RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

SEPARATION DATE:  20051224 

 
NAME:  XXXXXX.                                                              BRANCH OF SERVICE:   ARMY 
CASE NUMBER:  PD1200383 
BOARD DATE:  20121211 
 
 
SUMMARY  OF  CASE:    Data  extracted  from  the  available  evidence  of  record  reflects  that  this 
covered individual (CI) was an active duty SPC/E-4 (11B/Infantryman), medically separated for 
chronic  left  shoulder  pain.    Despite  physical  therapy  (PT),  duty  limitations,  medications  and 
surgery, the chronic left shoulder pain 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).    The  MEB  forwarded  no  other  conditions  for  Physical  Evaluation  Board  (PEB) 
adjudication.  The PEB adjudicated the chronic left shoulder pain condition as unfitting, rated 
0% initially, but then increased to 10% after administrative review with application of the US 
Army  Physical  Disability  Agency  (USAPDA)  pain  policy.    The  CI  made  no  appeals  and  was 
medically separated with a 10% disability rating.   
 
 
CI  CONTENTION:    The  CI  stated  “Same  as  item  4”  in  his  application,  implying  a  request  for 
consideration of all VA conditions. 
 
 
SCOPE OF REVIEW:  The Board wishes to clarify that the scope of its review as defined in DoDI 
6040.44, Enclosure 3, paragraph 5.e.(2) is limited to those conditions which were determined 
by the PEB to be specifically unfitting for continued military service; or, when requested by the 
CI, those condition(s) “identified but not determined to be unfitting by the PEB.”  The ratings 
for unfitting conditions will be reviewed in all cases.  Only the left shoulder condition is within 
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 Army Board for Correction of Military Records. 
 
 
RATING COMPARISON:   
 

Service Revised PEB – Dated 20051121 

VA (4 Mos. Post-Separation) – All Effective Date 20051225 

Combined:  10% 

0% X 1 / Not Service-Connected x 3 

Combined:  40%* 

*Overall rating increased to 80% effective 20071221 when PTSD (50%) and TBI (40%) added (20090401 VARD). 
 
 
ANALYSIS SUMMARY:   
 

Condition 

Code 

Chronic Left Shoulder Pain 

5099-5003 

Rating 
10% 

↓No Additional MEB/PEB Entries↓ 

Condition 

Left Shoulder Injury, s/p… 
Lumbosacral Strain w/… 
Residuals, Rt Knee Injury w/ DJD 
Residuals, Lt Knee Injury w/ DJD 
Tinnitus 

Code 

5010-5203 
5010-5237 
5010-5260 
5010-5260 

6260 

Rating 
10% 
10% 
10% 
10% 
10% 

Exam 

20060418 
20060418 
20060418 
20060418 
20060418 
20060418 

Chronic  Left  Shoulder  Pain  Condition.    There  were  four  goniometric  range-of-motion  (ROM) 
evaluations  in  evidence,  with  documentation  of  additional  ratable  criteria,  which  the  Board 
weighed in arriving at its rating recommendation; as summarized in the chart below.   
 
Left Shoulder ROM 

VA C&P ~4 Mos. 

PT ~4 Mos. Pre-Sep 

MEB ~6 Mos. Pre-Sep 

PT ~4 Mos. Pre-Sep 

Post-Sep 

115* 
100 

Degrees 

Flexion (0-180) 

Abduction (0-180) 

Comments 

120 
95 

100 
90 

110 
110 

Increased limitation 

with activity 

Nml neurological 

examination 

Limited by pain; 

abduction with capsular 

end feel 

*DeLuca positive for 

pain 

20% 

10% 

10% 

§4.71a Rating 

10% 

 
The right dominant CI dislocated his left shoulder in combat and had a reduction in the field.  
He had persistent pain and instability which did not respond to conservative management.  On 
27  January  2005,  he  had  surgical  repair  of  the  left  shoulder  capsule.    Post-operatively,  the 
instability was resolved, but pain and limitations in ROM persisted despite rehabilitation which 
impaired  duty  performance.    The  CI  declined  further  surgical  intervention.    At  the  MEB 
examination on 16 June 2005, 6 months prior to separation, the CI reported continued pain and 
restrictions in movement.  On examination, he was noted to have normal sensation, strength 
and  reflexes.    The  scar  was  well  healed.    At  the  VA  Compensation  and  Pension  (C&P) 
examination on 18 April 2006, 4 months after separation, the CI reported continued pain and 
subluxation,  the  latter  less  than  once  a  year.    On  examination  the  scars  were  well  healed.  
Sensation,  strength  and  reflexes  were normal.   The  labrum  and  rotator  cuff  were  normal  on 
magnetic  resonance  imaging  (MRI)  examination.    The  Board  directs  attention  to  its  rating 
recommendation based on the above evidence.  The PEB coded the left shoulder analogous to 
degenerative  arthritis,  5099-5003,  and  rated  it  at  10%  per  the  USA  pain  policy.    The  Board 
adjudicated the shoulder using the VA Schedule for Rating Disabilities (VASRD).  The VA also 
rated the left shoulder at 10%, but used coding options 5010 and 5203, traumatic arthritis and 
impairment  of  the  clavicle  or  scapula.    The  Board  noted  that  while  the  16  June  2005  ROM 
measurements  would  rate  20%,  the  other  three  measurements,  including  the  two  most 
proximate  to  separation,  rate  10%.    The  Board  considered  the  other  coding  options  for  the 
shoulder, but none provide an advantage to the CI.  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 for rating the left shoulder 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  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:   
 

Chronic Left Shoulder Pain 

UNFITTING CONDITION 

VASRD CODE  RATING 
5099-5003 
COMBINED 

10% 
10% 

 
The following documentary evidence was considered: 
 
Exhibit A.  DD Form 294, dated 20120425, w/atchs 
Exhibit B.  Service Treatment Record 
Exhibit C.  Department of Veterans’ Affairs Treatment Record 
 
 
 
 
 
 
 

           XXXXXXXX, DAF 
           President 
           Physical Disability Board of Review 

 
 
 

 
 

 
 
 

SFMR-RB 
 
 
 
 
MEMORANDUM FOR Commander, US Army Physical Disability Agency  
(TAPD-ZB /), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557 
 
SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
AR20120022676 (PD201200383) 
 
 
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 
 
 
 
CF:  
(  ) DoD PDBR 
(  ) DVA 

     XXXXXXX 
     Deputy Assistant Secretary 
         (Army Review Boards)