RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02715
BRANCH OF SERVICE:  Army	Separation Date:  20050508

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Human Resources Specialist, medically separated for “chronic mechanical LBP [low back pain],” “chronic left ankle pain and restricted motion,” and “chronic left shoulder pain” rated 10%, 10% and 0%, respectively, for a combined disability rating of 20%.  

CI CONTENTION:  The applicant requests review of all conditions.  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 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 – 20050120	VARD - 20060215	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Mechanical LBP	5237	10%	Lumbar Strain	5237	10%	20051202	
Chronic Left Ankle Pain	5271	10%	Status Post(S/P) Left Ankle Surgery With Chronic Pain	5271	10%	20051202	
Chronic Left Shoulder Pain	5099-5003	0%	S/P Left Shoulder Surgery with Residual Chronic Pain ….	5299-5203	10%	20051202	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Mechanical LBP.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s LBP condition began in January 2002 after standing heavy guard duty for long periods of time.  Radiographic studies showed mild broad based disc bulge at all levels between L1and S1 without any spinal canal narrowing or nerve root impingement.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic low back pain” for PEB adjudication.  The MEB NARSUM exam on 1 November 2004, 6 months prior to separation, noted complaints of constant LBP rated at 4-5/10 that increased with prolonged walking, standing, and heavy lifting.  The CI also reported left leg numbness and tingling with pain rated at 6-9/10.  There were functional limitations of no sit-ups, push-ups, flutter kicks, running, LBE heavy lifting, and no standing more than 15 minutes.  The physical exam findings indicated active range of motion (ROM) values for the lumbar spine as “80% AMA normal (48 degrees) forward flexion 32, 38, 34 degrees with increase pain,” with extension 15 of 20 degrees, lateral flexions 10 and 15 out of 30 degrees, and no entries for rotation.  Gait and posture were normal.  There was tenderness to palpation with mild scoliosis (lateral curve) of the lumbar spine.  There were no neurologic deficits and provocative maneuvers for signs of radiculopathy or radiating pain due to spinal nerve root or sciatic nerve involvement were negative.  

At the VA Compensation and Pension (C&P) examination on 2 December 2005, performed 7 months after separation, the CI reported daily LBP rated 5-6/10 with flares two to three times per week with pain rated at 8-9/10 exacerbated by exercise, heavy lifting or walking long distances.  He also reported occasional tingling in his left leg.  The radiographic study (X-ray) showed very slight scoliosis and a possible bilateral L5 defect without spondylolisthesis.  Physical exam documented normal gait with normal reflexes and strength.  The thoracolumbar spine was tender with pain-limited motion of forward flexion to 90 degrees (normal 90) and combined ROM of 215 degrees (normal 240).  

The Board directed attention to its rating recommendation based on the above evidence.  The Formal PEB assigned a 10% rating under the 5237 code (lumbosacral strain), citing paraspinal tenderness without radiculopathy, muscle spasm or ROM restrictions due to pain alone.  The VA also assigned a 10% rating using the 5237 code based on the VA C&P examination approximately 7 months after separation, citing a combined ROM of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees.  The Board considered the NARSUM ROMs were for the lumbar spine only and did not equate to thoracolumbar spine ROMs for direct rating under the VASRD spine formula (IAW VASRD §4.46, accurate measurement; and Plate V).  The “80% AMA normal” was adjudged as approximating greater than 60 degrees of the normal 90 degrees of forward flexion IAW VASRD §4.71a measurement criteria.  

The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and/or combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the Service exams and VA exams respectively (or alternatively tenderness or painful motion on all exams).  There was no muscle spasm or guarding severe enough to result in abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no evidence of intervertebral disc syndrome resulting in incapacitating episodes requiring bed rest prescribed by a physician to warrant consideration of rating under the alternate VASRD formula based on incapacitating episodes due to intervertebral disc syndrome.  There was no associated radiculopathy for separate peripheral nerve rating.  Although the CI experienced radiating pain, there was no objective evidence of a radiculopathy or functional impairment with a direct impact on fitness.  While the CI may have experienced radiating pain from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There is no evidence in this case that there was radiculopathy with associated impairments separately functionally impairing.  The Board therefore concluded that an additional disability rating was not justified on this basis.  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 LBP condition.  

Chronic Left Ankle Pain.  According to service treatment records and the MEB NARSUM, the CI underwent left ankle surgery in June 2001 for a micro fracture and an osteochondral defect of the left tibia.  Despite treatment, the CI’s ankle condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and was referred for a MEB.  At the MEB NARSUM exam on 1 November 2004, the CI reported occasional left ankle pain and stiffness during daily physical training and any type of strenuous physical activity and standing more than 15 minutes.  The physical exam findings are summarized in the chart below.  

At the VA C&P examination on 2 December 2005, the CI reported occasional give away, swelling, pain rated 5/10, joint catching, and repetitive motion which caused fatigue and decreased ROM.  The radiographic study (X-ray) was normal.  The physical exam findings are summarized in the chart below.  The 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.  

Left Ankle ROM
(Degrees)	MEB ~6 Mo. Pre-Sep	VA C&P ~7 Mo. Post-Sep	
Dorsiflexion (20)	2, 4, 4 (opposite 12, 12, 14)	8	
Plantar Flexion (45)	50, 54, 54 (opposite 60, 60, 62)	43	
Comment	Gait normal; decreased ROM due to pain	Deluca +,increased pain; tenderness medial, lateral malleus; scar pink tissue, non-adherent; mild decreased sensation to light touch	
§4.71a Rating	10%-20% (PEB 10%)	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The Formal PEB assigned a 10% rating (moderate) under code 5271 (ankle, limited motion of), citing pain and restricted motion (dorsiflexion 4 degrees).  The VA also assigned a 10% rating using code 5271 based on the VA C&P examination, based on moderate limited motion of the ankle.  The Board considered if the limitation of motion was moderate or marked when considered under code 5271 criteria.  Although the MEB exam may have reached the marked level for 4 degrees of dorsiflexion, the CI’s normal gait, plantar flexion beyond normal limits, and improved dorsiflexion by the time of the VA exam (approximately equidistant from the date of separation), indicated that the CI’s disability picture at separation more nearly approximated the 10% (moderate) limitation.  

The Board then deliberated if the scar was separately unfitting and ratable.  The Board’s threshold for adding unfitting associated conditions for rating requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The scar was not listed on the NARSUM as not meeting retention standards and was not on the MEB or PEB forms.  There was no mention of the scar by the MEB examiner.  The VA examiner noted that the scar was nontender, non-adherent; had no keloid formation and there was only a mild decreased sensation to light touch.  There was no mention that boots or other military footgear irritated the scar.  The Board adjudged that there was not a preponderance of evidence that the scar condition caused duty limitations.  The Board concluded therefore that the scar condition could not be recommended for additional disability 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 left ankle condition.  

Chronic Left Shoulder Pain.  According to service treatment records and the MEB NARSUM, the right hand dominant CI injured his left shoulder in 1997.  Ongoing pain led to a surgical repair (Superior Labral Tear from Anterior to Posterior [SLAP]) in August 2000.  The left shoulder pain continued and the CI underwent arthroscopic surgery in July 2002.  The CI’s shoulder condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and was referred for a MEB.  According to the MEB NARSUM evaluation on 1 November 2004, the CI complained of shoulder pain that caused an inability to perform any type of strenuous activity such as lifting or carrying objects.  Shoulder dislocations were not reported.  The physical exam findings are summarized in the chart below.  

At the VA C&P examination on 2 December 2005, the CI reported constant pain rated at 6-7/10 with flare-ups that increased pain to 9/10.  He also reported an inability to sleep on his chest or left side due to his shoulder condition.  The CI also reported an occasional left shoulder popping, and intermittent left arm numbness and tingling.  The radiographic study (X-ray) was normal.  The physical exam findings are summarized in the chart below.  The 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.  

Left Shoulder ROM
(Degrees)	MEB ~6 Mo. Pre-Sep	VA C&P ~7 Mo. Post-Sep 	
Flexion (180 Normal)	170, 170, 172	160	
Abduction (180)	184, 184, 184	160	
Comments:  
Right Hand Dominant 	Painful motion; no extension; internal rotation pain and tightness	Painful motion; tenderness to palpation over scarred areas; significant pain with all ROM; Deluca + increased pain	
§4.71a Rating	10% (PEB 0%)	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The Formal PEB assigned a 0% rating under an analogous code 5003 (arthritis, degenerative) citing “without significant loss of joint motion (flexion 174⁰, abduction 184⁰).”  The VA assigned a 10% rating using an analogous code 5203 (clavicle or scapula, impairment of) for malunion or non-union of the clavicle or scapula.  

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), and the ROM in evidence demonstrated motion above this level.  Although there was insufficient limitation of motion to support a rating under 5201, 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 code 5202 (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 recommended a disability rating of 10% for the left shoulder condition.  

BOARD FINDINGS:  In the matter of the low back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic left ankle pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic left shoulder pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  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 recharacterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:  

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Mechanical LBP	5237	10%	
Chronic Left Ankle Pain	5271	10%	
Chronic Left Shoulder Pain	5099-5003	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140516, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20160007638, 

Dear 

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 30% 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,
(AHRC-DO), XXXXXXXXXXXXXXXXXXX.

A copy of this decision has also been provided to the Department of Veterans Affairs
and to the counsel you listed on your application, 

Enclosure