RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-01553
BRANCH OF SERVICE:  Army	BOARD DATE:  20150206
Separation Date:  20040813

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve E-4 (Motor Transport Operator) medically separated for left shoulder pain and back pain.  The conditions 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/L3 profile and referred for a Medical Evaluation Board (MEB).  The back and left shoulder conditions, characterized as “left shoulder rotator cuff tear, status post (s/p) repair and back pain secondary to T12 compression fracture” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two other conditions (anxiety disorder not otherwise specified and hypercholesterolemia [sic]) for PEB adjudication.  The Informal PEB (IPEB) adjudicated low back pain (LBP) and left shoulder pain as unfitting rated 10% and 0%, respectively, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “The disability should have been rated higher due to the disability becoming more painful between the time of discovery, the time of board and the time of discharge.”

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:

Service Admin PEB – Dated 20040813	VA - (~1.5 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain (LBP) with a History of Injury to T12	5299-5235	10%	Residuals of Compression Fracture T12	5235	10%	20040929	
Left Shoulder Pain s/p Repair of Rotator Cuff	5099-5003	0%	s/p Left Rotator Cuff Tear with Residuals	5203*	Deferred		
Other x2 (Not In Scope)	Other x0	
Combined:  10%	Combined:  10%	
Derived from VA Rating Decision (VARD) dated 20041021 (most proximate to date of separation [DOS])
*VARD dated 20070920 changed the code to 5019 and rated the left shoulder 10% effective the day after DOS

ANALYSIS SUMMARY:

LBP with a History of Injury to T12 Condition.  The CI sustained a T12 compression fracture on 23 September 1988.  He was taken for a back evaluation and the examiner diagnosed a T12 compression fracture.  The CI was placed on light duty and towards the end of January 1989; he went on terminal leave and was sent to CONUS.  He joined the Army National Guard in 1995 as the back stopped bothering him; however he could not pass the physical training test.  He separated in 1998 and reenlisted in the Guard in April 2000 and noted that his back was fine.  He still had problems with the PT test; however, his back was “OK” when he deployed.  He had recurring back pain and was evaluated.  The MEB narrative summary (NARSUM) exam approximately 5 months prior to separation documented intermittent, chronic back pain exacerbated by his weight gain of 20 pounds.  The MEB NARSUM physical exam findings are summarized in the chart below.  Approximately 5 months prior to separation the physical therapist (PT) performed range-of-motion (ROM) measurements for the MEB.  The PT physical exam findings are summarized in the chart below.  Two months prior to separation, a lumbar spine X-ray showed severe degenerative changes of L4-5 and L5-S1 and no definitive compression fracture was noted.  The VA Compensation and Pension (C&P) exam accomplished approximately a month after separation documented that the back stiffness had worsening with daily pain.  The VA C&P physical exam findings are summarized in the chart below.  Five months after separation, a lumbar spine X-ray showed very mild degenerative changes and mild chronic T12 compression.

There were two 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.

Thoracolumbar ROM (Degrees)	MEB ~5.5 Mos. Pre Sep	PT ~5.5 Mos. Pre-Sep	VA C&P ~1.5 Mos. Post-Sep	
Flexion (90 Normal)	No ROM’s	90	90	
Combined (240)	-	235	240	
Comment	Normal gait; Pos. tenderness to palpation; Neg. straight leg raise	-	Normal gait; No spasm; Normal strength & reflexes; “Repetitive motion significant for increased symptoms”	
§4.71a Rating	10%	-	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the LBP with a history of injury to T12 condition as 5299 analogous to 5235 (Vertebral fracture or dislocation) and rated at 10%.  The VA coded as 5235 (residuals of compression fracture) also rated at 10%.  The General Rating Formula for Diseases and Injuries of the Spine considers the CI’s pain symptoms “with or without symptoms such as pain (whether or not it radiates), stiffness or aching in the area of the spine affected by residuals of injury or disease.”  All probative exams document that the CI met the 10% rating criteria for “localized tenderness not resulting in abnormal gait.”  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 LBP with a history of injury to T12 condition.

Left Shoulder Pain s/p Repair of Rotator Cuff and Repair Condition:  The CI sustained a left shoulder injury while deployed to Kuwait when he was climbing down a truck ladder, fell and landed on his left upper extremity with his arm behind him.  The CI was evaluated and X-rays were done, which were normal.  A left shoulder magnetic resonance imaging showed a complete tear of the supraspinatus tendon.  The CI underwent left rotator cuff repair surgery on 9 May 2003.  The Orthopedist noted limited ROM secondary to pain and discomfort.  The PT documented that the ROM was within functional limits but pain was still 4/10.  The MEB NARSUM exam approximately 5 months prior to separation documented chronic left shoulder pain made worse by weather changes.  The physical exam findings are summarized in the chart below.  

Left Shoulder ROM(Degrees)	MEB ~5.5 Mos. Pre-Sep	PT ~5.5 Mos. Pre-Sep	VA C&P ~1.5 Mo5. Post-Sep	
Flexion (180 Normal)	160	-	145	
Abduction (180)	160	165	145	
Comments	Pos. painful motion; No instability; Normal strength	-	Pos. painful motion, tenderness & crepitus; Normal reflexes	
§4.71a Rating	10%*	-	10%*	
*IAW VASRD §4.59, Painful Motion

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded 5099 (left shoulder pain s/p repair of rotator cuff and repair) condition analogous to 5003 (degenerative arthritis), and rated at 10%.  The VA coded as 5203 (s/p left rotator cuff tear with residuals) and deferred the rating based on receipt and review of service records from the CI’s second period of service (2003-2004).  The VARD dated 20 September 2007 rated the left shoulder at 10% effective on 14 August 2004 and coded as 5019 (bursitis).  The MEB and C&P exams both documented pain limited motion.  No exam indicated limited ROM to a compensable level without application of §4.59, (painful motion).  The Board considered the coding schema of 5201, (limitation of arm motion), and 5019; however, neither of these rating schemes would result in a higher 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 left shoulder pain 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 LBP with a history of injury to T12 condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left shoulder pain s/p repair of rotator cuff 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 re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130923, 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 XXXXXXXXXXXXXXX, AR20150009921 (PD201301553)

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