RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03480
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040826

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve E6, Motor Transport Operator, medically separated for “left shoulder pain,” rated at 0%.  The low back pain condition existed prior to service without permanent service aggravation.  

CI CONTENTION: The CI asserts that she should have received a higher rating percentage and both her shoulder and back should have been rated.  She further contends her back was permanently aggravated by service.  Her 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 – 20040629	VARD - 20050124	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Shoulder Pain…	5099-5003	0%	Left Rotator Cuff Strain	5203	10%	20041025	
Low Back Pain…	5237	EPTS/NO PSA	Chronic Low Back Pain	5237	NSC	20051024	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Left Shoulder.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the left shoulder condition began approximately 9 years prior to referral for MEB.  During basic training the CI fell while wearing a rucksack and struck the ground with her left shoulder and lower back.  A left shoulder X-ray was normal.  The NARSUM, 4 months before separation, recounted the history and interventions.  The CI complained of constant 5/10 left shoulder pain with exacerbations to 8/10.  The pain was characterized as “aching inside” with associated left-sided numbness and tingling when she lay on the left.  Pain was exacerbated by cold weather, standing at parade rest, load bearing, carrying a weapon, prolonged computer use, prolonged driving, running, and lying on her left side and somewhat relieved by ice and medications.  The CI did not have significant improvement with conservative management that included activity modification, ice, shoulder exercises, physical therapy (PT) and nonsteroidal anti-inflammatory drugs (NSAIDs).  Active medications were an NSAID (Vioxx) and occasional muscle relaxant (Flexeril).  The upper extremity examination revealed full range of motion (ROM) without difficulty in her shoulders.  There was slight discomfort raising her arm overhead but strength (5/5) was normal bilaterally.  The remainder of her physical was normal.  The examiner recounted the normal left shoulder X-rays.  The diagnosis listed chronic left shoulder pain.  The left shoulder repetitive active ROM values measured by PT were full.  Flexion was 180/180/180 degrees (180 normal), abduction was 180/180/180 degrees (180 normal), internal rotation was 90/90/90 degrees (90 normal), and external rotation was degrees 90/90/90 (90 normal).  The VA rating decision (VARD) included transcribed C&P examination findings.  The left shoulder ROM values were abduction of 165 degrees (180 normal), internal rotation of 80 degrees (90 normal), and external rotation of 80 degrees (90 normal).

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under an analogous 5003 code (degenerative arthritis), citing pain, normal X-rays, full ROM, no joint laxity and no focal neurological deficits.  The VA assigned a 10% rating under the 5203 code (impairment of clavicle or scapula) based on the VA C&P examinations 2 months after separation, citing pain, normal X-rays, positive apprehension test, positive biceps tendinitis, positive sulcus sign, positive load and shift consistent with multidirectional instability, internal impingement, ROM, and ROM not additionally limited by pain, fatigue, weakness, or lack of endurance.  Based upon the proximate PT, NARSUM, and C&P examinations, there was no compensable limitation of motion for consideration under 5201.  There was no evidence of scapulohumeral ankylosis to support a rating under 5200, and no evidence of nonunion, malunion, or dislocation of the humerus, clavicle or scapula to support a rating under 5202 or 5203.  The Board agreed there was sufficient evidence of painful motion (§4.59) and functional loss (§4.40) to support a 10% 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 left shoulder condition, coded 5099-5003.  

Contended PEB Condition.  

Low Back.  According to the STR and NARSUM, the low back condition began approximately 9 years prior to referral for MEB.  The initial back injury occurred during a previous period of active duty from which the CI was discharged.  A lumbosacral spine X-ray was normal.  The thoracolumbar repetitive active ROM values measured by PT on 7 May 2004 were full.  Flexion was 90 degrees (90 normal), extension was 30 degrees (30 normal), bilateral lateral flexion was 30 degrees (30 normal), and bilateral rotation was 30 degrees (30 normal).  The NARSUM recounted the history and interventions.  The CI reported a history of sporadic low back pain since her basic training injury.  She complained of intermittent at 5-6/10 pain since re-injury during annual training 2 years ago.  Pain was exacerbated by load bearing, carrying a weapon, prolonged sitting, prolonged driving, prolonged standing, and lifting and somewhat relieved by ice and medications.  The CI did not have significant improvement with conservative management and active medications were Vioxx and occasional Flexeril.  The physical examination documented the CI could heel, toe, and duck walk normally.  The back examination revealed mild tenderness at the midline L2 area with no sciatic notch tenderness.  The straight leg raise (SLR) test (assesses for herniated disc causing sciatic nerve root [L5-S1] radiculopathy) was negative.  The remainder of her physical was normal.  The examiner recounted the normal lumbosacral spine X-rays.  The diagnosis listed chronic low back pain.  The VARD included transcribed C&P examination findings.  The pain limited lumbar spine ROM values were flexion of 40 degrees (90 normal), extension of 20 degrees (30 normal), bilateral lateral flexion of 25 degrees (30 normal), and bilateral rotation of 25 degrees (30 normal).

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB determined the low back condition was EPTS and not permanently aggravated and therefore was not compensable.  The VA denied service connection based on the VA C&P examinations 2 months after separation.  The Board considered whether or not there was evidence of service aggravation.  The evidence indicates the CI was an active participant in the Reserves subsequent to her release from active duty in 1996.  She was promoted twice and attained the rank of SSG (E-6).  A physical fitness score card noted the CI successfully completed the standard three event physical fitness test in May and November 2001.  The 2001-2002 NCO evaluation report indicated performance was “successful” and potential was “superior.” The NCOER also documented the CI passed another physical fitness test in 2002.  There was no performance based evidence that her back was interfering with her ability to perform her military occupational specialty prior to her mobilization in February 2003.  The STR noted the CI sought treatment for her back on 27 March 2003 (2 months after mobilization) and reported low back pain for 2 days.  Tenderness to palpation and sharp spasms were noted by the examiner.  The thoracolumbar spine ROM values in the PT examinations were full.  Although there was insufficient limitation of motion to support a minimum rating, the Board agreed a 10% rating was justified for the presence of tenderness.  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.  After due deliberation, considering all of the evidence the Board concluded the contended low back condition was permanently aggravated and recommends a disability rating of 10%, coded 5237.

BOARD FINDINGS:  In the matter of the left shoulder condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the low back EPTS condition, the Board unanimously concluded there was permanent service aggravation and recommends a disability rating of 10%, coded 5237 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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Shoulder Pain	5099-5003	10%	
Low Back Pain	5237	10%	
COMBINED	20%	

The following documentary evidence was considered:
Exhibit A.  DD Form 294, dated 20140527, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-00), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXXX AR20160008099 (PD201403480)

1 . 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,
accept the Board's recommendation to modify the individual's disability rating to 20%
without re-characterization of the individual's separation. This decision is final.

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.

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:

CF:
( ) DoD PDBR
()DVA