RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXXX	CASE: PD-2019-00160
BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20030428

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Operations Specialist, medically separated for “left shoulder posttraumatic and postoperative loss of motion/adhesive capsulitis” with a disability rating of 10%.

CI CONTENTION: Review requested of the left shoulder condition, which has worsened, as well as additional conditions not identified by the Medical Evaluation Board (MEB) and/or Physical Evaluation Board (PEB). 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 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 - 20030122	VARD - 20040413	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Shoulder…Loss of
Motion/Adhesive Capsulitis	5299-5003	10%	

Left Shoulder, Post- Operative	

5201	

20%	

20030702	
Left Shoulder Instability, Status Post (S/P) Anterior Capsular Shift	Cat II					
Left Shoulder Ulnar Nerve Myelopathy	Cat II					
Left Shoulder Instability, S/P Scope
Posterior Capsular Shift	Cat II					
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 20%	

ANALYSIS SUMMARY:

Left Shoulder Loss of Motion/Adhesive Capsulitis. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI injured his left (non-dominant) shoulder in September 2000 while playing flag football, and underwent an open posterior capsular shift in September 2001 and second stage procedure for anterior stabilization in June 2002. During the 30 September 2002 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, he reported left shoulder pain and tenderness, and the examiner noted numbness from the left shoulder to the hand with certain positional changes, and limited use of the left shoulder and arm. The 31 October 2002 MEB NARSUM examination noted complaints of significant pain with certain activities and weather changes, and numbness with abduction. On

examination, left shoulder flexion was to 110 degrees (normal 180) and abduction to 90 degrees (normal 180), after repetition, and with painful motion and guarding. Physical findings showed pain with apprehension and load shift, but negative sulcus signs and no posterior instability.

At the 2 July 2003 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported constant pain and numbness of the ulnar distribution of the left upper extremity with decreased range of motion (ROM) and flare-ups 3-4 times per week. He was also unable to lift more than 10 pounds and could not reach up above his head with the left arm. Physical examination showed both flexion and abduction to 90 degrees, with pain present during all motion, but no fatigue, weakness, lack of endurance, or incoordination.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the shoulder condition 10%, analogously coded 5299-5003 (arthritis, degenerative). All three Category II conditions noted by the PEB constituted various components of the CI’s left shoulder condition already captured by the 5299-5003 coding, and thus were not separately ratable IAW VASRD §4.14 (avoidance of pyramiding). The VA rated the shoulder condition 20%, coded 5201 (arm, limitation of motion of), based on the C&P examination, citing mild tenderness with flexion, abduction, flexion, and internal/external rotation to 90 degrees, and pain in two planes. The VASRD §4.71a threshold for rating non-dominant arm ROM impairment under code 5201 (arm limitation of motion) is “at shoulder level,” and the examinations in evidence reflected this degree of limitation. 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 5299-5003.

BOARD FINDINGS: In the matter of the left shoulder condition, the panel recommends a disability rating of 20%, coded 5299-5003 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	
Left Shoulder Posttraumatic and Postoperative Loss of Motion/Adhesive Capsulitis	5299-5003	20%	

2	PD-2019-00160

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

IN REPLY REFER TO,
1850
CORB:003 12 Oct 20

From: To:

Subj:

Ref:

Director, Secretary of the Navy Council of Review Boards 

PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)
(a) DoDI 6040.44
(b)	PDBR ltr of 18 May 20
(b)	

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation to the Department of the Navy for appropriate action.

2.	On 7 October 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) took action in your case by accepting the recommendation of the PDBR. Accordingly, your records will be corrected to reflect an increase in the disability rating awarded by the Department of the Navy Physical Evaluation Board (PEB) from 10% to 20% without re-characterization of your discharge.

3.	For your information, since all disability ratings from 0% to 20% qualify for disability severance pay, the above stated increase will not result in your entitlement to additional compensation.

4.	The Assistant Secretary's determination, which represents final action in your case by the Department of the Navy, has been forwarded to the Navy Personnel Command for appropriate changes to your personnel records and notification to you upon completion.