RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXXXX		CASE: PD-2017-03254 BRANCH OF SERVICE: MARINE CORPS	SEPARATION DATE: 20090730

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Automotive Mechanic, medically separated for “instability of shoulder [right]” with a disability rating of 10%.

CI CONTENTION: Review requested of the higher VA rating and additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB) was therefore implicated as 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 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 - 20090504	VARD - 20090901	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Instability of Shoulder [Right]	5099-5003	10%	Status Post Right Shoulder Arthroscopic Repair	5201	20%	20070312	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 40%	

ANALYSIS SUMMARY:

Right Shoulder Instability. According to the service treatment record and MEB narrative summary (NARSUM), the CI initially injured his right (dominant) shoulder (felt it pop out of place) during basic training in September 2006, and subsequently re-injured it in 2007. On 14 December 2007, he underwent arthroscopic surgery with an anterior labral repair, subacromial decompression, and distal clavicle resection. An MRI performed in 2008 showed no labral tear or acromioclavicular joint arthrosis.

At the 16 December 2008 MEB NARSUM examination, 8 months prior to separation, CI reported right shoulder pain and instability exacerbated by lifting, wearing a flight jacket and running; he was unable to do pushups. Physical examination revealed no right shoulder swelling, but tenderness was present as well as a positive apprehension test (guarding of shoulder movement), and shoulder load and shift tests that elicited pain but no subluxation (partial dislocation). Right shoulder strength was good with internal and external rotation, and range of motion (ROM) showed flexion and abduction to 160 degrees (normal 180); painful motion was not addressed.

During the 11 February 2009 VA Compensation and Pension (C&P) examination, 6 months before separation, the CI complained of right shoulder pain that radiated to the back of the neck and upper back, and was associated with stiffness, weakness, heat, giving way, dislocation and lack of endurance. He denied having any periods of incapacitation in the past year. Physical examination revealed no right shoulder swelling, abnormal movement, instability or weakness. Repetitive goniometrically measured flexion was to 120 degrees and abduction to 90 degrees, with painful motion. There was no additional ROM loss following repetitive use.

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 (degenerative arthritis). The VA rated the right shoulder condition 20%, coded 5201 (arm, limitation of motion), based on C&P examination, citing limitation of abduction. The VASRD §4.71a threshold for rating ROM impairment under code 5201 is “at shoulder level” (approximately 90 degrees from the side), and the VA ROM evidence (VASRD §4.46 compliant) prior to and closest to separation, supports a 20% rating. There was no fibrous union or nonunion of the humerus (5202) with marked deformity or recurrent dislocation at the scapulohumeral joint with frequent episodes and guarding of all arm movements to support a higher 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 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	
Instability of Shoulder (Right)	5201	20%	

The following documentary evidence was considered:

2	PD-2017-03254

DEPARTMENT OF THE NAVY
SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309
WASHINGTON NAVY YARD, DC 20374-5023

IN REPLY REFER TO
6040
CORB:003 14 May 21

From: Director, Secretary of the Navy Council of Review Boards To:	XXXXXXXXXXXXXXXX

Subj:	Physical Disability Board of Review Determination Ref:	(a) 6040.44(Series)
1.	The Physical Disability Board of Review (PBDR) reviewed your case in accordance with reference
(a) and forwarded their recommendation for action.

2.	On 23 April 2021 the Assistant Secretary of the Navy (Manpower and Reserve Affairs) accepted the PDBR’s recommendation of an increase in disability rating to 20%. This decision was then sent to Navy Personnel Command for appropriate action.

3.	The PDBR determination is final and not subject to appeal or review.