic calcification with restricted elbow extension” which was most likely a transcription error as there was no shoulder ectopic calcification.  After due deliberation, the panel agreed the preponderance of the evidence with regard to the functional impairment of the left elbow condition favors its recommendation as an additionally unfitting condition for disability rating.  Regarding rating, the panel members adjudged that although the VA examination was closest to separation and noted left elbow favorable ankylosis, it was however, closest to surgery and considered an outlier, as pre-separation notes indicated left elbow motion following surgery and subsequent VA treatment indicated full active ROM, or near full ROM), with painful motion.  Although absent the initial C&P examination, there was insufficient limitation of motion to support a rating under codes 5205 through 5209, and panel members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion) and functional loss.  Since there was surgical repair of the olecranon, coding analogous to 5211 (ulna, impairment) was chosen IAW VASRD §4.20 (analogous ratings).  There was no nonunion or false joint for any higher rating.  After due deliberation, the panel agreed the preponderance of the evidence with regard to the functional impairment of the left elbow ectopic calcification favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 5299-5211 and meets the VASRD §4.71a criteria for a 10% rating.  

BOARD FINDINGS:  In the matter of the left shoulder condition, the panel recommends a disability rating of 20%, coded 5201 IAW VASRD §4.71a.  In the matter of the contended left elbow condition, the panel agrees it was unfitting and recommends a disability rating of 10%, coded 5299-5211 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; 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	
Left Shoulder Adhesive Capsulitis	5201	20%	
Left Elbow Ectopic Calcification with Restricted Elbow Extension	5299-5211	10%	
COMBINED	30%	

Dear XXXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-06153.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not in accordance with the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay

I have carefully reviewed the evidence of record and the recommendation of the Board.    I concur with that finding, accept the recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at (210) 565-2273 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 90 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married, in such a case, failure to render an election will result in automatic enrollment by law.