RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXXXXXXX CASE: PD1201730 

BRANCH OF SERVICE: ARMY BOARD DATE: 20130327 

SEPARATION DATE: 20060223 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty SGT/E-5 (11C/Mortar-Man) medically separated for 
left shoulder pain. He initially injured his left shoulder in a football game while deployed to 
Bosnia in 2000. Despite physical therapy, immobilization, and medication the left shoulder 
could not be adequately rehabilitated to meet the requirements of his Military Occupational 
Specialty (MOS) or physical fitness standards. He was issued a permanent U3 profile and 
referred for a Medical Evaluation Board (MEB). The left shoulder condition, characterized as 
“Chronic left shoulder pain,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-
501. No other conditions were submitted by the MEB. The PEB adjudicated the “Chronic pain, 
left shoulder, rated as slight/constant” condition as unfitting and rated it 10% IAW the US Army 
Physical Disability Agency (USAPDA) pain policy. The CI made no appeals and was medically 
separated with that disability rating. 

 

 

CI CONTENTION: “Left shoulder, stomach.” The application does not elaborate. 

 

 

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. The contended stomach condition was not identified by either 
the MEB or the PEB so is not in the 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 PEB – Dated 20060123 

VA - based on Service Treatment Records (STR) 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Chronic Pain, Left Shoulder 

5099-5003 

10% 

Degenerative Joint Disease Left 
Shoulder, Status Post Injury 

5010 

10% 

STR 

No Additional MEB/PEB Entries 

Other x 5 

STR 

Combined: 10% 

Combined: 10% 



Derived from VA Rating Decision (VARD) dated 20060923. CI did not report for VA C&P exam appointment. 

 

 

ANALYSIS SUMMARY: 

 

Left Shoulder Condition: The CI was right hand dominate. The narrative summary (NARSUM) 
notes that CI injured his shoulder when he was tackled while playing football for physical 
training while deployed in Bosnia in November 2000. He was treated for an acromioclavicular 


joint (AC) separation with immobilization and physical therapy. He reinjured it while wrestling 
in 2003 and it was again treated with immobilization. Pain gradually progressed and was 
significantly exacerbated by his deployment to Iraq November 2003 to March 2004. He was 
treated with physical therapy, medication and injections without relief of pain. Range-of-
motion (ROM) measurements done in July 2005, 7 months prior to separation, were recorded 
as forward flexion 140 degrees (180 degrees is normal), abduction 110 degrees (180 degrees is 
normal). Another measurement done about 6 months prior to separation showed forward 
flexion to 150 degrees and abduction to 140 degrees with 4/5 motor weakness to external 
rotation as well as 4/5 weakness of the deltoid muscle. Both examinations noted that motion 
was limited by pain. Orthopedic Consult on 5 Oct 2005 described “range of motion is complete. 
Has some discomfort with a variety of shoulder tests. With each states the pain is superior, 
over AC joint…“ Neurological exam at that time demonstrated no motor dysfunction and noted 
normal muscle tone and normal reflexes. Imaging studies included an X-ray exam performed 
22 May 2004 which showed normal distance in the AC joint and stated that the findings were 
most consistent with chronic, traumatic change. However, X-rays quoted in the NARSUM, (not 
available in documents provided) presumably more proximate to date of separation, reportedly 
revealed mild elevation of the distal left clavicle at the AC joint with mild widening of the AC 
joint as well as widening of the coracoclavicular distance. Magnetic resonance imaging (MRI) 
performed in August 2005 showed “intrasubstance chronic appearing signal abnormality with 
some fraying of the glenoid labrum due likely to degenerative joint disease of the AC joint.” At 
the MEB exam, performed on 21 November 2005, 2 months prior to separation, the CI reported 
continued left shoulder pain. He said that pain was exacerbated by activities such as pushups, 
overhead exercises and wearing Individual Body Armor (IBA’s). He reported numbness and 
paresthesias in the left arm when wearing IBA’s and when standing at parade rest. The MEB 
physical exam demonstrated tenderness with palpation directly over the AC joint. ROM of the 
left shoulder was limited to 120 degrees of abduction and 80 degrees external rotation (90 
degrees is normal). ROM for forward flexion and internal rotation was not provided. AC joint 
prominence (3+) with motion at the joint, slight subacromial crepitance, tenderness to 
palpation directly over the AC joint and mild pain with resisted abduction, and 4/5 motor 
strength were also noted on that exam. The diagnosis was left shoulder AC and glenohumeral 
joint degenerative joint disease (DJD) with associated impingement syndrome. 

 

The Board directs attention to its rating recommendation based on the above evidence. The 
applicable codes are 5003 (degenerative arthritis) and 5010 (Arthritis due to trauma 
substantiated by X-ray findings). The PEB’s DA Form 199 reflected application of 5099-5003 
with use of the USAPDA pain policy for rating, but its 10% determination was consistent with 
§4.71a standards. The VA, in the absence of a current C&P examination, used the physical 
exam data from the MEB exam performed 7 months previously. They coded DJD, left shoulder, 
status post injury, 5010 and rated the disability at 10%. While these ROM exams by the service 
show non-compensable limitation of motion by application of 5201, the Board agreed that 
there was ample evidence of degenerative change and painful motion (IAW VASRD §4.59) to 
justify a minimal compensable rating of 10% under code 5099-5003 or 5010. A higher 20% 
evaluation would require objective medical evidence of limitation of motion of the arm at the 
shoulder level which was not demonstrated by the data available. The Board further 
considered coding 5203 (Impairment of clavicle or scapula), but concluded that there was 
insufficient clinical and/or radiologic evidence in the examinations proximate to separation that 
would justify any rating higher than 10% under that coding or application of any other available 
joint code for the shoulder with a higher rating potential. 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. As discussed above, PEB 
reliance on the USAPDA pain policy DoDI 1332.39 for rating left shoulder pain condition was 
operant in this case and the condition was adjudicated independently of that policy by the 
Board. In the matter of the left shoulder pain 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 

Chronic Left Shoulder Pain 

5099-5003 

10% 

COMBINED 

10% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120806, w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

 xxxxxxxxxxxxxxxxxxxxxxxx, DAF 

 Acting Director 

 Physical Disability Board of Review 

 


SFMR-RB 


 

 

MEMORANDUM FOR Commander, US Army Physical Disability Agency 

(TAPD-ZB / xxxxxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 

 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for 
xxxxxxxxxxxxxxxxxxxxxxxxxx, AR20130008756 (PD201201730) 

 

 

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 xxxxxxxxxxxxxxxxxxxx 

 Deputy Assistant Secretary 

 (Army Review Boards)