RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-01319
BRANCH OF SERVICE:  Army	BOARD DATE:  20140729
SEPARATION DATE:  20040909

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (92A10/Automated Logistic Specialist) medically separated for chronic neck pain, without radiculopathy and chronic right shoulder pain with impingement.  The conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  The CI was issued a permanent U3 profile and she was referred to the Medical Evaluation Board (MEB).  The neck and shoulder conditions, characterized as “chronic neck pain secondary to cervical disk disease” and “right shoulder pain with decreased range of motion” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded one other condition, migraine headaches as medically acceptable.  The Informal PEB adjudicated “chronic neck pain, onset after strain injury…” and “chronic right shoulder pain due to impingement…” as unfitting, rated both at 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in her application.

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 ratings for the unfitting neck and shoulder conditions are addressed below and 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 20040826	VA - 2 ½ Mos. Post-Separation*	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain 	5243	10%	Cervical Strain with C6 Radiculitis	5237	10%	20041129	
Chronic Right Shoulder Pain 	5099-5003	10%	Chronic Right Shoulder Pain 	5299-5201	20%	20041129	
Other X 1  (Not in Scope)	Others x 5	20041129	
Combined:  20%	Combined:  50%	
*Derived from VA Rating Decision (VARD) dated 20050324 (most proximate to date of separation).   

ANALYSIS SUMMARY:  

Chronic Neck Pain Condition.  Review of the service treatment record (STR) reveals that, in January 2003, the CI reported to sick call with neck pain (10/10), attributed to lifting a heavy object several weeks previously.  Originally diagnosed as trapezius muscle strain, with “marked tenderness in right neck;” later noting right arm pain with weakness that was unresponsive to conservative treatment, including physical therapy, medications and epidural steroid injection.  Initially referred to an MEB, which was later postponed pending the results of surgery for a co-occurring right shoulder condition (see below), in May 2003 she reported “severe” right lateral neck pain (9/10), occasionally less intense (5/10), worsening over previous several months and worse with head movement or sneezing.  At this examination, the examiner revealed tenderness in the midline and right paraspinal musculature.  Magnetic resonance imagery (MRI) of the neck in May 2003 revealed bulging discs “causing mild to moderate bilateral foraminal stenosis” (narrowing), greater on the right than on the left, but without mention of possible nerve compression at these sites.  Symptoms in the right arm and hand suggested radiculopathy (nerve root involvement), but the MRI revealed no nerve compression, a cervical myelogram (radiographic imaging of the spinal cord using contrast) was performed in June 2003, revealing mild compression of the thecal sac (not touching the spinal cord itself), but without nerve root involvement.  Additionally, an electromyogram (EMG) with nerve conduction velocity (NCV) in June 2003, found “no electrodiagnostic evidence for acute right C5-T1 [cervical] motor radiculopathy.”  Physical examination at this occasion revealed normal strength testing of the upper extremities, except for that attributable to a co-occurring shoulder injury discussed below, with decreased sensation in the right arm consistent with radiculitis from nerve C6 only.  Computerized tomography scan of the neck in late June 2003 revealed “no extruded discs” and “no evidence of central spinal stenosis or foraminal stenosis.”

Neck pain continued, worsening with movement; and tingling in right fingertips was noted.  The STR documented that a neurosurgical evaluation on 25 June 2003 recommended no surgery and the diagnosis of “non operative cervical spondylosis.”  At this time (10 months prior to separation), it was determined that the neurological symptoms in her right upper extremity were not due to cervical radiculopathy (nerve compression at the neck) but were due both to a compressive neuropathy of the medical nerve at the right wrist, also known as carpal tunnel syndrome (CTS) and also to entrapment of the ulnar nerve at the right elbow.  As a result, to treat the neurologic symptoms in her hand and arm; in December 2003, while undergoing shoulder surgery she simultaneously underwent surgical release of the median nerve and an ulnar nerve transposition.  Chronic neck pain continued and she was referred for a MEB.   At the MEB examination (3 months prior to separation), the CI reported “spasms in her neck and flares in her neck pain,” with “herniated discs in my neck which are irreparable.”  She reported that “load bearing equipment and Kevlar headgear worsen her neck pain.”  The Report of Medical History (DD Form 2807) for the MEB reported the presence of herniated discs with “no surgery.”  The MEB physical exam noted surgical scars on the right palm and elbow, decreased strength in the right hand, a history of surgery on the right shoulder, right ulnar nerve (at the elbow) and right carpal tunnel (in the hand).  The narrative summary (NARSUM) notes “decreased [neck] range-of-motion on rotation, extension and flexion secondary to pain.”  The examiner noted her inability to perform sit-ups due to neck pain.  The MEB (6 weeks prior to separation) forwarded to the PEB that the chronic neck pain was unacceptable for continued service.  The PEB (2 weeks prior to separation) concluded that chronic neck pain, with “painful range of motion” and with disc bulging but without radiculopathy, was unfitting. 

At the VA Compensation and Pension (C&P) exam (3 months after separation), the CI reported neck pain, expressing her opinion that the neck condition was the cause of her arm symptoms.  She described daily neck pain (4/10), radiating to the right shoulder, with weakness and limited endurance of her neck.  On physical examination, there was normal alignment of the cervical vertebrae, without kyphosis or scoliosis, with steady, normal gait and smooth motion of the cervical spine.  Tenderness to palpation of the cervical spine and the paraspinal muscles was noted.  The goniometric range-of-motion (ROM) evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Cervical ROM
(Degrees)	1st MEB (postponed)
 ~ 11 Mo. Pre-Sep
(20031008) 	2nd MEB ~ 2 ½ Mo. Pre-Sep
(20040622) 	VA C&P ~ 2 ½ Mo. Post-Sep
(20041129) 	
Flex (45 Normal)	40	40	45	
Extension (45)	50	45	45	
R Lat Flexion (45)	30	45	45	
L Lat Flexion (45)	30	35	45	
R Rotation (80)	50	70	80	
L Rotation (80)	50	75	80	
Combined (340)	250	310	340	
Comment	N/A	Neck is supple without muscle rigidity or tenderness, with “some decreased ROM on rotation, extension and flexion secondary to pain.”  	No kyphosis or scoliosis; normal gait. TTP C-spine & paraspinous muscles. No spasm. No weakness of neck muscles, without muscle atrophy. 	
§4.71a Rating	10%	10%	10%	

The Board directs attention to its rating recommendation based on the above evidence.  In accordance with DoDI 6040.44, the Board is required to recommend a rating IAW the VASRD in effect at the time of separation and notes that the current §4.71a rating standards were incorporated prior to her separation.  The PEB, having found the neck pain condition to be unfitting and in the absence of neurological abnormality, rated the condition at 10% under VASRD code 5243 (intervertebral disc syndrome), specifically noting its “onset after strain injury, with MRI findings of disc bulging C6/C7, C6/C7, without radiculopathy or chronic muscle spasm and painful neck range of motion.”  The VA Rating Decision (VARD), 4 months after separation, rated the condition at 10%, using code 5237 as “cervical strain with C6 radiculitis,” notes also the bulging discs at C5-C6 and C6-C7.  Both the MEB NARSUM and the VA C&P examinations support a 10% disability rating IAW VASRD General Rating Formula for Diseases and Injuries of the Spine.  The VARD noted that the 10% rating was appropriate due to cervical flexion of 45 degrees, with normal vertebral alignment, normal gait, no evidence of muscle spasm.  The cervical ROM impairment in evidence and associated physical findings are clinically incongruent with the degree of “muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour”, as required under VASRD §4.71a in order to achieve a 20% 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 chronic neck pain condition.

The Board considered whether a separate neuropathy existed in this case, since disc pathology of the cervical spine can account for radiculopathy in the upper extremity and since the surgeries to correct the arm symptoms did co-occur with the shoulder surgery mentioned below.  Although the CI was experiencing neck pain, with bulging discs, and right arm symptoms; the radiographic imaging did note bulging discs, but did not note if any of the nerves were compressed by the discs, which would result in the radiculopathy.  Additionally, the EMG and NCV studies demonstrated normal motor function of the upper extremity.  Finally, the source of the pain and neurological symptoms was determined to be the carpal tunnel syndrome (CTS) and the ulnar nerve entrapmen; which are separate conditions, originating in the wrist and elbow respectively, not in the neck for which the CI received corrective surgery in December 2003.  Noting that radiation of pain, in the absence of radiculopathy (nerve involvement), is subsumed under the spinal rating formula, the Board did consider if any radicular component in this case warranted additional disability rating under peripheral nerve coding.  However, the Board members agreed that there was no objective evidence for motor radiculopathy and that no requisite link with functional impairment was in evidence.  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 an additional disability rating for a separate peripheral neuropathy.  The Board concluded therefore that the radiation of pain into the right arm could not be recommended as an additionally unfitting condition.  

Chronic Right Shoulder Pain Condition.  Review of the STR reveals that, in January 2003 the CI, who is right handed, reported to sick call with right shoulder pain, attributed to lifting a heavy object several weeks previously.  Diagnostic evaluation, including radiographic imaging, resulted in a diagnosis of acute rotator cuff tear and impingement of the acromioclavicular (AC) joint.  Arthroscopy of the right shoulder in June 2003 resulted in a repair of the rotator cuff tendon and also subacromial decompression and claviculoplasty (modifications of the bony parts of the shoulder joint in order to allow unimpeded movement of the rotator cuff tendons).  Subsequent to the surgery and in spite of physical therapy (PT), she continued to experience pain, now with decreased ROM of her right shoulder.  A second surgery in December 2003 involved removal of the outer tip of the clavicle (distal claviculectomy), but did not relieve her symptoms sufficiently to allow for a return to full duty.  At the MEB exam, the CI reported right shoulder pain (3/10), with “decreased use of her right upper extremity,” with “difficulties with basic activities of daily living such as writing and fine motor skills,” plus inability to lift more than twenty pounds or to wear protective gear.  The MEB NARSUM notes that MEB was pursued secondary to the CI’s “still significant decreased range of motion and limitation in activity.”  The NARSUM bases its assessment of right shoulder ROM to a physical therapy note, dated 6 months prior to separation, which “reveals abduction to 170 degrees,” but did not state if this was active or passive abduction.  The MEB ROM, measured by PT a month prior to the MEB (3 months prior to separation) reveals repeated measurements of active abduction of the right shoulder at a consistent 85 degrees.  (PT clinic records 5 months earlier include measurements of active abduction at 90 degrees, 90 degrees and 130 degrees.)  The MEB (2 months prior to separation) determined that right shoulder pain with decreased ROM was unacceptable for continued military service.  The PEB found the right shoulder condition unfitting and, “rated as analogous to degenerative arthritis with loss of joint motion,” noted “some loss of passive shoulder motion.” 

At the VA compensation and pension (C&P) examination, 3 months after separation), the CI reported daily pain (4/10) over the right AC joint with fatigue, locking, “weakness and limited endurance of the shoulder,” but without dislocation or subluxation (instability).  Examination of the right shoulder revealed “tenderness over the superior shoulder musculature,” tenderness of the AC joint, “impingement with abduction of right arm motion with pain” but without weakness of the rotator cuff or evidence of instability.  The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Active Shoulder ROM
(Degrees)	1stMEB(postponed)
11 Mo. Pre-Sep
(20031008) 	 MEB 
2 ½ Mo. Pre-Sep
(20040622) 	VA C&P 
 2 ½ Mo. Post-Sep
(20041129) 	
	Right	Right 	Right	
Flexion (180 Normal)	160	175	160	
Extension 	40	45	Not measured	
Abduction (180)	130	85	90	
Adduction	20	45	Not measured	
Internal Rotation	55	70	60	
External Rotation	75	85	30	
Comments	N/A	No instability. Unable to control over 2.5 lbs. 	Tenderness of AC joint. No rotator cuff weakness. Impingement noted w/ abduction. Pain limits abduction. No evidence of instability.	
§4.71a Rating	40%	20%	20%	

The Board directs attention to its rating recommendation based on the above evidence , noting that shoulder conditions can be coded and rated for ROM (code 5201) for instability, (code 5202) for rotator cuff injury (analogously to 5203) and with consideration of painful motion and functional loss, IAW VASRD §4.59 and §4.40.  The PEB coded the condition analogous to 5003 rated at 10% based on painful motion and reduced passive abduction to 170 degrees.  Eight months later, the VARD coded the condition as 5201 (arm, limitation of motion) and assigned a 20% rating based on motion of the dominant shoulder limited to 90 degrees of abduction.

There is a clear discrepancy between the limitations of abduction documented on the NARSUM, on multiple PT evaluations and at the VA C&P examination.  As illustrated in VASRD §4.71, Plate I, this Board considers shoulder abduction of 90 degrees equivalent to “shoulder level,” as listed in VASRD code 5201.  The Board thus carefully deliberated the probative value assignment to each of the conflicting evaluations and carefully reviewed the service file for corroborating evidence.  The NARSUM referenced an evaluation by PT quoting “abduction to 170 degrees,” not stating if this was active or passive ROM.  Other PT measurements of active, not passive, abduction of the right shoulder were significantly more limited than that noted in the NARSUM, in which the value noted is more closely aligned with the measurements for passive abduction.  The shoulder ROM measurements, taken specifically for the MEB (2 months prior to separation) and those closest to the date of separation, revealed a consistent active abduction of 85 degrees and a passive abduction of 180 degrees.  This degree of diminished shoulder abduction meets the criteria for a 20% rating under VASRD code 5201.  Noting that shoulder disability can also be rated based upon instability, the Board noted that both the NARSUM and the VA C&P determined that there was no instability in the dominant shoulder; as a result, VASRD code 5202 would not be indicated.  Additionally, as neither the NARSUM nor the C&P noted weakness in the rotator cuff, despite the history of rotator cuff repair, VASRD code 5203 (to which injury of the rotor cuff is analogously assigned) would also not be appropriate.  Concluding that limitation of shoulder motion to less than 90 degrees of abduction meets the criteria for a 20% rating under VASRD code 5201, the Board examined the remaining codes applicable to shoulder injury and did not find another rating code, for which the criteria would allow any ratings higher than 20%.  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 right shoulder pain condition, under VASRD code 5201.

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 neck pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic right shoulder pain 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 and, that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Right Shoulder Pain  	5201	20%	
Chronic Neck Pain	5243	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130909, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXXXX, AR20150002627 (PD201301319)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to recharacterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.  

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:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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						     
						
CF: 
(  ) DoD PDBR
(  ) DVA