RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW
NAME: BRANCH OF SERVICE: Army
CASE NUMBER: PD0900158 COMPONENT: REGULAR
BOARD DATE: 20090630 SEPARATION DATE: 20020627
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SUMMARY OF CASE: This covered individual (CI) was an E-5 counter intelligence agent medically separated from the Army in 2006. The medical basis for the separation was chronic bilateral shoulder pain with history of popping while doing pull-ups. CI is right handed and injured both shoulders in airborne training. CI’s painful shoulders escalated months later with repeated complaints of both shoulders popping (coming out of socket) and painful motion. CI had surgery on his Right shoulder (rotator cuff repair) that worked for a few months; however, his shoulder was reinjured and ‘went back to square one.’ Repeat right shoulder surgery, and left shoulder surgery were not unreasonable to decline. PEB, profiles, and commander’s letter supported both shoulders as unfitting. CI was referred to the PEB, was found unfit and separated at 0% disability. The VA rated CI’s shoulders at 30% combined using a combination of 10% for the left shoulder instability, 10% for the right shoulder instability and 10% for the right shoulder painful scar. The VA also added ringing in the ears (tinnitus) at 10% and right knee at 0% for a combined 40% VA rating.
The CI contends that he should be rated at 40% like the VA not 0%. He was rushed through the PEB and didn’t understand the process. He has chronic pain and disability even after surgery on one shoulder, can’t lift over 10 lbs, has limited ROM, painful shoulders and right knee; painful running due to both knee and shoulders (slide in and out of socket); shoulder pain making sleep difficult, and that all were combat wounds and not adequately treated.
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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 carefully analyzed the CI’s tinnitus and knee pain. Tinnitus was not part of the PEB evaluation and would not have been unfitting. Knee pain was mentioned in the NARSUM and was not to the level of being unfitting. There was no indication that CI’s unfitting conditions were due to actual combat, but there was linkage to airborne training and exacerbation in a combat area as noted by the PEB.
Absent the Army pain policy, each shoulder should be rated individually at a minimum of 10% each for painful motion alone. However, the treatment record and VA exam clearly indicated bilateral shoulder instability (subluxation) which is rated using different VASRD coding criteria. The shoulder instability was opined to be subluxation and not full dislocation. The operated right shoulder was clearly worse (more easily subluxed in all directions) than the left shoulder, had documented mechanically limited ROMs, and included a tender scar which might have interfered with wear of equipment. There were numerous coding schema considered including rating the tender scar separately as in combination unfitting, which was not adjudged to be predominant. The Board unanimously voted to rate the left shoulder 10% for instability and the right shoulder 20% for instability.
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RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows and that the discharge with severance pay be recharacterized to reflect disability retirement, effective as of the date of his prior medical separation.
| Unfitting Condition | VASRD Code | Rating |
|---|---|---|
| Right shoulder instability and painful motion, s/p right shoulder surgery | 5299-5203 | 20% |
| Left shoulder anterior instability | 5299-5203 | 10% |
| Combined | 30% |
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The following documentary evidence was considered:
Exhibit A. DD Form 294, dated 20090208, w/atchs.
Exhibit B. Service Treatment Record.
Exhibit C. Department of Veteran's Affairs Treatment Record.
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