RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01419
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20091104

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Food Service Specialist, medically separated for “chronic right shoulder pain…” and “chronic neck pain…,” each rated 10%, with a combined disability rating of 20%.

CI CONTENTION:  “I have limited forward motion flexibility.”  The CI’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 based upon a 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 - 20090714	VARD - 20100802	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic R Shoulder Pain…	5099-5003	10%	Adhesive Capsulitis, R Shoulder	5201	10%	20100301	
Chronic Neck Pain…	5237	10%	Cervical Spine Strain	5237	0%		
Chronic Low Back Pain…	Not Unfitting	Thoracolumbar…Scoliosis	5237-5239	20%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Chronic Right Shoulder Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-hand dominant CI began experiencing right shoulder pain in October 2007 with no specific trauma or injury.  

Magnetic resonance imaging in February 2009 showed “very mild” degenerative changes (arthropathy) of the acromioclavicular joint, along with findings suggestive of frozen shoulder (adhesive capsulitis, characterized by limited motion, stiffness and pain in the shoulder).
Evaluation by orthopedics concluded with a diagnosis of “joint pain localized in the shoulder.”  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic right shoulder pain due to acromioclavicular joint arthropathy” for PEB adjudication.

The 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. 

Right Shoulder ROM
(Degrees)	PT ~7 Mos. Pre-Sep
	VA ~4 Mos. Post-Sep
	
Flexion (180 Normal)	100 (105, ?, 100)	130	
Abduction (180)	105 (100, ?, 105)	115	
Comments	Painful Motion	Painful Motion	
§4.71a Rating	10%	10%	

At the MEB NARSUM evaluation on 27 April 2009, 6 months prior to separation, the CI complained of constant right shoulder pain exacerbated by heavy lifting.  Physical examination revealed no guarding, spasm, ligamentous laxity or signs of impingement.  Shoulder ROM was as noted at the 2 April 2009 PT evaluation cited above.

At the 1 March 2010 VA Compensation and Pension (C&P) examination, performed 4 months after separation, the right hand dominant CI reported daily right shoulder pain rated 5/10 in severity that prevented her from sleeping well and caused pain with overhead activity, carrying objects or lifting overhead.  She denied flare-ups and instability.  Physical examination showed tenderness over the AC joint and the rotator cuff (the group of muscles and tendons that surround the shoulder joint).  Shoulder ROM was as noted in the chart above, with painful motion.  There was no additional loss of ROM with repetition.  Testing for stability and impingement was normal, and there was decreased strength in one of the rotator cuff muscles (supraspinatus).
 
The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5003 code (degenerative arthritis), citing limitation of motion.  The VA assigned a 10% rating, also based upon limitation of motion, but used the 5201 code (arm, limitation of motion of).  

The VASRD §4.71a threshold for rating for ROM impairment (code 5201, arm limitation of motion) is “at shoulder level” (approximately 90 degrees from the side), and the examinations in evidence demonstrated motion above this level.  Although there was insufficient limitation of motion to support a rating under the 5201 code, Board members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion).  There was no malunion or recurrent dislocation of the humerus to justify a rating under the 5202 code (humerus, other impairment of); and no nonunion with loose movement of the clavicle to warrant the next higher 20% rating under the 5203 code (clavicle or scapula, impairment of).  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 right shoulder pain.

Chronic Neck Pain. According to STR and the MEB NARSUM, the CI’s neck pain began in October 2007 with no specific injury or trauma identified.  The CI reported neck pain with radiation to the right arm with intermittent numbness of the first three fingers.  Cervical spine MRI in January 2008 was normal and electrodiagnostic studies in September 2008 were negative for radiculopathy.  Evaluation by orthopedics in March 2009 concluded with a diagnosis of neck pain.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty. The MEB forwarded “chronic neck pain…” for PEB adjudication.

The ROM examinations 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)	MEB PT ~6 Mos. 
Pre-Sep
	VA ~4 Mos. 
Post-Sep
	
Flexion (45 Normal)	45 (50, ?, 55)	45 (45)	
Combined (340)	305	340	
Comments	Painful motion	Tenderness	
§4.71a Rating	10%	10% (VA 0%)	

The MEB NARSUM examination on 27 April 2009 (6 months prior to separation) noted complaints of constant neck pain.  Physical examination showed a normal gait and stance.  There was muscle tenderness to palpation, but no spasm or loss of cervical lordosis was noted.  Strength and sensation of all extremities was normal.  Physical therapy measured ROM for the MEB the same day and the MEB NARSUM examiner was in attendance.  Cervical spine ROM was as noted in the chart above and pain was observed with motion.  Cervical muscle spasm was noted along with tenderness.  

At the 1 March 2010 VA Compensation and Pension (C&P) examination, performed 4 months after separation, the CI reported constant neck pain without radiation, rated 4-5/10 in severity with flare-ups due to activity, lasting several hours and occurring 2-3 times per week.  She denied incapacitating episodes.  Physical examination showed a normal gait.  There was TTP without muscle spasm.  Cervical spine ROM was as noted in the chart above, with the examiner making no observations regarding painful motion.  There was no additional loss of ROM with repetition.  Upper and lower extremity strength, sensation, and reflexes were normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck pain 10% using the 5237 code (cervical strain), citing limitation of combined motion.  The VA also used the 5237 code, but assigned a 0% rating, based upon the C&P examination.  The Board agreed that a 10% rating, but no higher, was justified for tenderness reported on the NARSUM and VA examinations.  Although muscle spasm was noted with PT ROM testing for the MEB there was no abnormal spinal contour noted by the MEB NARSUM examiner who performed his examination just before the ROM testing and was in attendance at the time of PT ROM testing.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula or evidence of ratable peripheral nerve impairment which would provide for additional 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 neck pain condition.  
 
Contended PEB Condition:  Chronic Lower Back Pain.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was permanently profiled and was judged to fail retention standards by the NARSUM examiner and the MEB.  However, back ROM at the MEB NARSUM examination was normal and the MEB NARSUM examiner indicated under “current status and prognosis” that “regarding back pain, this soldier has no significant limitation.”  The commander’s statement did not specifically implicate any medical condition and only referred to the CI’s “medical conditions/limitations.”  The Board concluded there was not a preponderance of evidence that the low back pain condition significantly interfered with satisfactory duty performance at separation to overcome the PEB determination that the condition was not unfitting.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the low back condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matters of the chronic right shoulder pain and the chronic neck pain and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudications.  In the matter of the contended chronic lower back pain, the Board unanimously recommends no change from the PEB determination as not unfitting.  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 20140318, 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 XXXXXXXXXXXXXXXXXXXXX AR20160013469 (PD201401419)

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