RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02803
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090220

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4 (Light Wheeled Vehicle Mechanic) medically separated by the Informal Physical Evaluation Board for “left shoulder pain” and “lumbar spondylolisthesis” rated 10% and 10% respectively; with a combined disability rating of 20%. 

CI CONTENTION:  His conditions continue to worsen and negatively impact his daily activities.  His complete submission is at Exhibit A.

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 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 - 20090105	VARD – 20090929	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Non-Dominant Shoulder Pain	5099-5003	10%	Residuals, Left Shoulder Injury (Non-Dominant)	5201	10%	20090713	
Spondylolisthesis…	5239	10%	Degenerative Joint Disease Thoracolumbar Spine	5242	10%	20090713	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Left (Non-Dominant) Shoulder Pain Condition.  According to the service treatment record (STR) and the MEB narrative summary (NARSUM), the right hand dominant CI injured his left shoulder in 2007.  Ongoing pain and instability led to left shoulder arthroscopic reconstruction in May 2008.  Surgery and physical therapy failed to adequately improve the condition.  The shoulder condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty, and he was referred for a Medical Evaluation Board (MEB).
An orthopedic examination on 17 September 2008 (4 months after surgery and 5 months prior to separation) recorded no swelling or tenderness.  Shoulder motion was considered “normal” and there was no muscle atrophy or weakness.  At the physical therapy (PT) exam on 14 October 2008 (4 months prior to separation) measured flexion was 106 degrees (normal 180 degrees) and abduction was also 106 degrees (normal 180 degrees).  There was no change in ROM after repetition.  According to the MEB NARSUM evaluation on 22 October 2008 the CI complained of shoulder pain that was constant, achy, rated 4/10 and exacerbated by movement.  Dislocations were not reported.  The examiner observed “full range of motion…except internal rotation.”  Shoulder tenderness and painful motion were present, and muscle strength was normal.

At the VA Compensation and Pension (C&P) examination on 13 July 2009 (5 months after separation) the CI reported left shoulder pain but no dislocations since the surgical repair.  Examination showed flexion of 130 degrees and abduction of 150 degrees.  Tenderness and painful motion were present.  

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 limitation of motion of one major joint.  The VA also assigned a 10% rating using the 5201 code (arm, limitation of motion).  The VASRD §4.71a (code 5201, arm limitation of motion) threshold for a minimum rating for ROM impairment is “at shoulder level” (90 degrees from the side), and the ROM in evidence demonstrated motion above this level.  Although the limitation of motion did not support a minimum compensable rating under VASRD diagnostic code 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 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 left shoulder condition.

Lumbosacral Spondylolisthesis Condition.  According to the STR and the MEB narrative summary (NARSUM), the CI’s back condition began in February 2008 while working as a mechanic, but without a history of specific injury or trauma.  Radiographic studies showed bilateral spondylolysis at L5, and degenerative discs with some bulging.  A mild degree of spondylolisthesis (slippage) of the L5 vertebra on S1 was present.  There was no surgical indication.  Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and was referred for a Medical Evaluation Board (MEB).

At an orthopedic clinic visit on 16 July 2008 (7 months prior to separation), the CI reported 2-5/10 non-radiating back pain that was worse with use and controlled by rest and position change.  Examination showed a normal lumbosacral spine appearance.  “Spine motion” was “normal” and there was no tenderness or spasm.  Painful motion was present.  A neurologic evaluation on 16 September 2008 (5 months prior to separation) reported that the low back pain radiated into the right leg.  Weakness was denied and an electrodiagnostic study (EMG) was normal.  A follow-up orthopedic examination on 17 September 2008 observed tenderness at L5, but a normal gait and spine appearance.  Spasm was absent and lower extremity muscle strength was normal.  Goniometric range-of-motion (ROM) measurements by physical therapy (PT) on 14 October 2008 (4 months prior to separation) reported forward flexion of 90 degrees (normal 90 degrees) and combined ROM of 225 degrees (normal 240 degrees).  There was no change in ROM after repetition.

The MEB NARSUM exam on 22 October 2008 noted complaints of sharp, intermittent back pain rated at 3/10 in severity.  Bending to lift objects caused exacerbations of 7/10 severity.  Physical exam showed “full range of motion of lower back except in forward flexion” although measurements were not provided.  Painful motion was present.  There was no lumbar spine tenderness, and gait and muscle strength were normal.

At the VA Compensation and Pension (C&P) examination on 29 September 2009 (5 months after separation) the CI reported progressive worsening, and he experienced flare-ups every 3-4 months that lasted for hours.  Physical exam showed painful motion and tenderness.  Flexion was 90 degrees and combined ROM was 230 degrees after 3 repetitions.  Gait and muscle strength were normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5239 code (spondylolisthesis or segmental instability), citing limitation of combined ROM.  The VA also assigned a 10% rating using the 5242 code (degenerative arthritis of the spine) citing painful reduced range of motion.  The Board agreed that a 10% rating, but no higher, was justified for limitation of combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the PT and VA 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.  Furthermore, there was no documentation of incapacitating episodes which would provide for a higher rating under that formula.  Finally, although the CI reported radiating pain, there was no evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve 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 lumbosacral spondylolisthesis condition.

BOARD FINDINGS:  In the matter of the left shoulder condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the lumbosacral spondylolisthesis 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.  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 20141006, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXX,AR20160004021 (PD201402803)

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