RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-01975
BRANCH OF SERVICE:  Army	BOARD DATE:  20150318
SEPARATION DATE:  20051017

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E-4 (Food Service Specialist) medically separated for back and right shoulder conditions.  The conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty.  Her profile allowed for an alternate aerobic event to satisfy physical fitness requirements.  She was issued a permanent U3L3 profile and referred for a Medical Evaluation Board (MEB).  The “Chronic right shoulder pain post arthroscopy” and “chronic low back pain,” were forwarded by the MEB to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “back strain…has radiculitis without radiculopathy” and “right shoulder injury” as unfitting, rated 10% and 0% respectively, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI appealed to the Formal PEB but later withdrew the request and was medically separated.

CI CONTENTION:  The CI listed “10% torn rotator cuff and 10% spinal disc bulge.”

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:

IPEB – Dated 20050803	VA* - (~7 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Back Strain	5237	10%	Paralumbar and Parathoracic Spine Muscle Spasm …	5237-5243	10%**	20060526	
Right Shoulder	5099-5003	0%	Right Shoulder Rotator …	5201-5024	10%	20060526	
Other x 0 (Not In Scope)	Other x 0 	
RATING: 10%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20060714 (most proximate to date of separation [DOS]).  **Previous VA rating for back.

ANALYSIS SUMMARY:

Back Strain Condition.  The CI was first seen for back pain on 23 October 1998 when she reported pain since she had lifted a box of milk.  Her examination was normal other than “taut” neck muscles.  She was treated conservatively with medications and duty limitations for several weeks with apparent resolution.  She was next seen on 3 June 1999, with recurrent low back pain (LBP) after an injury the previous day.  The range-of-motion (ROM) was reduced in all planes and she was again treated conservatively.  X-rays showed a small degree of thoracic scoliosis.  In physical therapy (PT) on 9 June 1999, she reported a history of upper back pain for over 2 years (she had been in the Army for 18 months) as well as constant low level LBP.  She was treated in PT for several months with persistent pain.  A lumbar X-ray on 7 October 1999 showed minimal narrowing of the L5-S1 joint space.  She was again noted to have had bad back pain prior to entering active duty.  She was subsequently issued a L2 profile and authorized an alternate physical fitness test.  She had a VA Compensation and Pension (C&P) examination on 9 November 2000 and was found to have a normal gait and ROM.  She was adjudicated a 10% rating for her LBP effective the DOS from her first tour of active duty on 3 February 2001.  She was reactivated on 9 December 2003.  On 21 January 2004, she presented with recurrent back pain.  An X-ray on 1 April 2004 again showed narrowing of the L5-S1 disc space.  Repeat X-rays on 8 November 2004 also showed degenerative joint disease at L5-S1 and the right sacro-iliac joint (the joint between the lower spine and the pelvis).  A magnetic resonance imaging (MRI) the next day showed a disc bulge without herniation at L5-S1 with possible nerve root impingement.  She was seen in PT on 13 January 2005 and noted to have major limitations in the ROM as well as a motor deficit of the right lower extremity.  Sensation and reflexes were intact.  She was also seen in case management that day and wanted her (anticipated) MEB expedited so that she could go to school.  On 24 February, her lumbar flexion was limited to 20 degrees (90 is normal), but she had normal ROM in the other planes including extension and a normal gait.  She was seen in neurology on 14 March 2005 and noted to have a peroneal nerve (a peripheral nerve in the leg), right > left on electrodiagnostic (EDX) testing.  She was also noted to have changes which could be consistent with a left L5 radiculopathy.  Another case management note, dated 26 March 2005, documented that she had sent an email the previous day which indicated “deep depression and frustration with military life.”  A week later, a case management note dated 2 April 2005, documented that “conversations with the SM (service member) show frustration and deep dislike for constraints placed on her by military lifestyle.”  She was given the opportunity to REFRAD (release from active duty), but declined “due to lack of financial instability.”  At a follow-up neurology evaluation on 7 April 2005, 6 months prior to separation, she was noted to have persistent pain despite medications and PT.  On examination her reflexes were normal.  Sensation was decreased in an L5 distribution bilaterally.  Slight weakness (5-/5) was noted on the right in the L5 distribution as well.  On 12 April 2005, the CI had ROM measurements in PT as charted below.  The motion was limited by pain.  Repeat EDX testing on 14 April 2005 was consistent with L5>L4 right sided radiculopathy.

The narrative summary (NARSUM) was dated 13 May 2005.  On examination, the CI has diffuse lumbar tenderness with marked limitation of flexion and some limitation in all planes.  Sensation, strength, and reflexes were normal.  Provocative testing for nerve root irritation was negative.  Signs of non-organic causes of pain were absent.  A repeat neurology evaluation on 13 September 2005 documented normal reflexes and gait, but mild weakness on the right in the L5 distribution and also decreased sensation on the right.  At the VA C&P examination performed on 26 May 2006, 7 months after separation, the CI reported that she was working full-time, a full-time student, and caring for her father who suffered from substance abuse.  She reported multiple aches and pains (arthralgias and myalgias) secondary to stress and tension.  On examination, her gait and posture were normal and her head held erect.  No neurological abnormalities were found on examination although the right hip showed some decrease in extension and flexion compared to the left.  Muscle tenderness, atrophy, and spasm were absent.  The ROM was normal with a pulling sensation to the right, but without further symptoms with repetition.  Repeat EDX testing on 30 May 2006 was normal.  There were no further records in evidence regarding the back until a 13 October 2009 pain clinic evaluation, 4 years after separation and well outside of the normal one-year period assigned high probative value.  In this case though, the examinations, before and after separation, were inconsistent.  The CI was observed to sit and stand up normally, but with pain.  Gait, balance, and posture were normal.  She could toe and heel walk, squat, and had normal strength.  Strength and reflexes were normal.  Flexion was normal to 90 degrees, but with mild pain.  Extension was limited to 10 degrees, but with moderate pain.  She was noted to have a normal body habitus implying an absence of atrophy.  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.

Thoracolumbar ROM
(Degrees)	MEB ~6 Mos. Pre-Sep	VA C&P ~8 Mos. Post-Sep	
Flexion (90 Normal)	60 	90	
Combined (240)	160	240	
Comment	Limited by pain	Pulling to right	
§4.71a Rating	20%	0%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition at 10% using the code 5237 (lumbosacral strain).  The VA also rated the back at 10% using the code 5237 as well as the code 5243 (intervertebral disc syndrome).  The Board considered the evidence.  The ROM obtained by the MEB supports a 20% rating for limitation.  The ROM on the VA examination was normal in all planes and supports a 0% rating; in addition, atrophy was absent implying that her function was typically normal or near normal.  Both examinations were proximate to separation.  The Board considered other evidence more remote from the DOS.  The CI had a normal ROM on 21 January 2004 at the initial evaluation during her second activation.  A month later, her flexion was reduced to 20 degrees even though the ROM was normal for extension, rotation, and side bending as well as gait.  There was marked limitation in flexion at the NARSUM, but this was not quantified.  The pain clinic examination remote from separation noted normal, but painful flexion and reduced and painful extension.  However, atrophy was absent and she could squat without difficulty.  In addition, 10 days prior to the MEB ROM measurements she was noted to have “frustration and deep dislike for constraints placed on her by military lifestyle.”  The Board also considered that the values documented by the MEB were derived from reported pain threshold with motion during an exam performed in the context of expressly providing a basis for disability rating; thus subject to loss of objectivity.  The Board also considered if an unfitting radiculopathy was present at separation.  While there were clearly abnormal findings on the prior to separation EDX studies, those done after separation were normal.  The neurological examination was normal at some visits and abnormal on others.  Even when abnormalities were present on examination though, her gait and station were typically normal.  Even if a radiculopathy was present at separation, the evidence does not support that it was unfitting.  The Board considered VASRD §4.73 (higher of two ratings), which states “Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned.”  The Board determined that the VA C&P examination was more reflective of the totality of evidence.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the back condition.

Right Shoulder Condition.  The CI was first seen for a one-week history of atraumatic right shoulder pain on 24 February 1998, 3 weeks after accession.  She was treated conservatively and apparently returned to full duty.  She was seen again 5 years later.  An X-ray on 6 April 2003 of the right shoulder was normal.  A primary care note in the VA clinic on 13 May 2003 noted a 5-year history of back and right shoulder pain.  No further details were recorded.  On 21 January 2004, a repeat right shoulder X-ray was normal.  A referral to orthopedics noted an injury in September 2003 doing push-ups with subsequent decreased strength and a possible rotator cuff tear.  Her initial evaluation in PT was 11 February 2004.  She was noted to have painful, but full ROM.  Weakness was noted consistent with impingement of one of the shoulder muscles.  Her pain continued despite PT and an MRI on 9 March 2004 showed a partial tear of one of the shoulder muscles (infraspinatus).  She was evaluated in orthopedics 2 days later and thought to have overuse.  Continued PT and activity modification were recommended.  Her pain persisted though and arthroscopy was performed on 13 July 2004.  Following the rotator cuff repair, she again attended PT for rehabilitation.  Her pain persisted and she was given an injection (steroids and pain killer) in orthopedics on 4 October 2004.  A week later in PT, she had 160 degrees of flexion and abduction, near normal but painful.  Repeat X-rays were again normal.  She continued PT and had identical measurements for flexion and abduction on 6 December 2004.  A repeat MRI showed a small tear of the under surface of the supraspinatus tendon.  In orthopedics on 3 February 2005, flexion was noted to be 170 degrees and abduction 120 degrees and painful.  Atrophy was absent.  She was thought to have a partial rotator cuff tear and likely impingement.  A repeat MRI on 27 April 2005 was consistent with these findings.  The NARSUM was on 13 May 2005.  The right dominant CI had no atrophy or tenderness on examination.  Motion was painful in all planes.  Testing for impingement was positive.  The CI had a second repair of the shoulder on 5 July 2005.  She was again referred to PT for rehabilitation.  A PT note dated 19 July 2005 recorded that the CI was not wearing her sling and that she was cautioned to do so.  She continued PT with gradual improvement in motion.  At the last orthopedic evaluation on 3 October 2005, 2 weeks prior to separation and 3 months after surgery, her flexion was 140 degrees with pain and abduction 90 degrees.  X-rays that day showed good alignment of the repair.  At the VA C&P examination performed 7 months after separation and over 10 months after surgery, the CI reported that continued pain precluded a regular exercise program.  She reported difficulty with overhead activities.  On examination, she had good strength of both upper extremities.  She was tender to palpation, but without spasm.  The ROM is charted below and was painful at endpoint.  Repetition did not cause further limitation, but did result in residual discomfort.  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.

Right Shoulder ROM
(Degrees)	MEB ~6 Mos. Pre-Sep	VA C&P ~7 Mos. Post-Sep	
Flexion (180 Normal)	130, 127, 135	160	
Abduction (180)	121, 118, 117	160	
Comments	Painful motion.  Before second surgery	Painful motion.  Over ten months after second surgery	
§4.71a Rating	10% (4.59)	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the shoulder at 0% using the analogous code 5099-5003 (degenerative arthritis).  The VA rated the right shoulder condition at 10% using the dual code 5201-5024 (limitation of motion - tenosynovitis).  The Board considered these codes as well as the others applicable to the shoulder.  It noted that the limitation in motion was not compensable, but that there were radiological changes after surgery.  Incapacitation was not recorded as a 20% rating is not supported.  However, there was limited (but non compensable) and painful motion supporting a rating of 10% using the code 5003 or 5024.  The Board determined that the code 5024 better described the actual pathology.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% using the code 5024 for the right 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.  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 back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the right shoulder condition, the Board unanimously recommends a disability rating of 10%, coded 5204 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 her prior medical separation:

CONDITION	VASRD CODE	RATING	
Back Strain	5237	10%	
Right Shoulder Injury 	5099-5003 	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131025, 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, AR20150011195 (PD201301975)

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 to 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			

CF: 
(  ) DoD PDBR
(  ) DVA