Author: JOHN J. D'ORAZIO
Last saved by: ADA, ROBERT P CIV USAF SAF/MRBD
Company: Pre-installed Company

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  xxxxxxxxxxxxxxxxxxxx	CASE:  PD1300500
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20130827
Date of SEPARATION:  20090911

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SRA/E-4 (3P051/Security Forces Journeyman) medically separated for a left shoulder condition.  He began having left shoulder problems in 2007 after a backyard football game where he reportedly dislocated his shoulder and underwent three surgical repairs.  The shoulder condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty or satisfy physical fitness standards.  He was given duty and mobility restrictions and referred for a Medical Evaluation Board (MEB).  The left shoulder condition, characterized as “left shoulder anterior labral tear, s/p surgical correction,” “left shoulder type II SLAP tear, s/p surgical correction” and “left shoulder multidirectional instability, s/p surgical repair,” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The PEB adjudicated “left shoulder bidirectional instability due to left anterior labral tear and type II SLAP tear” as unfitting, rated 20%, with cited application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals, and was medically separated.

CI CONTENTION:  “I have had numerous problems our of shoulder which was resulted in another surgery.”

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; 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 Military Records.

RATING COMPARISON:

Service IPEB – Dated 20090819 | VA - (7 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Lt Shoulder Bidirectional Instability due to Lt Anterior Labral Tear & Type II SLAP Tear | 5399-5304 | 20% | S/P Chronic Lt Shoulder Instability | 5202 | 20% | 20100421
No Additional MEB/PEB Entries | Other x 2 | 20100416
Combined:  20% | Combined:  40%
Derived from VA Rating Decision (VARD) dated 20100610 (most proximate to date of separation [DOS]).   

ANALYSIS SUMMARY:

Left Shoulder Bidirectional Instability due to Left Anterior Labral Tear and Type II SLAP Tear Condition.  The MEB narrative summary notes the right-hand dominant CI dislocated his left shoulder playing backyard football.  Magnetic resonance imaging (MRI) indicated possible partial supraspinatus tendon tear at the rotator cuff.  The CI under arthroscopic surgery in August 2007 for shoulder impingement and cartilage tear "subacromial impingement and repair of anterior labrum."  He did well for about 7 months when his shoulder dislocated again during pre-deployment training.  MRI suggested recurrent labral tear.  The rotator cuff was intact with slight tendonopathy; but the “muscles and tendons of the rotator cuff (subscapularis, supraspinatus, infraspinatus, and teres minor) look excellent without edema or atrophy.”  His deployment was cancelled and he underwent a second operation (arthroscopy) performed in April 2008.  He had continued pain after maximal post-surgery treatment including physical therapy (PT).  Another orthopedist consultation resulted in a diagnosis of "left shoulder bi-directional instability" and along with additional labral cartilage tear of the shoulder for which the CI underwent a third arthroscopic operation in January 2009 with repair of a superior and anterior labral tears, and application of redundant capsule tissue.  No rotator cuff tears were noted at the time of surgery.  The CI did improve after the third surgery, but continued to have pain and the orthopedist recommended retraining to a job that requires less physical and strenuous activity.  Post-surgery orthopedic evaluation on 6 April 2009 noted left shoulder flexion and abduction to 170 degrees each.  Rotator cuff strength was noted to be good.  The orthopedic surgeon commented that the labrum felt good (on examination) and there was not any increased anterior/posterior instability.  Left shoulder range-of-motion (ROM) examination performed by PT on 14 April 2009 recorded left shoulder flexion 120/120/124 (normal 180) and abduction to be 115/110/115 (normal 180).  At the VA Compensation and Pension (C&P) exam, performed 7 months after separation, the CI reported constant pain in the left shoulder.  He had no feelings of instability and he had good functional use of the arm below the shoulder level and had significant problems with overhead type activity.  On exam, the left shoulder ROM was 180 degrees flexion (normal) and 180 degrees abduction (normal).  The examiner did document pain at end of ROM.  He had tenderness to palpation over the anterior shoulder.  There were no signs of joint instability.  Shoulder strength was normal.  The general C&P exam noted that the CI is right handed.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the condition at 20% analogously for shoulder dysfunction under Group IV muscle disability (5399-5304).  The VA also rated at 20%, but instead coded for shoulder dislocation (5202).  The Board first considered the VASRD criteria for muscle disabilities (5304, muscle Group IV) used by the PEB.  The Board observed that use of this code would be appropriate for a predominant rotator cuff condition, however the CI’s shoulder condition was of the labrum, and muscle examinations including prior to separation orthopedic and post separation C&P examination reported normal strength.  Regardless, the PEB adjudicated the maximum rating of 20% for the non-dominant extremity under this code.  No higher rating is possible under this code.  The Board then considered the musculoskeletal codes (applicable codes are 5201 limitation of arm motion and 5202 recurrent dislocation).  The ROM limitation on MEB and C&P examinations do not support a minimum rating under 5201.  Although there was a history of repeated dislocations necessitating multiple surgeries, there were no recurrent dislocations after the third surgery, and the post-operative orthopedic examination and the post-separation C&P examination found no instability.  The 20% rating adjudicated by the VA is the highest rating under the 5202 code for recurrent dislocation of the non-dominant extremity (without loss of humeral head, non-union, false flail joint or fibrous union).  There were no other applicable VASRD diagnostic codes for rating consideration.  The Board could find no route to a higher rating.  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.  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 and IAW VASRD §4.73, 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
Lt Shoulder Bidirectional Instability due to Lt Anterior Labral Tear & Type II SLAP Tear | 5399-5304 | 20%
COMBINED | 20%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130515, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

xxxxxxxxxxxxxxxxxxxx, DAF
President
Physical Disability Board of Review

SAF/MRB
1500 West Perimeter Road, Suite 3770
Joint Base Andrews, MD 20762

Dear XXXXXXXXXXXXXXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2013-00500.

	After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

	I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

							Sincerely,

XXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

PD1300500