RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXXXXX CASE: PD1201740 

BRANCH OF SERVICE: ARMY BOARD DATE: 20130321 

SEPARATION DATE: 20030529 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty Soldier, PFC/E-3(11B/INFANTRYMAN) medically 
separated for chronic left shoulder pain and instability w/existed prior to service (EPTS) history 
of shoulder dislocation in 1997. The CI injured his shoulder in a high school football game in 
1997, undergoing surgery in 1999, prior to enlistment. He received a waiver to enlist and 
reinjured his shoulder in basic training. Despite physical therapy, the shoulder 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). Anterior shoulder instability, left, severe; and 
bilateral pes planus, mild, were characterized as medically unacceptable, and forwarded to the 
Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the 
MEB. The PEB adjudicated chronic left shoulder pain and instability with EPTS history of 
shoulder dislocation as unfitting, rated 10% with application of the Veteran’s Affairs Schedule 
for Rating Disabilities (VASRD). There was no deduction for the EPTS. The PEB adjudicated the 
bilateral pes planus, mild, as not unfitting. The CI made no appeals and was medically separated 
with a 10% disability rating. 

 

 

CI CONTENTION: The CI writes: “As a result of the injury I sustained while serving on active 
duty, I have had two major left shoulder operations. The only operation left to perform (if I 
ever injure the shoulder again) is to get a prosthetic left shoulder. After my second left 
shoulder surgery 29 July 2010, I incurred severe nerve damage to my left hand limiting 
movement and strength. My current VA disability rating is 70% (service connected). I would just 
like to add that my shoulder and hand disabilities impact my life on a daily basis. My son L--- 
(18 months old) was born profoundly deaf. He uses sign language to communicate. Because of 
the nerve damage in my left hand, I am unable to sign correctly to communicate with my son. I 
have also had a lot of atrophy to my left arm and hand. My grip strength for left hand was 
recently measured at 18 lbs. While my right hand measured at 128 lbs. My left ring and pinky 
fingers are curled (known as “claw hand”), and unable to straighten. My first surgery was at 
Beth Israel/Deaconess Hospital in Boston, MA. May 2007 (Dr. D----) and second was at VA 
Hospital Jamaica Plain, MA. 29 July 2010.” 

 

 

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; however, the additional requested condition of the left hand is 
not 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 Correction of Military Records. The 
Board acknowledges the CI’s information regarding the significant impairment with which his 
service-connected condition continues to burden him; but, must emphasize 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. That role and authority is granted by Congress to the Department of Veterans 
Affairs (DVA), operating under a different set of laws. The Board considers DVA evidence 
proximate to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12-
month interval for special consideration to post-separation evidence. Post-separation evidence 
is probative to the Board’s recommendations only to the extent that it reasonably reflects the 
disability at the time of separation. 

 

 

RATING COMPARISON: 

 

Service IPEB – Dated 20030305 

VA (4 Mos. Post-Separation) – Effective 20030530 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Chronic Left Shoulder Pain 
and Instability 

5099-5010 

10% 

S/P Bankart Repair, Left 
Shoulder* 

5201 

30% 

20030915 

Bilateral Mild Pes Planus 

Not Unfitting 

Bilateral Pes Planus 

5276 

NSC** 

20030915 

No Additional MEB/PEB Entries 

Other x 0 

20030915 

Combined: 10% 

Combined: 30% 



*Bankart surgical repair performed less than one month after separation and prior to VA exam 

**Derived from VA Rating Decision (VARD) dated 20031106 (most proximate to date of separation [DOS]). That VARD deferred 
the decision on bilateral pes planus, which was NSC’d by VARD of 20040318. 

 

 

ANALYSIS SUMMARY: 

 

CHRONIC LEFT SHOULDER PAIN AND INSTABILITY. Magnetic resonance imaging (MRI) in August 
2002 showed a tear in the inferior labrum (rim of cartilage in the joint) and a complete rotator 
cuff tear. The right hand dominant CI was offered repeat reconstructive surgery to address 
pain and instability, but due to the uncertainty of outcome he declined this option. An 
orthopedic examiner on 13 September 2002 (8 months prior to separation) noted a positive 
apprehension test, a positive sulcus sign, and ligamentous laxity (signs of joint instability); a 
relocation test was equivocal. The examination was rendered difficult because of guarding. At 
the narrative summary (NARSUM) exam in December 2002, 5 months prior to separation, the CI 
reported pain and subjective instability in daily activities. The examiner noted 3+ out of 5 
rotator cuff strength and reduced flexion and abduction. Flexion was 90 degrees (normal 180 
degrees) and abduction was 120 degrees (normal 180 degrees). At the VA Compensation and 
Pension (C&P) exam in September 2003, 3 months after a second shoulder repair and 4 months 
after separation, the CI rated his baseline pain as 4 on a 1-10 scale and flare-ups as 7 out of 10. 
He reported subjective stiffness and occasional swelling and fatigue. The examiner noted 
stiffness and guarding, and no swelling, deformity, or tenderness. Pain on range-of-motion 
(ROM) occurred only with slight external rotation. X-rays of the shoulder (September 2003) 
showed no abnormalities. 

 

The Board directs attention to its rating recommendation based on the above evidence. The 
PEB adjudicated the condition as permanently service aggravated and assigned a 10% rating 
under an analogous 5010 code (traumatic arthritis) for "slight reduction in range of motion, no 
documented subluxation/dislocations." The VA assigned a 30% rating under code 5201 for 
limitation of motion of the non-dominant arm “to 25 degrees from side,” which did not appear 
to align with the C&P exam. The Board assigned higher probative value to the NARSUM exam 
because intervening surgery after separation rendered ROM findings by the VA examiner 
irrelevant to the time of separation. The VASRD §4.71a threshold for compensable ROM 
impairment is “shoulder level”, i.e., 90 degrees, and the examination demonstrated motion at 
this level in one plane (flexion), but above this level in another plane (abduction). The Board 
agreed that this evidence most closely approximated the 20% criteria. Board members also 
deliberated the presence of instability in this case. Under the 5202 code (humerus, other 
impairment of: recurrent dislocation of at scapulohumeral joint) a 20% rating is justified for 


"infrequent episodes, and guarding of movement only at shoulder level." The Board agreed 
that although there were objective findings of instability, there was no record of any 
dislocations; thus a compensable rating was not justified under this code. After due 
deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the 
Board recommends a disability rating of 20% for the chronic left shoulder pain and 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 chronic left shoulder pain and instability condition, the 
Board unanimously recommends a disability rating of 20%, coded 5201 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 his prior medical separation: 

 

UNFITTING CONDITION 

VASRD CODE 

RATING 

Chronic Left Shoulder Pain and Instability 

5201 

20% 

COMBINED 

20% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120820, w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

 XXXXXXXXXXXXXXXXXXXX, 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 XXXXXXXXXXXXX, AR20130006102 (PD201201740) 

 

 

1. 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 to modify the individual’s disability rating 20% 
without recharacterization of the individual’s separation. This decision is final. 

 

2. I direct that all the Department of the Army records of the individual concerned be 
corrected accordingly no later than 120 days from the date of this memorandum. 

 

3. I request that a copy of the corrections and any related correspondence be provided 
to the individual concerned, counsel (if any), any Members of Congress who have 
shown interest, and to the Army Review Boards Agency with a copy of this 
memorandum without enclosures. 

 

 BY ORDER OF THE SECRETARY OF THE ARMY: 

 

 

 

 

Encl XXXXXXXXXXXXXXXXXXX 

 Deputy Assistant Secretary 

 (Army Review Boards)