RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-02566
BRANCH OF SERVICE:  Army		SEPARATION DATE:  20050128

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4, Abrams Tank System Maintainer, medically separated for “chronic thoracic back pain, status post T3/T4 Spinal Fusion” and “chronic left shoulder pain” rated 10% and 10%, respectfully, with a combined disability rating of 20%.

CI CONTENTION:  The applicant contends that he should have been medically separated instead of separated with severance pay.  His 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 - 20041015	VARD - 20050822	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Thoracic Back Pain, Status Post T3/T4 Spinal Fusion	5299-5243	10%	Intervertebral Disc Syndrome…Thoracic Spine	5243	20%	20041103	
			Scar; Back associated with Intervertebral Disc Syndrome…	7804	0%	20041103	
			Limitation of Motion; Right (Major) Shoulder associated with Intervertebral Disc Syndrome…	5243-5201	0%	20041103	
			Erectile Dysfunction associated with Intervertebral Disc Syndrome…	5243-7522	0%	20041103	
			Neurodermatitis associated with Intervertebral Disc Syndrome…	7806	10%	20050615	
			Diminished Sensation, Upper Extremities secondary Thoracic Discectomy	8599-8510	NSC	20050615	
Chronic Left Shoulder Pain	5099-5003	10%	Limitation of Motion, Left (Minor) Shoulder associated with Intervertebral Disc Syndrome…	5243-5201	20%	20041103	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:

Thoracic Back.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI injured his back in April 2002 when he attempted to lift a transmission cooler that was still attached to an M1A1 tank.  A thoracic spine diagnostic imaging (MRI) revealed T2-T3 and T3-T4 level disc herniations.  The CI failed conservative management and underwent a T2-T3 and T3-T4 discectomy with decompression and fusion on 9 May 2003.  At the 4-week postoperative neurosurgery evaluation (June 2003), the CI reported he was doing much better with good relief of the back pain.  He also related marked improvement with erectile function and no longer dribbled or leaked urine.  The CI complained of left arm and shoulder pain with movement due to the resection.  The physical examination documented a normal gait and strength.  Back range of motion (ROM) was restricted with pain in all planes, especially in flexion.  A thoracic spine X-ray revealed excellent fusion mass with intact hardware in good position.

During the 30 July 2004 MEB NARSUM by orthopedic surgery, 6 months before separation, the CI reported his lower extremities would fall asleep, he had trouble telling when he finished voiding, and difficulty with erections as he did prior to surgery.  The CI complained of 7-9/10 upper back pain from the shoulder blades to his neck with associated upper back and left axilla numbness.  Pain was described as dull, sharp, and burning and characterized as frequent and moderate.  Pain was exacerbated by pushups, sit-ups, running, working, and load bearing and incompletely relieved by non-steroidal anti-inflammatory drugs, a muscle relaxant, or narcotic/analgesic combination.  The physical examination documented a slow gait.  The cervical, thoracic, and lumbar spine appeared normal except for abnormal thoracic kyphosis (curvature).  There was no muscle spasm, atrophy, swelling, redness, or heat.  The thoracic spine examination revealed tenderness to moderate palpation over the upper mid thoracic spine.  The lumbar ROM value was flexion to within 4 inches of the floor ~ 90 degrees (normal 90) with the remaining ROMs incomplete.  The straight leg raise tests (assess for herniated disc causing sciatic nerve root [L5-S1] radiculopathy) were negative.

During the 3 November 2004 VA Compensation and Pension (C&P) examination, 3 months before separation, the CI complained of chronic upper back (between shoulder blades) and lower neck pain which radiated into the left shoulder.  Postoperatively, the CI reported increased sensation of the left shoulder blade and arm and decreased sensation of the left chest wall, axilla, scapular area, pectoral area, and arm.  Pain was exacerbated by activity and heavy lifting.  The physical examination documented a slow gait and guarding against movements of the left arm and upper back.  Cervical flexion and extension caused upper thoracic spine and lower neck pain.  The examiner did not document thoracic or lumbar ROM.  Strength and deep tendon reflexes were normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the thoracic back condition 10% analogously coded 5243 (intervertebral disc syndrome) citing paraspinous muscle tenderness.  The VA rated the thoracic back condition 20% coded 5243 based on the VA C&P examination, 3 months before separation, citing intervertebral disc syndrome, and painful and limited ROM.

The Board agreed that the MEB NARSUM examination which documented back ROM flexion to 70 degrees was consistent with a 10% rating (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 Board assigned more probative value to the MEB NARSUM examination because it documented lumbar spine ROM measurements while the C&P examination documented cervical, but no thoracic or lumbar spine ROM.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  While the CI complained of pain radiating into the left shoulder and decreased sensation of the left chest wall, axilla, scapular area, pectoral area, and arm, there was no evidence that motor weakness or sensory impairment significantly interfered with satisfactory duty performance.  The Board therefore concluded that additional disability rating was not justified on this basis.  There was no documentation of incapacitating episodes that would justify a minimum rating under the alternative formula for rating intervertebral disc disease.  While the proximate examinations to separation documented guarding against movements of the left arm and upper back and localized spinal tenderness, these symptoms did not result in an abnormal gait or abnormal spinal contour consistent with the 20% rating.  Other routes to a rating higher than the PEB’s 10% were considered, but there was no evidence of additional functional loss from repetitive use to warrant application of VASRD §4.45.  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 back condition.

Left Shoulder.  According to the STR and MEB NARSUM, the CI complained of left shoulder and arm pain with movement.  At the June 2003 (4 week postoperative) neurosurgery evaluation, the CI complained of left arm and shoulder pain with movement due to the back surgery/resection.  During the MEB NARSUM (6 months before separation) the CI complained of upper back pain from the shoulder blades to his neck with associated upper back and left axilla numbness.  The left shoulder examination revealed a well healed curved parascapular incision with no tenderness, swelling, or heat.  Sensation was increased over the left scapula and decreased over the left deltoid and pectoral area.  The goniometer measured active ROM of flexion 95 degrees (normal 180) and abduction 110 (180).

During the VA C&P examination (3 months before separation) the CI complained of chronic upper back and lower neck pain which radiated into the left shoulder.  Postoperatively, the CI reported increased sensation of the left shoulder blade and arm and decreased sensation of the left chest wall, axilla, scapular area, pectoral area, and arm.  Pain was exacerbated by activity and heavy lifting.  The physical examination documented the left arm held in a flexed position and guarded against movements of the left arm and upper back.  The left shoulder examination revealed no atrophy, swelling, redness, or warmth.  Sensation was increased over the left forearm and decreased over the surgical scar and left upper back, pectoral area, axilla, and upper arm.  The pain limited active ROM was flexion of 90 degrees and abduction 90.  Upper back discomfort limited the ROM and repeated movements did not change the ROM or cause left shoulder joint pain.  Strength and deep tendon reflexes were normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5003 code (arthritis, degenerative) citing chronic left shoulder pain following left thoracotomy, limited left shoulder function due to pain, and rated as moderate and frequent pain.  The VA assigned a 20% rating under the 5243-5201 codes (intervertebral disc syndrome - arm, limitation of motion of) based on the VA C&P examination citing left shoulder limitation of motion, secondary to thoracic spine  intervertebral disc syndrome, status post left thoracotomy, discectomy, and fusion, ROM limited by back pain rather than shoulder dysfunction, pain in upper back and not in shoulder, repeated movements did not change ROM or cause shoulder joint pain, no upper extremity atrophy, and normal strength.  The Board considered that the commander stated, “His [CI] duties require him to twist and turn, heavy and lift equipment over his head.”  He deemed the CI unfit for reasonable performance of duties as a System Tank Mechanic because he was “currently incapable of performing these requirements let alone routine vehicle maintenance, due to his back and shoulder condition.”  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  Based upon the MEB NARSUM examination, the Board majority agreed, there was no compensable limitation of motion for consideration under 5201 (at shoulder level is minimum 20% rating).  However, the ROM documented by the VA C&P examination was consistent with the 20% rating (90 degrees flexion and abduction).  Recognizing the temporal relationship to the date of separation, the Board assigned less probative value to the MEB NARSUM examination.  The Board assigned higher probative value to the VA C&P examination as accurately reflecting the CI’s condition at the time of separation.  There was no evidence of scapulohumeral ankylosis (code 5200), recurrent dislocations, loss of humeral head, nonunion, fibrous union, or malunion of the humerus (5202), or nonunion or malunion of the clavicle or scapula (5203) to support a rating under the respective codes.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 20% for the left shoulder condition, coded 5201.

BOARD FINDINGS:  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 left shoulder condition, the Board majority recommends a disability rating of 20%, coded 5201 IAW VASRD §4.71a.  The single voter for dissent recommended no change and did not elect to submit a minority opinion.  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 his prior medical separation:

CONDITION	VASRD CODE	RATING	
Thoracic Back Pain… 	5243	10%	
Left Shoulder Pain…	5201	20%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20141103, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX, AR20160016877 (PD201402566)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.  

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:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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:

			       
						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA