RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1201138 SEPARATION DATE: 20021219 BOARD DATE: 20130307 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (31F20/Network Switching System Operator), medically separated for left shoulder instability. His first shoulder dislocation occurred in October 1999. He underwent multiple shoulder reconstructive surgeries, and extensive courses of physical therapy. Despite extensive management and multiple operations, he had persistent left shoulder instability as well as diffuse left shoulder pain and limited range- of-motion (ROM). The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB). The left shoulder condition characterized as “recurrent left shoulder instability despite operative management x 3” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. One other condition (Gastroesophageal Reflux Disease) was submitted by the MEB as meets retention standards. The PEB adjudicated the left shoulder condition as unfitting, rated 20%, citing criteria of the Veterans Administration Schedule for Rating Disabilities (VASRD). The CI made no appeals, and was medically separated with a 20% disability rating. CI CONTENTION: “Rating is not concurrent with THREE [sic] open shoulder surgeries. I am uncertain as to whether or not the 2 operations done at civilian surgeon’s office were even considered. Also, date of separation now classified as time of war. Total of 3 open-Bbankart surgeries, not one. Scar tissue after 3 procedures. 1st was @ Madigan Army Med Center (jun 01) 2nd & 3rd @ Seattle Surg. Center (mar 02, jun02. Just recently had records from S.S.C. sent to V.A.M.C. in 2002. If they weren’t in the medical records, how were they used to determine disability%? Separation date of Dec 2002 was previously not classified as time of war, but now is. Is this Reviewable? I have always felt that being medically separated was an unfair classification, and I do believe that after reviewing my records/data, the classification could be a retirement instead, and @ the least found that 20% per surgery would be more appropriate. And thank you for finally looking into this, on behalf of most grieving veterans, such as myself.” SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in Department of Defense Instruction (DoDI) 6040.44 (Enclosure 3, paragraph 5.e.2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The rating for the unfitting left shoulder condition is addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board. 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 the Correction of Military Records. RATING COMPARISON: Service PEB – Dated 20021009 VA (~2 Mos. Pre-Separation) – All Effective Date 20021220 Condition Code Rating Condition Code Rating Exam Multi-directional Left Shoulder Instability, Status Post Open Capsular Shift and Bankart Repair 5202 20% Residuals Left Shoulder Surgery 5202 20% 20021030 Surgical Scarring Left Shoulder 7804 10% 20021030 Gastroesophageal Reflux Disease Not Unfitting Gastroesophageal Reflux Disease 7346 0% 20021030 .No Additional MEB/PEB Entries. Compression Fracture Thoracic Spine 5291 10% 20021030 Combined: 20% Combined: 40% ANALYSIS SUMMARY: The Board acknowledges the sentiment expressed in the CI’s application, i.e., that there should be additional disability assigned for conditions which will predictably worsen over time. It is a fact, however, that the Disability Evaluation System (DES) has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation. This role and authority is granted by Congress to the Department of Veterans Affairs (DVA). We note that the applicant asks the Board for specific correction of records and specified “Separation date of Dec 2002 was previously not classified as time of war, but now is. By law the Board authority is limited to making recommendation on correcting disability determinations.” The actual correction of records and consequential entitlement determinations is the responsibility of the applicable secretary and accounting service. The applicant's request will of course remain with the application as it is processed. The Board will review all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on severity at the time of separation. Left Shoulder Instability Condition. During training in October 1999 the CI was playing football and landed on his, non-dominant, left shoulder which resulted in a dislocation injury. Attempts were made to conservatively treat with physical therapy, temporary profiles and medications however there was persistence of frequent dislocations, pain, limitation of motion and instability. Orthopedics surgically treated the shoulder instability with a Bankart repair and capsular shift a year after the injury. There was an uncomplicated postoperative course, however he continued to have frequent dislocations and subsequently underwent two surgical revisions without success. He remained very symptomatic reporting dislocations 15 to 20 times with minimal trauma to the shoulder, often awakening at night with a dislocated shoulder. Despite extensive rehabilitative management and multiple operations, he continued to have persistent left shoulder instability as well as diffuse left shoulder pain and limited ROM. The permanent profile limitations included; no push-ups, overhead activities, lifting, pulling, parade rest activity, back pack use, carrying a rifle, marching greater than 5 miles, or sit-ups. The commander’s statement documented that the profile limitations did not facilitate the unit's mission and therefore the CI was considered more of a liability than an asset. The MEB physical exam demonstrated a well-healed anterior surgical scar, diffuse tenderness to palpation both along the surgical site as well as the posterior shoulder, apprehension in bringing his shoulder to higher levels of abduction or of forward flexion, and normal upper extremity motor strength and sensory findings. Instability testing was not performed due significant guarding. X-rays revealed no evidence of current dislocation and radiolucency’s about the glenoid consistent with his previous surgical repairs and a small Hill-Sachs lesion. At the VA Compensation and Pension (C&P) exam prior to separation, the CI additionally reported taking nonsteroidal anti-inflammatory and narcotic medications for pain. The C&P exam demonstrated surgical scar tenderness otherwise no additional findings. There were two goniometric ROM evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below. Left Shoulder ROM (Measurements in Degrees) MEB ~ 3 Mo. Pre-Sep VA C&P ~ 2 Mo. Pre-Sep Flexion (180 Normal) 90 75 Abduction (180) 90 50 Comments Painful limited motion, Apprehension, significant guarding -- §4.71a Rating 20% 20% The Board directs attention to its rating recommendation based on the above evidence. Both the PEB and the VA rated the CI’s left shoulder condition at 20% coded 5202 which is consistent IAW VASRD §4.71a—Schedule of ratings–musculoskeletal system. The Board agreed there is no evidence of malunion or fibrous union of the humerus and no limited motion of 25 degrees from the side to consider a higher rating under the 5202 code or the 5201 code, respectively. The Board also considered an additional rating for residual scars after three surgeries. By precedent, the Board does not recommend separation rating for scars unless their presence imposes a direct limitation on fitness. There is no tenderness of the scar, nor functional uniform limitations documented on the profile and therefore the Board agreed the evidence does not support functional loss or ratable criteria using VASRD §4.118—Schedule of ratings– skin. 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 instability 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. The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. In the matter of the left shoulder instability 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 Multi-directional Left Shoulder Instability, Status Post Open Capsular Shift and Bankart Repair 5202 20% COMBINED 20% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120626, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxxxx, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxxxxxxxxx, AR20130007814 (PD201201138) 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 xxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)