RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2013-00656
BRANCH OF SERVICE:  NAVY	BOARD DATE:  20140318
SEPARATION DATE:  20050930

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PH2/E-5 (Photographer's Mate Second Class) medically separated for a left shoulder problem.  The CI suffered a shoulder injury while wrestling with her son.  The shoulder condition could not be adequately rehabilitated to meet the physical requirements of her rating or satisfy physical fitness standards.  She was placed on limited duty and referred for a Medical Evaluation Board (MEB).  The shoulder condition, characterized as “other joint derangement, not elsewhere classified, shoulder region” and “unspecified disorders of bursae and tendons in shoulder region,” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The MEB also identified and forwarded three other conditions (see rating chart below) for PEB adjudication.  The Informal PEB (IPEB) found the CI fit for duty.  The CI non-concurred and requested the IPEB reconsider its findings.  The reconsideration PEB adjudicated “multidirectional instability, left shoulder” as unfitting, rated 0%, with application of the VA Schedule for Rating Disabilities (VASRD).  The PEB adjudicated rotator cuff tendinopathy, left shoulder as a Category II diagnosis (one that contributes to the unfit condition) and rated the other conditions forwarded by the MEB as Category III (conditions that are not separately unfitting and do not contribute to the unfitting condition).  The CI made no further appeals and was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in her application.

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; 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 Board for Correction of Naval Records.

RATING COMPARISON:
   
Service Recon PEB – Dated 20050718	VA - (1 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Multidirectional Instability, L Shoulder	5299-5003	0%	S/P Recurrent Dislocations, Left  Shoulder	5201	0%	20050816	
Rotator Cuff Tendinopathy, L Shoulder	Category II	No VA Entry				
R Knee Pain and Instability	Category III	S/P Anterior Cruciate Ligament Repair	5260	10%	20050816	
Mild Bleeding Disorder, NOS	Category III	Bleeding Disorder	7705	NSC		
Mild Partial Tear of the Supraspinatus Tendon	Category III	No VA Entry				
No Additional MEB/PEB Entries	Other x 5	20050816	
Combined:  0%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20060125 (most proximate to date of separation [DOS]).
ANALYSIS SUMMARY:

Left Shoulder Condition.  After the initial 2003 diagnosis of chronic left shoulder instability, exacerbated while wrestling with a family member, the CI experienced an audible pop with pain and stated, “It felt like it popped out and went back in.”  She was treated with anti-inflammatory medication and followed in physical therapy (PT).  She denies previous history of this type of injury.  Despite aggressive PT her pain and feelings of instability continued.  Over a 2-year period (May 2003-May 2005) she underwent three separate arthroscopic shoulder surgeries; the first two were restorative for instability and the last was diagnostic and revealed a rotator cuff tendinopathy.  PT was her mainstay of treatment after surgery and this continued throughout the MEB process.

At the MEB narrative summary performed on 14 Jan 2005 (8 months prior to separation) she endorsed a painful left shoulder with overhead activities with feelings of dislocations when reaching for a seatbelt or taking items out of the refrigerator.  The examination revealed evidence of ball and socket type shoulder laxity with tenderness about the anterior shoulder.  Other specific laxity tests were positive as well as impingement.  Although range-of-motion (ROM) testing was not specifically performed, laxity tests indicated her ability to abduct and externally rotate to at least 90 degrees.  The neuro-vascularity of the shoulder was normal.  There was no comment about crepitus or evidence of guarding.  Her diagnosis was multi-directional instability of the left shoulder.  The commander’s non-medical assessment provided no details for specific limitations other than the profile proscriptions.

At the VA Compensation and Pension examination performed on 16 August 2005 (6 weeks prior to separation), the CI reported a full ability to accomplish activities of daily living.  She endorsed constant left shoulder pain (scale; 3/10) with daily flare-ups to 7/10 intensity and, worsens with any weight in her left hand.  Pain frequently wakes her up for 20 minutes at a time.  Her examination revealed tenderness to anterior left shoulder with a slight decrease in overall strength of the left upper extremity.  There was no swelling, discoloration, subluxation or obvious deformity and no comment in regards to guarding.

The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

DOS 20050930
Left Shoulder ROM
(Degrees)	Ortho ~8 Mo. Pre-Sep
(20050110) 	MEB ~8 Mo. Pre-Sep
(20050114) 	VA C&P ~1 Mo. Pre-Sep
(20050816) 	
Flexion (180)	160	-	145	
Abduction (180)	140	90	110	
Comments	-	+ instability	painful motion	
§4.71a Rating	0%	10%	10%	

The Board directs attention to its rating recommendation based on the above evidence.  The Board first considered available coding options in light of non-compensable ROM.  The PEB’s 0% rating analogous to 5003 (degenerative arthritis) was supported and consistent with VASRD §4.71a criteria for the ROMs under consideration.  The VA rated under 5201 (shoulder limitation of motion); and the rationale stated in the rating decision for a 0% was “based on limited ROM.”  The lowest compensable rating under 5201 is 20% when abduction is limited to “shoulder level;” this case well exceeded 90 degrees.  Consideration was given to code 5202 (humerus, impairment) however, there was no evidence from the service or VA files which could be cited to support a conclusion that recurrent dislocations were frequent or that motion was guarded at or below shoulder level.  None of the VASRD §4.71a joint codes for the shoulder which might be applied in this case would support a rating greater than 10%; except for 5201, if the MEB ROM evidence was significantly different.  Board members also considered application of §4.56 (muscle disabilities) under code 5301 noting atrophy of the trapezium muscle over the left shoulder as indicated in the MEB.  Due to other normal findings within the left shoulder, the muscle code rating levels of “severe” (30%) and “moderately severe” (20%) are not applicable.  The highest remaining rating would be 10% at “moderate” impairment.  Additionally, painful motion was consistent in evidence to support a 10% rating under (PEB’s) analogous 5003 coding.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left shoulder condition under the analogous code of 5299-5003.

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 condition, the Board unanimously recommends a disability rating of 10%, coded 5299-5003 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Left Shoulder Instability	5299-5003	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130506, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				
XXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

MEMORANDUM FOR DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
	         COMMANDER, NAVY PERSONNEL COMMAND
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:   (a) DoDI 6040.44
       (b) PDBR ltr dtd 21 Nov 14 ICO XXXXXXXXXXXXXX  
       (c) PDBR ltr dtd 9 Dec 14 ICO XXXXXXXXXXXXXX
       (d) PDBR ltr dtd 9 Dec 14 ICO XXXXXXXXXXXXXX
          
1.  Pursuant to reference (a) I approve the recommendations of the Physical Disability Board of Review set forth in references (b) through (d).

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 40 percent (increased from 10 percent) disability rating effective date of discharge. 
  
     b. XXXXXXXXXXXXXX, former USN: Disability separation with a final disability rating of 10 percent (increased from 0%) effective date of discharge.   

     c. XXXXXXXXXXXXXX, former USN: Disability separation with a final disability rating of 20 percent (increased from 10%) effective date of discharge.

3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are completed.

	XXXXXXXXXXXXXX
	Assistant General Counsel
	  (Manpower & Reserve Affairs)