RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2014-01693
BRANCH OF SERVICE:  Army	BOARD DATE:  20140805
Separation Date:  20060519

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (52D/Power Generator Equipment Repair Specialist) medically separated for chronic upper back pain and chronic right (dominant) shoulder 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 profile and referred for a Medical Evaluation Board (MEB).  The upper back and shoulder pain condition, characterized as “right chronic shoulder pain, status post open reduction and chronic upper back pain secondary to T3 compression fracture,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “chronic upper back pain and chronic right (dominant) shoulder pain” as unfitting, rated 10% and 10% respectively, citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy for the shoulder.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Would have continued military service without these disabilities, it has been impossible to maintain employment in the civilian workforce since getting out of the service. Have chronic pain which leads to a decreased quality of life.”

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 rating for the unfitting upper back and right shoulder pain condition is 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 20060316	VA - (3 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Upper Back Pain	5235	10%	Degenerative Joint Disease (DJD) Thoracic Spine*	5252*-5010	0%	20060828	
			DJD Cervical Spine*	5010-5242	0%	20060828	
Chronic Right (dominant) Shoulder Pain	5099-5003	10%	Healed Right Clavicular Fracture with DJD of the Right Shoulder	5203-5010	10%	20060828	
No Additional MEB/PEB Entries	Other x2	
Combined:  20%	Combined:  20%	
Derived from VA Rating Decision (VARD) dated 20060828 (most proximate to date of separation [DOS])
*VARD 20080506 combined the DJD of the C-spine and T-spine coded as 5010-5242 and rated at 10%.

ANALYSIS SUMMARY:  The Board acknowledges the sentiment expressed in the CI’s application regarding the significant impact that his service-incurred condition has had on his current earning ability and quality of life.  It is a fact, however, that the Disability Evaluation System (DES) has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation.  This role and authority is granted by Congress to the Department of Veterans Affairs (DVA).  The Board utilizes DVA evidence proximal to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12-month interval for special consideration to post-separation evidence.  The Board’s authority as defined in DoDI 6044.40, however, resides in evaluating the fairness of DES fitness determinations and rating decisions for disability at the time of separation.  Post-separation evidence therefore is probative only to the extent that it reasonably reflects the disability and fitness implications at the time of separation.

Chronic Upper Back Pain Condition.  The CI was injured in an all-terrain vehicle in February 2004 and sustained injuries to his right shoulder and upper back.  He was initially diagnosed with a muscle strain.  His back pain continued and the battalion aid station doctor ordered a magnetic resonance imaging (MRI), which showed a compression wedge fracture of T3.  The chiropractor noted that the back pain worsened with most daily activities of living and was relieved with medication.  The CI fell approximately 35 feet down a ravine while hiking in April and reinjured his back and neck.  He was seen in primary care and was noted to have pain in the right trapezius and mid thoracic area.  The examiner diagnosed cervical strain and, referred him to a chiropractor and gave him a temporary profile for 2 weeks with restrictions of no running, jumping arching, no lifting over 20 pounds and physical training.  A thoracic spine MRI showed subtle anterior wedge deformities of T3 and T5 vertebral bodies, right para-central disc protrusion at T4-5, left para-central disc protrusion at T5-6 and mild multi-level degenerative disc changes.  The CI was seen by neurosurgery who noted that the CI was deployed on Morphine and Percocet and was able to perform his duties on these narcotics for pain control.  The physical exam findings were normal strength in the upper and lower extremities and 1+ reflexes throughout.  The examiner opined that there were no neurosurgical indications at that time.  A repeat thoracic spine MRI showed a chronic anterior wedge compression fracture of T3 with mild exaggeration of thoracic kyphosis due to this anterior compression and T2-T3 anterior bridging osteophytes, signifying mild spondylosis.  The CI was sent to physical therapy (PT) for a range-of-motion (ROM) exam for the MEB.  The PT physical exam findings are summarized in the chart below.  The Family Practice examiner documented that the CI reported upper back tenderness to palpation (TTP) and middle diffuse TTP, forward bends with mild pain and rotation of upper back was painful.  The physical exam findings are summarized in the chart below.  The MEB narrative summary (NARSUM) exam approximately 3.5 months prior to separation documented that the CI continued with chronic mechanical back pain, which was alleviated with a transcutaneous electrical nerve stimulation (TENS) unit and was undergoing a MEB evaluation in neurosurgery for his back condition.  This exam focused solely on the shoulder condition.  The CI was given a permanent U3 profile for chronic right shoulder pain, chronic upper back pain (T3 compression fracture).  Based on the CI’s continued upper back pain, the pain management examiner administered a trigger point injection and administered a second trigger point injection in April.  The pain management examiner ordered a TENS unit for pain control.  The pain management examiner administered a thoracic block for possible facet mediated pain.  The pain management examiner documented that the CI reported pain was aggravated by lying on his back, twisting and returning to upright after bending.  The VA Compensation and Pension (C&P) exam documented mid-line mid-back pain started gradually and was present on awakening and was made worse with sitting, with standing, stooping, bending and turning.  The CI reported aching, sticking pain with physical activity and pressure on the back when he was recumbent.  The functional impairment was a diminished ability to lift, carry or work above the head.  The C&P physical exam findings are summarized in the chart below.  A thoracic spine X-ray demonstrated mild to moderate degenerative narrowing of the intervertebral disc spaces and mild degenerative changes of the facets.

There was a single range-of-motion (ROM) evaluation 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)	PT for MEB  4 Mos. Pre-Sep	VA C&P 3.5 Mos. Pre-Sep	
Flexion (90⁰ Normal)	“full”	90	
Combined (240⁰)		240	
Comment	Slightly limited side-bending with mechanical limits	No radiating pain on movement; No muscle; spasm; Non tender; neg. straight leg raise bilat.	
§4.71a Rating	0%	0%	

The Board directs attention to its rating recommendation based on the above evidence.  The PEB coded the chronic upper back pain condition as 5235 (vertebral fracture or dislocation) and rated at 10%.  The VA applied the combination code of 5242 (degenerative arthritis of the spine) with 5010 (arthritis due to trauma) substantiated by X-ray findings, for the DJD thoracic spine condition.  The VARD dated 6 May 2008, combined the DJD of the C-spine and T-spine and rated them at 0%.  The next VARD that considered those two conditions increased that rating to 10% effective the day after separation.  The PEB’s 5235 code and the VA’s 5242 code are rated based on ROM measurement IAW the general rating formula for diseases and injuries of the spine.  That formula also 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.”  Both exams proximate to separation document non-compensable ROM measurements of the thoracolumbar spine.  The service treatment records provide satisfactory evidence for the application of VASRD §4.59 (painful motion) which is consistent with a 10% rating.  The Board reviewed the 10% rating criteria under the spine formula and agreed that the CI also met those criteria.  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 upper back pain condition.

Chronic Right (dominant) Shoulder Pain:  The CI was injured in an all-terrain vehicle in February 2004 and sustained injuries to his right collar bone and shoulder.  He was subsequently treated in a non-operative manner with a sling and ROM exercises for the following 8 months.  This non-operative treatment resulted in a hypertrophic nonunion of the right clavicle.  The CI underwent an open reduction internal fixation with autologous bone graft from the left tibia on 15 March 2005.  The CI was followed by orthopedics for post-operative follow-up and noted to have a malunion of the clavicle with constant pain.  He underwent a right stellate ganglion block on 21 April 2005 for pain reduction.  The right clavicle healed; however the orthopedic hardware caused pain over the prominence and the hardware was removed on 7 July 2007.  The pain clinic examiner documented severe incisional pain over the right shoulder scar and treated with a steroid injection into the right shoulder.  The orthopedist documented continued moderate pain with activity and directly over the fracture site with physical exam findings of tenderness across the acromion and proximal humerus and focal tenderness over the mid third of the clavicle and incision.  The examiner noted that the CI wanted to deploy and was able to do his job.  The PT noted that the shoulder was stable and he was able to do his MOS and deploy.  The CI was seen in pain management prior to deploying for pain medications due to the chronic clavicle and shoulder pain.  The CI was sent to PT for a ROM exam for the MEB exam.  The PT physical exam findings are summarized in the chart below.  The MEB consultation exam approximately 3 months prior to separation documented that the CI had been given a P2 profile to allow him to deploy despite the fact that he continued to have chronic right shoulder pain, specifically with cross-arm abduction as well as overhead maneuvering.  The CI was functionally impaired in that he was unable to provide maintenance and upkeep of generators as part of his MOS duties.  The MEB consultation physical exam findings are summarized in the chart below.  The MEB NARSUM exam, approximately 3 months prior to separation, offered no new evidence.  The CI was given a permanent U3 profile for chronic right shoulder pain, chronic upper back pain (T3 compression fracture).  The C&P exam documented constant aching, sticking, pain that radiated from the right shoulder down to the arm elicited by physical activity and resting on the right side.  The CI had incapacitating episodes as often as two times per year for 21 days.  The functional impairment was that he could not work with arms overhead for an extended length of time.  The C&P physical exam findings are summarized in the chart below.

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.

Right Shoulder ROM	PT exam  4 Mos. Pre-Sep	MEB  3 Mos. Pre-Sep	VA C&P  3.50 Mo. Post-Sep	
Flexion (0-180⁰)	145 	-	180	
Abduction (0-180⁰)	145 	-	160	
Comments
Right hand dominant	Pos. painful motion	Focal tenderness to palpation over distal clavicle; Pain exacerbated with cross-body adduction and overhead activity above 120 degrees focused at clavicle; normal strength; stable shoulder	Pos. painful motion; repetitive use-limited joint function by 10 degrees; no weakness, tenderness or guarding of movement	
§4.71a Rating	10%	10%	10%	

The Board directs attention to its rating recommendation based on the above evidence.  The PEB coded the chronic right shoulder pain condition as 5099 analogous to 5003 as arthritis, degenerative (hypertrophic or osteoarthritis) and rated at 10% and applied the USAPDA pain policy.  The VA coded the healed right clavicular fracture with DJD of the right shoulder condition as 5203 (impairment of the clavicle or scapula due to malunion) with 5010 (arthritis due to trauma) and rated at 10%.  All exams proximate to separation document pain limited motion with non-compensable ROM measurements of the right shoulder.  VASRD §4.71a specifies for 5003 that “satisfactory evidence of painful motion constitutes limitation of motion and specifies application of a 10% rating “for each major joint or group of minor joints affected by limitation of motion.”  The Board considered assigning a rating for malunion of clavicle with arthritis due to trauma as did the VA; however, this would not result in a rating greater than 10% as arthritis due to trauma is also rated under code 5003.  The Board also determined that no alternate coding/rating schema would provide 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 chronic right (dominant) 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.  As discussed above, PEB reliance on the USAPDA pain policy for rating the chronic right (dominant) shoulder pain condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the chronic upper back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic right (dominant) shoulder pain 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:  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 20140410, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			
XXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

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, AR20150006239 (PD201401693)

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						     XXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA