RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02279
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20071201

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E6, Calvary Scout, medically separated for “lumbosacral strain causing low back pain” and “chronic left shoulder impingement,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  The CI request consideration of all of his conditions as well as PTSD.  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 - 20070906	VARD - 20080624	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbosacral Strain	5237	10%	IDS Lumbar Spine, with Degenerative Changes and Sciatic Nerve Involvement	5243-5242	20%	20071009	
Chronic Left Shoulder Impingement	5099-5003	0%	Left Shoulder Impingement with Degenerative Changes	5003-5201	20%	20071009	
Hypertension	Not Unfitting	Hypertension	7101	0%	20071009	
Dentures (Full Top Plate)		Dental Trauma	9999-9913	NSC	20071017	
Bilateral Meralgia Paresthetica		Sciatic Nerve Involvement from IDS, Left Lower Extremity	5243-8720	10%	20071009	
		Sciatic Nerve Involvement from IDS, Right Lower Extremity	5243-8720	10%	20071009	
Tinnitus		Tinnitus	6260	10%	20071011	
Headaches		Traumatic Brain Injury with Headaches	8199-8100	10%	20071009	
PTSD		PTSD	9411	30%	20071026	
Hyperlipidemia		No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  100%	

ANALYSIS SUMMARY:  

Lumbosacral Strain Causing Chronic Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s lumbosacral strain condition began in January 2005 after the vehicle in which he was riding was struck by an improvised explosive device (IED).  Magnetic resonance imaging (MRI) studies on 24 April 2006 showed herniated intervertebral discs at L1 level.  There were bulging intervertebral discs at L4-5 without nerve root impingement.  Electro-diagnostic studies (EMG) performed on 14 November 2006 were negative for radiculopathy. Diagnostic imaging (X-ray) studies 20 June 2007 showed degenerative disc disease.  There was a bulging intervertebral disc at L1 level.  There was narrowing of the posterior aspect of the L5-S1 disc space.  There was disc fusion on the left of the L5 intervertebral disc with narrowing of the L5-S1 disc space and degenerative disc disease noted.  There was no evidence of disc fracture.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty. The MEB forwarded “low back pain,” for PEB adjudication.

The MEB NARSUM examination on 29 June 2007, 5 months prior to separation, noted complaints of constant low back pain rated as 5-9/10 scale.  The pain was aggravated by prolonged walking, standing, lifting, twisting, and driving for long periods.  The pain was relieved by lying down, rest and medication.  The pain prevented the CI from wearing body armor, a rucksack, load bearing equipment, and could not perform the aerobic event of the physical fitness test.  He could not perform maintenance on his military vehicle, was unable to ride in a military vehicle, and could not lift heavy objects; requirements of his military occupational specialty.  Physical examination showed tenderness to palpation without muscle spasm.  Reflexes and gait were normal.  He had decreased sensation on the entire left lower extremity and to the lateral right thigh.  Provocative maneuvers for signs of radiculopathy or radiating pain due to spinal nerve root or sciatic nerve involvement were negative bilaterally.  The CI reported pain with examination maneuvers not expected to elicit pain based on the known pathology.  Thoracolumbar ROM after repetition was limited by pain as recorded in the chart.  
 
At the 9 October 2007 VA Compensation and Pension (C&P) evaluation, 2 months before separation, the CI reported constant, chronic low back pain that radiated to his legs and upper back.  The pain was accompanied with stiffness and weakness, rated 1-10/10 scale, 10 when at its worst, described as burning, aching, sharp, and sticking in nature.  There was no ankylosis or muscle spasm.  The pain was aggravated by physical activity to include bending, sitting, and standing and was relieved by medication (Oxycodone, Naproxen, and Gabapentin).  There were not incapacitating episodes.  The pain prevented him from walking more than 200 feet, standing for long periods, and carrying heavy weight.  Physical examination showed abnormal gait with limping in the left leg.  There was tenderness to the lumbar area without muscle spasm.  The spinal contour was normal.  Provocative maneuvers for signs of radiculopathy or radiating pain due to spinal nerve root or sciatic nerve involvement were negative.  Thoracolumbar ROM after repetition was limited by pain as recorded in the chart.          

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the lumbosacral strain condition 10% coded 5237 (lumbar spine strain), citing localized tenderness.  The VA rated the lumbosacral strain condition 20% coded 5243-5242 (intervertebral disc syndrome – degenerative arthritis of the spine), based on the VA C&P examination 2 months before separation, citing limited forward flexion with tenderness and pain on motion.  The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  
 
The CI reported intermittent radiating pain down his legs; however electro-diagnostic studies showed no evidence of neuropathy or radiculopathy.  The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting.  While the CI may have suffered additional pain from the nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  Therefore the critical decision is whether or not there was a significant motor weakness which would impact military occupation-specific activities.  There was no evidence in this case that motor weakness existed to any degree that could be described as functionally impairing.  The Board therefore concluded that an additional disability rating was not justified on this basis.  

The Board therefore relied more heavily on the VA C&P examination ROM measurements as being of higher probative value relative to the date of separation.  The Board agreed that a 20% rating, was justified for limitation of flexion greater than 30 degrees but not greater than 60 degrees reported on the 9 October 2007 C&P examination.  After due deliberation, and considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the lumbosacral strain condition, coded 5237.

Chronic Left Shoulder Impingement.  According to STR and the MEB NARSUM, the right hand dominant CI injured his left shoulder in May 2004.  The condition was not associated with a surgical indication.  Physical therapy failed to adequately improve the condition.  Despite treatment, the left shoulder condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “left shoulder pain,” for PEB adjudication.

According to the MEB NARSUM Addendum evaluation on 20 June 2007, 5 months prior to separation, the CI complained of shoulder pain that caused limited flexion and abduction and he was unable to fire his individual weapon or don his protective gear or uniform.  The pain was relieved by medication (Gabapentin, Oxycodone, and Naprosyn).  Shoulder dislocations were not reported.  Physical examination showed no evidence of instability and tests for impingement signs (Hawkins and Neer tests), tests suggestive of AC joint arthritis (Cross arm test), and test suggestive of bicipital tendon issues (Yergason’s and Speeds tests) were positive.  Sensation and strength were normal with no muscular atrophy or tenderness to palpation around the muscular areas of the left shoulder.  There was tenderness to palpation over the A/C joint however.  The ROM measurements for flexion and abduction were limited by pain as recorded in the chart.

At the MEB examination (recorded on DD FormS 2807 and 2808) dated 29 June 2007, 5 months prior to separation, the CI reported constant left shoulder pain rated 4-7/10 scale, described as sharp achy.  The pain was aggravated by overhead arm use and lifting and was relieved by heat and rest.  He was unable to wear body armor, a rucksack, load bearing equipment, and could not perform the aerobic portion of the Army physical fitness test.  He could not perform maintenance on his vehicle and could not tolerate riding in a military vehicle or lift heavy objects.  Physical exam showed no muscular atrophy or tenderness around the muscular areas of his left shoulder.  He did have tenderness to palpation over the A/C joint of his left shoulder.  There was normal strength and sensation.  Tests for impingement signs (Hawkins and Neer tests), tests suggestive of AC joint arthritis (Cross arm test), and test suggestive of bicipital tendon issues (Yergason’s and Speeds tests) were positive.  The ROM measurements for flexion and abduction were limited by pain as reported in the chart.

At the VA Compensation and Pension (C&P) examination on 9 October 2007, performed 2 months before separation, the CI reported constant left shoulder pain rated 1-8/10 scale, described as squeezing in nature.  The pain caused weakness, stiffness, and heat to the left shoulder and prevented him from carrying or lifting his arm.  The pain was aggravated by physical activity and was relieved by rest and medication (Oxycodone, Naproxen, and Gabapentin).  Physical exam showed no edema, effusion, weakness, redness, heat, guarding, or subluxation.  There was tenderness and the ROM measurements for flexion and abduction were limited by pain as reported in the chart  
 
The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under the analogous 5099-5003 code (arthritis, degenerative), citing painful limitation of motion).  The VA assigned a 20% rating using the analogous 5003-5201 code (arthritis, degenerative, limitation of motion of) for limitation of forward flexion and abduction.  The VASRD §4.71a (code 5201, arm limitation of motion) threshold for a rating for ROM impairment is “at shoulder level” (90 degrees from the side).  The 20% rating for the non-dominant arm requires motion limited to “at shoulder level/25° from side” and examinations reflected this degree of limitation.  The MEB Addendum examination reflected a limited flexion of 60 degrees that approaches a 30% rating of limited flexion mid-way between the side and shoulder level (approximately 45 degrees), however, the remainder of the record in evidence does not approximate this limitation and therefore, the MEB NARSUM and VA examinations were deemed of more probative value.  There was no fibrous union or nonunion of the humerus to justify a higher rating under the 5202 code (humerus, other impairment of), and no higher rating available 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 recommends a disability rating of 20% for the left shoulder condition.  

Contended PEB Conditions:  Hyperlipidemia, hypertension, dentures, bilateral meralgia paresthetica, tinnitus, headaches, and PTSD 

PTSD.  The PTSD addendum noted the CI had intrusive thoughts and occasional nightmares, but “nothing too bad or recurrent” after his injuries.  He was in weekly group therapy to address anxiety symptoms and took a sleep aid for insomnia.  He was getting a divorce.  Mental status examination (MSE) was normal.  A diagnosis of PTSD was rendered with a Global Assessment of Functioning (GAF) score of 81-90 (mild/transient symptoms, impairment.)  No impairment for social and vocational adaptation was noted.  MSE was essentially normal during the C&P exam and a diagnosis of PTSD was rendered with a GAF score of 60-65 (mild-moderate symptoms, impairment.)  MH follow-up note March 2008 noted the CI reported he was content and happy and denied depression and panic attacks.  
 
The hyperlipidemia, hypertension, dentures, bilateral meralgia paresthetica, tinnitus, headaches, and PTSD were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  There was no performance-based evidence from the record that the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, and 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 contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the lumbosacral strain condition, the Board unanimously recommends a disability rating of 20%, coded 5237 IAW VASRD §4.71a.  In the matter of the left shoulder condition, the Board unanimously recommends a disability rating of 20%, coded 5201 IAW VASRD §4.71a.  In the matter of the contended hyperlipidemia, hypertension, dentures, bilateral meralgia paresthetica, tinnitus, headaches, and PTSD conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  

The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Lumbosacral Strain	5237	20%	
Chronic Left Shoulder Impingement	5201	20%	
COMBINED	40% 	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140428, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20160011083, XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 40% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board's recommendation and record of proceedings for your information.

The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.

The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances. These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits. Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted. Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (HRC-DO}, XXXXXXXXXXXXXXXXXXX.

A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,

XXXXXXXXXXXXXXXXXXX
Deputy Assistant Secretary of the Army

Enclosure