RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01044
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090227

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Infantryman, medically separated for “degenerative arthritis, lumbar spine” and “chronic left non-dominant shoulder pain,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI made no contentions.  The applicant’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 PEB - 20081205	VARD - 20091029	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Degenerative Arthritis, Lumbar Spine	5242	10%	Degenerative Joint Disease And Intervertebral Disc
Disease Of The Lumbar Spine	5237	10%	2090512	
Chronic Left Non-Dominant Shoulder Pain	5099-5003	10%	Degenerative Joint Disease Of The Left Shoulder (Non-dominant)	5010-5201	10%	20090512	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), low back pain (LBP) began approximately 2 years prior to referral for MEB.  A lumbar spine X-ray showed mild degenerative joint disease (DJD) in the lower lumbar spine.  A lumbar spine magnetic resonance imaging (MRI) showed suspected spondylolysis (deficient development or degeneration of a vertebral component [pars interarticularis]) at L5, disc bulges at L3-L4 and L4-L5, and moderate facet arthropathy (joint disease) throughout the lumbar levels.  Physical therapy (PT) measured active range-of-motion (ROM) with a goniometer.  Thoracolumbar spine flexion was 90 (90 normal), extension was 29 (30), left lateral flexion was 33 (30), right lateral flexion was 31 (30), left rotation was 23 (30), and right rotation was 32 (30) degrees.  There was no change in ROM after three repetitions.  In the NARSUM, 3 months before separation, the CI reported LBP began in a Joint Readiness Training Center (JRTC) rotation prior to deployment.  The LBP gradually worsened during the deployment, but the CI did not seek care until 15 months later.  The focused physical examination documented no abnormal gait, localized tenderness, muscle spasm, guarding, or abnormal spinal contour.  The straight leg raise (SLR) tests (assess for herniated disc causing sciatic nerve root [L5-S1] radiculopathy) were negative.  Repetitive active ROM was measured with a goniometer.  Thoracolumbar spine flexion was 80/90/90 (90), extension was 30/30/30 (30), bilateral lateral flexion was 30/30/30 (30), left rotation was 60/40/40 (30), and right rotation was 50/50/50 (30) degrees.  There was pain only with left rotation.  Fatigue, weakness, lack of endurance, or incoordination did not appear to significantly limit functional ability with repetitive ROM.  Lower extremity strength, sensation, and deep tendon reflexes (DTRs) were normal.  The examiner recounted the findings of the MRI.  The diagnoses listed herniated disc (L4-L5) and lumbar spondylosis (spine degenerative disease).  The compensation and pension (C&P) examination recounted the history and interventions.  The CI reported his back pain began when he jumped from a truck while deployed to Iraq.  He complained of stiffness, limited motion, and pain.  The intermittent lumbosacral pain was characterized as mild to moderate and dull.  Pain was exacerbated by prolonged standing and prolonged walking and relieved by joint cream and ice.  The CI reported moderate pain flare-ups occurred every 2 to 3 weeks and lasted for hours.  The CI denied a history of trauma, urinary incontinence, fecal incontinence, erectile dysfunction, numbness, and paresthesias (abnormal sensation, tingling, burning, and prickling), weakness, falls, unsteadiness, fatigue, spasms, radiation of pain, or incapacitating episodes.  The physical examination documented a normal gait with no assistive device.  The spine examination revealed normal posture and symmetry with no abnormal spinal curvatures, ankylosis, weakness, atrophy, spasm, tenderness, guarding, or pain with motion.  There was no muscle spasm, localized tenderness, or guarding severe enough to be responsible for an abnormal gait or abnormal spinal contour.  The SLR tests were positive.  Thoracolumbar spine active ROM values were measured at baseline and following repetitive ROM (X3).  Baseline/repetitive flexion was 75/70 (90), extension was 20/17 (30), left lateral flexion was 25/20 (30), right lateral flexion was 26/22 (30), left rotation was 26/20 (30), and right rotation was 27/24 (30) degrees.  The ROM was additionally limited after repetitive motion by pain.  Strength, sensation, and DTRs were normal and pathologic reflexes were absent.  The examiner recounted the findings of the MRI.  The diagnoses listed DJD and intervertebral disc disease.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5242 code (degenerative arthritis of the spine) citing lumbar spine degenerative arthritis described as herniated disc and lumbar spondylosis, ROM, no spasm, no guarding, normal strength, normal DTRs, and MRI findings of degenerative changes and L4-L5 disc bulge without evidence of herniation.  The VA assigned a 10% rating under the 5237 code (lumbosacral or cervical strain) based on the VA C&P examination 3 months after separation, citing disc bulge, ROM, pain on active ROM, and repetitive ROM additionally limited by pain.  The ROM values in the NARSUM examination did not attain the minimum 10% rating based upon the General Rating Formula for Diseases and Injuries of the Spine.  The higher 10% rating would require flexion of greater than 60 degrees but not greater than 85 degrees; or a combined ROM of greater than 120 degrees but not greater than 235 degrees of the thoracolumbar spine.  The ROM values in the PT and C&P examinations were consistent with the 10% rating.  There was no documentation of incapacitating episodes, or evidence of ratable peripheral nerve impairment, which would provide for additional or higher rating.  The Board agreed there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.40, §4.45, and §4.59).  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 low back condition.

Left Shoulder Condition.  According to STR and NARSUM, the CI injured his left shoulder during basic training, approximately 2 years prior to referral for MEB.  At a clinic encounter, the CI reported his left shoulder gave out while he was doing dips on the bars.  A left shoulder X-ray showed DJD changes at the acromioclavicular (AC) joint and the greater tuberosity which could cause an impingement syndrome.  A left shoulder MRI showed a full thickness tear of the distal supraspinatus tendon and AC joint degenerative changes and impingement.  The CI underwent an arthroscopic subacromial decompression followed by an open rotator cuff repair and Mumford procedure (distal clavicle excision/resection).  Left shoulder active ROM was measured with a goniometer by PT.  Flexion was 180 (180), abduction was 180 (180), internal rotation was 90 (90), and external rotation was 82 (90) degrees.  There was no change in ROM after three repetitions.  There was pain at end range with flexion and abduction and half way through the range with external rotation.  A left shoulder MRI showed postoperative changes, a possible element of supraspinatus tendon re-tearing, and a possible small area of superior labrum tearing.  A left shoulder MRI arthrogram (joint imaging following contrast injection) showed postoperative changes, no definite full thickness rotator cuff recurrent tear, and no definite labral tear.  The NARSUM recounted the history and interventions.  The CI reported that in the month following his surgery, he was placed on a detail to prepare a sound stage for a Christmas show, and some scaffolding fell on him.  He continued PT and noted some improvement in his left shoulder.  Pain was exacerbated by activity and relieved by over-the-counter (OTC) muscle rubs and muscle relaxers.  There were pain flare-ups with extensive use or cold weather, and pain occasionally interfered with sleep.  The focused left shoulder examination revealed slight subluxation (incomplete or partial dislocation) with manipulation and no tenderness.  Repetitive active ROM was measured with a goniometer.  Left shoulder flexion was 170/170/170 (180), abduction was 150/150/150 (180), internal rotation was 90/90/90 (90), and external rotation was 80/80/80 (90) degrees.  There was pain with flexion, abduction, and external rotation.  There was weakness related to pain with abduction.  Fatigue, weakness, lack of endurance, or incoordination did not appear to significantly limit functional ability with repetitive ROM.  The examiner cited the operative report and recounted the findings of the postoperative MRIs.  The diagnosis listed left shoulder pain after surgery.  The C&P examination recounted the history and interventions.  The right-hand dominant CI reported his left shoulder pain began during training, and worsened while deployed to Iraq.  His symptoms improved, following surgery and 6 months of PT, but he did not recover his ROM.  He complained of stiffness, limited motion, decreased speed of motion, fatigability, and pain.  The CI denied muscle symptoms, flare-ups, giving way, instability, weakness, incoordination, dislocation, subluxation, locking episodes, effusions, or symptoms of inflammation.  The left shoulder examination revealed tenderness with no swelling, effusion, laxity, ankylosis, deformity, or evidence of inflammatory arthritis.  Left shoulder active ROM values were measured at baseline and following repetitive ROM (X3).  Baseline/repetitive flexion was 120/110 (180), abduction was 150/110 (180), internal rotation was 70/55 (90), and external rotation was 75/65 (90) degrees.  The ROM was additionally limited after repetitive motion by pain.  Strength, sensation, and DTRs were normal.  The examiner recounted the findings of the MRI.  The diagnosis listed left shoulder DJD.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5003 code (degenerative arthritis) citing non-dominant left shoulder, chronic pain, secondary to rotator cuff tear with surgical repair, and ROM.  The VA assigned a 10% rating under the 5010-5201 codes (traumatic arthritis-limitation of arm motion) based on the VA C&P examination citing non-dominant left shoulder, shoulder injury, ROM, pain on active motion, and ROM additionally limited after repetitive motion by pain.  Based upon the proximate (PT, NARSUM, and C&P) exams, there was no compensable limitation of motion for consideration under 5201 (at shoulder level [90 degrees] is minimum 20% rating).  There was no evidence of scapulohumeral ankylosis to support a rating under 5200, and no evidence of nonunion, malunion, or dislocation of the humerus, clavicle or scapula to support a rating under 5202 or 5203.  The Board agreed there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.40, §4.45, and §4.59).  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:  In the matter of the low back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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.  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 20140228, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXXXX AR20160005875 (PD201401044)

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:

Enclosure

CF:
( ) DoD PDBR
( ) DVA