RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXX CASE: PD1200766 BRANCH OF SERVICE: ARMY BOARD DATE: 20120319 SEPARATION DATE: 20011031 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (68G/Aircraft Airframe Repairer) medically separated for left shoulder pain. The CI first injured his shoulder in 2000 at Air Assault School at Fort Drum, NY, when he suffered a dislocation. Despite treatment, the shoulder condition could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty (MOS) or physical fitness standards. He was therefore issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB). The shoulder condition, characterized as “Left shoulder pain and instability” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The PEB adjudicated “Left shoulder pain and instability” as unfitting and rated 10%, referencing the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals and was medically separated with that disability rating. CI CONTENTION: “I believe my records were not located and I was never seen by a physician for evaluation. I have daily pain in my L shoulder and arm. I have trouble sitting at my computer for extended periods of time while at work or at home. I have to get up and move my arm and shoulder to relieve the pain. I also have trouble doing certain exercises. Some exercises cause sharp pain.” [sic] ______________________________________________________________________________ SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The rating for the unfitting left shoulder condition is addressed below. Any conditions or contention not requested in this application or otherwise outside the Board’s defined scope of review remain eligible for future consideration by the Army Board for Correction of Military Records. RATING COMPARISON: Service PEB – Dated 20010816 VA – No exam records Condition Code Rating Condition Code Rating Exam Left Shoulder Pain and Instability… 5099-5003 10% Left Shoulder Condition Not Service Connected/Not Incurred/Caused by Service DNS* No Additional MEB/PEB Entries Other x 1 DNS Combined: 10% Combined: N/A *Did Not Show; CI failed to report for scheduled VA exam, no service treatment records were available for VA review. ANALYSIS SUMMARY: The Board acknowledges the CI’s assertions that records were not located and that he was never examined by a physician. It is noted for the record that the Board has neither the jurisdiction nor authority to scrutinize or render opinions in reference to the CI’s statements in the application regarding suspected Disability Evaluation System improprieties in care or in the processing of his case. Left Shoulder Condition. The CI sustained an injury to his left shoulder in June 2000 with subsequent episodes of shoulder dislocation. Magnetic resonance imaging (MRI)/Arthrogram revealed a tear of the cartilage rim of the shoulder joint. Corrective surgery was performed in November 2001. Postoperatively the CI suffered no further episodes of dislocation but continued with painful range-of-motion (ROM) of the shoulder. Additional surgery was recommended, but declined by the CI. On evaluation 5 February 2001, flexion of the shoulder was 110 and abduction 110 degrees. At the narrative summary (NARSUM) evaluation, 21 May 2001, 5 months prior to separation, the CI was unable to raise his arm above shoulder level, recorded as approximately 90 degrees. On addendum to the NARSUM, requested by the PEB, and performed 3 months prior to separation, ROM exam of the left shoulder revealed flexion of 132 and abduction of 140 degrees. No VA Compensation and Pension (C&P) exam was performed. The PEB rated the shoulder condition 10% code 5003 citing pain of motion. The VA adjudicated the condition to be NSC and not subject to rating. The Board agreed that the shoulder condition met the criteria for 10% rating IAW §4.59. The Board noted some variability in reported ROMs for the left shoulder condition in the record, but unanimously agreed the evaluation of 8 August 2001 was most consistent with the majority of antecedent evaluations and best reflected the shoulder condition at time of separation. The Board agreed that the shoulder condition was not compensable under ROM or instability codes and was unable to find any other VASRD codes for rating consideration. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left shoulder condition. BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. As discussed above, PEB reliance on the USAPDA pain policy (DoDI 1332.39) for rating left shoulder condition was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the left shoulder condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows: UNFITTING CONDITION VASRD CODE RATING Condition 5099-5003 10% COMBINED 10% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120610, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record XXXXXXXXXXXXXXXXXXXXX, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / XXXXXXXXXX), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXX, AR20130006089 (PD201200766) I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation and hereby deny the individual’s application. This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail. BY ORDER OF THE SECRETARY OF THE ARMY: Encl XXXXXXXXXXXXXXXXXXX Deputy Assistant Secretary (Army Review Boards)