RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03120
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20081122

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Reserve E5, Navy Law Enforcement Specialist, medically separated for “rotator cuff tears, bilateral shoulders, partial thickness,” “plantar fasciitis, bilateral,” “chronic olecranon bursitis,” “lumbo-sacral disc disease,” and “bilateral elbow bone spurs” with a disability rating of 0%.  

CI CONTENTION:  The CI requested consideration 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 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 - 20081021	VARD - 20090112	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Rotator Cuff Tears, Bilateral Shoulders, Partial Thickness	Overall Effect (OE)
	0%	Rotator Cuff Tear, Left Shoulder	5201	20%	20080827	
			Rotator Cuff Tear, Right Shoulder	5201	20%	20080827	
Plantar Fasciitis, Bilateral			Right Foot Plantar Fascitis and Arthritis	5003-5003	0%	20080827	
			Left Foot Plantar Fasciitis	5284	0%	20080827	
Chronic Olecranon Bursitis			No VA Placement	
Lumbo-sacral Disc Disease			Lumbar Arthritis	5242	10%	20080827	
Bilateral Elbow Bone Spurs			Right Elbow Enthesopathy	5207	0%	20080827	
			Right Elbow Enthesopathy	5207	0%	20080827	
Post Traumatic Stress Disorder, Mild	Cat III	Post Traumatic Stress Disorder	9411	30%	20080827	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY: 

Rotator Cuff Tears, Bilateral Shoulders, Partial Thickness.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right hand dominant (RHD) CI’s bilateral shoulder condition began in the summer of 2007 following numerous injuries to his shoulders while working on construction projects while deployed.  Since returning from deployment he reported difficulty working above shoulder height due to pain.  Magnetic resonance imaging (MRI) of the bilateral shoulders on 27 March 2008 showed degenerative changes, two partial tears of the rotator cuff on the right, tendinitis or possible tear of the biceps tendon and a suspected labral tear, and 2 partial RC tears on the left.  The CI was referred for injection of his shoulders and at the visit on 7 May 2008 he reported that months of physical therapy (PT) had improved the right shoulder but not the left.  The physical examination was limited to the left shoulder and showed tenderness to palpation (TTP) of the biceps tendon, with positive impingement signs and no evidence of instability.  Shoulder range of motion (ROM) was flexion of 170 degrees (normal 180 degrees) and abduction of 130 degrees (normal 180 degrees).  Strength, sensation, and reflexes of the upper extremities were normal.  The CI was diagnosed with bicipital tendinitis and extensive synovial/bursal inflammation and given injections of the left shoulder joint and biceps tendon.  At a primary care visit 23 May 2008, the CI reported that his shoulder was much improved after the injection.  The MEB forwarded “disorders of bursae and tendons of the shoulder region, unspecified” for PEB adjudication.

The CI was placed on limited duty (LIMDU) for a period of 6 months in April 2008 due to the bilateral RC injuries.  The non-medical assessment (NMA) did not implicate any specific medical condition and indicated that the CI desired to stay in the military and had good potential for continued service in his physical and mental condition.  The CI was not working within his military specialty.  The Joint Disability Evaluation Tracking System (JDETS) form dated 4 September 2008 was largely illegible, but noted multiple medical complaints and suggested some problems were chronic, with some symptom magnification and questions regarding the CI’s compliance with medical treatment.  An addendum to the JDETS for the Reconsideration PEB (RPEB) dated 17 October 2008 noted that the CI provided no new information and concurred that “a lot of his complaints are EPTS [existed prior to service].”  RPEB Board member notes stated “numerous conditions claimed w/o clear hx linked to Naval service” and “concur…regarding EPTS status of conditions.”  

At the MEB NARSUM examination on 13 June 2008, 3 months prior to separation, the CI reported multiple musculoskeletal complaints but chief among them was bilateral shoulder pain.  The physical examination showed full passive ROM of both shoulders and the examiner described active ROM as “active range of motion of both shoulders is limited by subjective pain and the subject is reluctant to elevate either shoulder above shoulder level.”  

At the VA Compensation and Pension (C&P) examination on 27 August 2008, 3 months before separation, the CI reported difficulty working overhead or lifting more than 50 pounds due to bilateral shoulder pain.  Physical examination noted the CI was RHD.  Bilateral shoulder ROM was flexion of 180 degrees and abduction of 130 degrees.  Repetitive motion caused increased pain of the shoulders.  Right shoulder X-rays were normal and left showed “mild” enthesopathy (abnormality of the ligaments or tendons).  At a VA preventive medicine visit dated 31 December 2008 the CI reported left shoulder pain that was “unacceptable” for the last 4 months.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the combined conditions listed above at 0% for overall effect, without any associated VASRD code.  The VA rated the right and left shoulders each 20%, coded 5201 (limitation of arm motion), citing arm limitation at shoulder level.  

The Board first considered if there was a preponderance of evidence that either the right or left shoulder was unfitting at the time of separation.  The right shoulder pain improved with physical therapy, but treatment notes in the STR support that the CI continued to have functionally limiting left shoulder pain supported by the pathology noted on imaging, including MRI.  The CI was on LIMDU for the shoulder conditions and the CI was not currently working in his specialty.  The Board consensus was that there was a preponderance of evidence that the left shoulder was unfitting at separation, but not a preponderance of evidence for the right shoulder and therefore deliberated a rating for the left shoulder.  

The VASRD §4.71a threshold for rating for ROM impairment (code 5201, arm limitation of motion) is “at shoulder level” (approximately 90 degrees from the side), and the examinations in evidence demonstrated motion above this level.  However, Board members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion) coded 5099-5003 (analogous to degenerative arthritis).  There was no malunion or recurrent dislocation of the humerus and no dislocation or nonunion of the clavicle or scapula to justify a higher rating under the 5202 (humerus, other impairment of) or 5203 (clavicle or scapula, impairment of) codes.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a not unfitting right shoulder condition and an unfitting left shoulder with a disability rating of 10%, coded 5099-5003.  

Plantar Fasciitis (PF), Bilateral.  According to STR and the MEB NARSUM, the CI’s bilateral PF condition began in the summer of 2007 while deployed.  He reported he had injections into the heel of each foot.  Foot X-rays dated 7 September 2007 (which did not indicate if right, left or bilateral) indicated calcaneal bone spurs present, with no swelling, fracture, or malalignment.  At a primary care visit on 11 October 2007, the CI reported that he only had pain in one foot now, and that when he did not have to wear boots it improved.  The CI was not placed on any period of limited duty for the bilateral PF.  The MEB forwarded “plantar fascial fibromatosis” for PEB adjudication.

At the MEB NARSUM examination on 13 June 2008, 3 months prior to separation, the CI reported multiple musculoskeletal complaints but no specific symptoms of the feet or a foot were reported.  Physical examination showed “mild tenderness to deep palpation” of the bottom of the feet near the heels bilaterally.  

At the VA C&P examination on 27 August 2008, 3 months before separation, the CI reported foot pain an awakening which went away after a period of time until it was aggravated again.  Physical examination noted generalized discomfort of the bottom of the foot.  There was no thickening of the PF.  Foot ROM was normal.  There was no increase in pain with repetitive motion.  Right and left foot X-rays showed degenerative arthritis of the first metatarsophalangeal (MTP) joint (the big joint of the big toe) and bone spurs of the heel.  

The PEB assigned a 0% rating for overall effect as elaborate above.  The VA assigned a 0% rating each for the right and left PF.  The right foot was coded 5003-5003 (degenerative arthritis) and the left foot was coded 5284 (other foot injury).  

The Board considered if there was a preponderance of evidence that either the right or left PF was unfitting at the time of separation.  At a primary care PC visit proximate to separation, the CI reported only one of his feet hurt, and it improved when he did not have to wear military footwear.  Neither foot condition required a LIMDU.  There was no performance based evidence that the bilateral PF conditions impaired the successful performance of the CI’s military duties.  The Board concluded that there was not a preponderance that either the right or left foot, or both, were unfitting at separation due to the PF condition and therefore no disability ratings are recommended.  

Chronic Olecranon (Elbow) Bursitis and Bilateral Elbow Bone Spurs.  According to STR and the MEB NARSUM, the CI’s elbow conditions began during deployment in June 2007.  The MEB NARSUM examiner noted that there was no documentation of elbow injury in the records.  The CI reported that he recalled being treated for elbow pain after repetitive lifting of heavy lumber in June 2007.  The CI had a history of a right elbow fracture in childhood.  Bilateral elbow X-rays in May 2008 noted olecranon spurs bilaterally with preserved joint space, no effusions, and no soft tissue swelling.  Orthopedic evaluation of the elbows noted normal left elbow ROM and near normal right elbow ROM without instability.  The elbows were abnormal in appearance with prominences at the olecranon.  Tenderness of the elbows was diffuse, without swelling or warmth.  The orthopedic interpretation of the X-rays included degenerative joint disease of the right elbow, but not the left, with the noted bony prominences.  The MEB forwarded “chronic olecranon bursitis associated with heavy lifting” to the PEB for adjudication.

The CI was not placed on any period of LIMDU due to the elbow conditions.  The NMA and JDETS are as noted above.  Additionally, the JDETS specifically noted that the elbow findings on X-rays were a chronic process that likely predated the CI’s current period of active duty.

At the MEB NARSUM examination on 13 June 2008, 3 months prior to separation, the CI reported multiple musculoskeletal complaints but no specific symptoms of the elbows were reported.  Physical examination noted the prominent olecranon process bilaterally.  Elbow ROM was full bilaterally without instability.   

At the VA C&P examination on 27 August 2008, 3 months before separation, the CI reported bilateral elbow pain aggravated by heavy lifting or lifting overhead.  He denied flare-ups.  The physical examination showed slight TTP of the olecranon process bilaterally.  Elbow ROM was 0 degrees extension (normal 0) and 145 degrees (normal 145) of flexion bilaterally.  There was no increase of pain, fatigue, lack of endurance or loss of coordination with repetition. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating for overall effect as elaborate above.  The VA assigned 0% ratings each for the right and left elbow, coded 5207 (limitation of forearm extension).  

The Board considered if there was a preponderance of evidence that either the bilateral elbows or the right or left elbow was unfitting at the time of separation.  Neither elbow condition required a LIMDU.  There was no performance based evidence that the bilateral elbow conditions impaired the successful performance of the CI’s military duties.  The Board concluded that there was not a preponderance to overcome the PEB’s not unfitting determination for either the right or left PF condition, and therefore no disability ratings are recommended.  

Lumbo-sacral Disc Disease.  According to STR and the MEB NARSUM, the CI’s back condition began in the summer of 2007 after heavy lifting and holding up building materials during construction projects while deployed.  He reported low back pain (LBP) with radiation to the right lower extremity (RLE).  Lumbar X-rays showed degenerative changes and MRI on 12 October 2007 showed evidence of degenerative disc disease (DDD), with a broad based disc bulge at L5-S1 with a tear of the L5-S1 annulus (fibrous connective tissues surrounding disc material).  The CI was evaluated by neurosurgery in 6 November 2007 and DDD with right leg syndrome due to the DDD was diagnosed and the neurosurgeon indicated that the CI was a surgical candidate, but conservative measures should be tried initially.  Due to limited improvement with therapy and chiropractic treatment, a repeat MRI was performed in 26 March 2008.  The MRI was largely unchanged but indicated that the degenerative spinal arthritis and DDD were causing impingement of the S1 nerve roots in the lateral recess.  At the neurosurgical follow-up visit on 3 April 2008, the neurosurgeon reaffirmed that the CI was a surgical candidate, but was functioning well without medication and the CI was not interested in surgery.  An epidural steroid injection was recommended, and the CI could follow-up after returning home as the condition was a chronic.  At a chiropractic visit 3 weeks later, the CI reported intermittent LBP and stiffness, with shooting pain in the RLE.  The examination noted tenderness of the lumbar region, without muscle spasm.  Back ROM was normal and straight leg testing to elicit radicular symptoms was negative.  The MEB forwarded “degeneration of lumbar or lumbosacral intervertebral disc” for PEB adjudication.

The CI was placed on LIMDU for a period of 6 months in April 2008 due to the “herniation of disc@L5-S1”.  The NMA did not implicate any specific medical condition and indicated that the CI desired to stay in the military and had good potential for continued service in his then current physical and mental condition.  The CI was not working within his military specialty.  As noted above, the JDETS dated 4 September 2008 was largely illegible but noted multiple medical complaints and suggested some problems were chronic.  An addendum to the JDETS for the RPEB dated 17 October 2008 noted that the CI provided no new information and concurred that “a lot of his complaints are EPTS.”  Board member notes stated “numerous conditions claimed w/o clear hx linked to Naval service” and “concur…regarding EPTS status of conditions.”  

At the MEB NARSUM examination on 13 June 2008, 3 months prior to separation, the CI reported LBP with RLE radiation aggravated by bending.  The physical examination noted “slight limitations” of lumbar flexion by LBP (CI was unable to reach beyond his ankles) and straight leg raise testing was negative.   Lower extremity strength, sensation, and reflexes were normal.  

At the VA C&P examination on 27 August 2008, 3 months before separation, the CI reported in May and June 2007 he was treated for LBP after loading lumber, without improvement from physical therapy or steroid injections.  He reported RLE pain, numbness and tingling without weakness.  He denied bowel or bladder problems.  He denied flare-ups.  Physical examination noted a normal gait and posture.  Lumbar spine flexion was 80 degrees, with all other ROM normal.  Lower extremity strength, sensation, and reflexes were normal.  Lumbar spine X-rays showed “mild” degenerative changes.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating based on overall effect as elaborated above.  The VA assigned a 10% rating, coded 5242 (spinal arthritis) based on the VA C&P examination 2 months before separation, citing limitation of forward flexion.

The Board first considered if there was a preponderance of evidence that the “lumbo-sacral disc disease” condition was unfitting at the time of separation.  Treatment notes in the STR support that the CI continued to have functionally limiting LBP.  Treatment began during deployment, continued after redeployment until separation, and the CI was recommended additional treatments which would continue after separation.  The CI was on LIMDU for the back conditions and the CI was not currently working in his specialty.  Based on a preponderance of the evidence the Board consensus was that the low back condition was unfitting at separation, and therefore deliberated a rating for the condition.  

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 MEB NARSUM and VA C&P exams.  There was no muscle spasm or guarding severe enough to result in an 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 (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula (for IVDS).  Imaging studies supported some level of radicular nerve irritation or involvement, but physical examinations (MEB NARSUM and VA C&P) proximate to separation revealed no objective findings of lumbar radiculopathy that would impact duty performance for consideration of a separate rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the “lumbo-sacral disc disease” condition, coded 5242-5243.  (spinal arthritis-intervertebral disc syndrome)

Contended PEB Conditions:  PTSD.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the bilateral shoulder condition, the Board unanimously recommends a disability rating as follows: an unfitting left shoulder, rated 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the “lumbo-sacral disc disease” condition, the Board unanimously or majority recommends a disability rating of 10%, coded 5242-5243 IAW VASRD §4.71a.  In the matter of the right shoulder condition, bilateral plantar fasciitis, chronic olecranon bursitis and bilateral elbow bone spurs and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended PTSD condition, the Board unanimously recommends no change from the PEB determination as Category III (condition that is not separately 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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Rotator Cuff Tears	5099-5003	10%	
Lumbosacral Disc Disease 	5242-5243	10%	
COMBINED	20%	

The following documentary evidence was considered:
Exhibit A.  DD Form 294, dated 20140628, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
	         DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 27 Jul 16 XXXXXXXXXXXXXXXXXXXX   
	(c) PDBR ltr dtd 27 Jul 16 XXXXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 27 Jul 16 XXXXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (e) are approved.

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge.

     b. XXXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.