RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02907
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041020

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Automated Logistics Specialist, medically separated for “chronic right shoulder pain” and “chronic subjective back pain,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI contended for his back and both shoulders. 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 - 20040525	VARD - 20050128	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Shoulder Pain…	5099-5003	10%	DJD, Right Humeral Head, ACL (Claimed as Slap Shoulder Impairment)	5010-5203	10%	20040903	
Chronic Subjective Back Pain…	5299-5237	10%	Degenerative Disc Disease, Lumbosacral Spine (Claimed as MLBP, Back Muscle Strain, Facet DJD)	5010-5242	30%	20040903	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Right Shoulder Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), this right hand dominant CI underwent right shoulder surgery in October 2003 for SLAP (superior labral tear from anterior to posterior) repair.  Following surgery, further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “right shoulder slap lesion, status post arthroscopic repair” and “chronic right shoulder pain, secondary to repaired right shoulder slap lesion” for PEB adjudication.

The range of motion (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. 

Right Shoulder ROM
(Degrees)	Ortho ~7 Mo. Pre-Sep	MEB ~6 Mo. Pre-Sep	VA C&P ~1 Mo. Pre-Sep	
Flexion (180 Normal)	170	170	160	
Abduction (180)	160	140	160	
Comments	Pain limited ROM 	Pain limited ROM; No tenderness, erythema; 4-5/5 strength; + Obrien; - Sulcus; - Load shifting; no atrophy	Motor and sensory exams normal;  painful motion	
§4.71a Rating	10%	10%	10%	

At the time of the orthopedic clinic appointment on 1 March 2004, 5 months post-surgery and 7 months prior to separation, the CI reported constant pain.  The examiner noted ROM measurements per chart above.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated March 2004, 5 months post-surgery and 7 months prior to separation, physical examination noted painful ROM

According to the MEB NARSUM evaluation on 15 April 2004, 6 months post-surgery and 6 months prior to separation, the CI reported right shoulder pain which was worsened with overhead activity, heavy lifting, internal rotation and abduction.  Physical examination revealed a normal appearing right shoulder with well-healed incisions and no evidence of erythema, discharge, or tenderness. ROM measurements were recorded per chart above.  Motor strength testing was 4-5/5 in all planes of shoulder motion.  The CI had a positive O'Brien's test (test showing evidence of SLAP lesion), negative Sulcus test (test for instability of the glenohumeral joint), and negative load-shift test.

At the VA Compensation and Pension (C&P) general medical and spine examinations on 3 September 2004, 11 months post-surgery and 1 month prior to separation, the CI reported discomfort in his right shoulder, described as a constant, dull ache with increased discomfort with repetitive movement and overhead lifting.  Physical examination showed symmetrical shoulders with a well healed surgical scar on the right.  There was no swelling, inflammation, edema, tenderness on palpation or instability.  There was no evidence of sensory or motor impairment.  ROM measurements were recorded per chart above.  There was evidence of discomfort (pain) on ROM testing, with loss of mobility.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating analogously coded 5003 (degenerative arthritis), citing “slight/frequent” (pain), likely applying the US Army Physical Disability Agency Pain Policy.  The VA also assigned a 10% rating analogously coded 5203 (humerus, other impairment of) based on the VA C&P examination 1 months before separation, citing functional loss of decreased mobility with discomfort on ROM.  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 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 found insufficient cause to recommend a change in the PEB adjudication for the chronic pain, right shoulder.  

Chronic Subjective Back Pain.  According to STRs and the MEB NARSUM, the CI was involved in a motor vehicle accident (MVA) in September 2003, exacerbating his low back condition which was present before and was of insidious origin.  In October 2003, diagnostic imaging studies showed mild to moderate diffuse spondylosis and degenerative facet disease at the L4-L5 and L5-S1 levels, with no herniated discs or any definite neural compression at any level.  There was no surgical indication, and conservative treatment (to include steroid injections from pain management) did not result in improvement sufficient to allow unrestricted duty. The CI was permanently profiled and referred to a MEB.  The MEB forwarded “chronic lower back pain” for PEB adjudication.  

At the primary care clinic visit on 2 March 2004, 8 months prior to separation, the CI complained of shooting pain to his right thigh with vague symptoms of tingling and numbness in his right knee.  His pain was exacerbated by walking or prolonged standing, relieved by medications and rest.  He had a normal gait, good strength and coordination on heels and toes, midline tenderness to palpation with forward flexion to 80 degrees and extension to 10 degrees with mild pain.  

The MEB NARSUM examination on 15 April 2004, 6 months prior to separation, noted complaints of chronic lower back pain, with occasional episodes of radiating pain to the right leg.  The CI denied any bowel or bladder dysfunction.  His symptoms were exacerbated with prolonged standing, walking, and heaving lifting.  Physical examination showed no obvious deformity of the CI’s spine.  There was no tenderness to palpation or palpable spasms present.  ROM was 70 degrees of forward flexion and approximately 20 degrees (30 normal for VA rating purposes) of extension.  Motor strength was 5/5 in all lower extremity groups, bilaterally.  Sensation was normal in lower extremities and there was no evidence of atrophy or spasticity.

At the VA C&P general medical and spine examinations the CI reported a constant dull ache of his lower back.  Pain increased with prolonged standing, walking, bending, lifting, and sitting. His pain occasionally radiated from the lower back into the (left) leg to the level of the left foot. Pain was relieved with medication.  The CI said he used a back brace and was able to walk 1 block without experiencing discomfort.  He did not use any assistive devices for walking.  Flare-ups did not cause additional limitation of motion or functional impairment.  There was no lost time from work over the past year requiring bed rest due to the CI’s back problem.  He could perform all activities of daily living without difficulty.  Physical examination showed a symmetrical spine without tenderness to palpation.  There was some evidence of loss of normal curvature of the lower back.  ROM testing revealed forward flexion to 45 degrees, extension to 15 degrees, left and right lateral bending to 30 degrees and left and right lateral rotation to 45 degrees (normal 30 degrees for rating purposes).  Combined ROM was 180 degrees.  Painful motion was noted.  There were no spasms, weakness, tenderness, or guarding. The CI’s gait was normal.  Neurological examination showed deep tendon reflexes at 2+/4 and symmetrical.  There was no evidence of sensory or motor impairment.  

The Board directed attention to its rating recommendation based on the evidence.  The PEB assigned a 10% rating under VASRD code 5299-5237 (analogous to lumbosacral strain), citing chronic subjective back pain without neurologic abnormality, with thoracolumbar ROM limited by pain.  The PEB likely applied AR 635-40 in making this determination.  The VA assigned a 30% rating using VASRD code 5010-5242 (degenerative arthritis of the spine) based on the VA C&P examination 1 month before separation, citing findings consistent with 20% rating criteria for 45 degrees of flexion and consideration of additional evaluation for functional loss due to pain on motion, for a combined rating of 30%.

The significant VA ROM limitation (45 degrees of forward flexion) was not corroborated by objective findings of significant spasm or guarding on physical exam. Multiple in-service examinations questioned the CI’s motivation to produce effort with respect to yielding accurate ROM testing.  Examinations occurring roughly 6 to 7 months prior to separation showed a spine disability with minimal loss of motion and few if any of the associated symptoms of a spine disability above the 10% rating level per VASRD §4.71a criteria under the General Rating Formula for Diseases and Injuries of the Spine. Although the VA rated the CI’s back at 30%, based on the VA C&P spine examination 1 month prior to separation, that examination specifically ruled out application of DeLuca (this being the rationale the VA rater used to raise the CI’s back to 30%, based on 45 degrees of forward flexion, equivocal to a 20% rated spine).  This examination showed the CI had not missed work due to his back condition and there were no symptoms equivocal to a spine disability above the 10% level, other than the singular forward flexion ROM measurement.  Members agreed that the MEB NARSUM examination was more consistent with outpatient notes and more reflective of the anticipated severity based on the clinical pathology (e.g. diagnostic imaging studies showed minimal spine pathology).  The Board therefore relied more heavily on the MEB NARSUM measurements, and therefore 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) as reported on the orthopedic and MEB NARSUM examinations proximate to separation.  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 documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula or evidence of ratable peripheral nerve impairment which would provide for additional rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority found insufficient cause to recommend a change in the PEB adjudication for the chronic subjective back pain condition. 

BOARD FINDINGS:  In the matter of the chronic right shoulder pain, and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic subjective back pain, and IAW VASRD §4.71a, the Board majority recommends no change in the PEB adjudication.  The single voter for dissent recommended modification of the rating to 20%, but did not elect to submit a minority opinion.  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 20140616, 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 XXXXXXXXXXXXXXXXXXXX, AR20160011087 (PD201402907)

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