RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00941
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040517

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Multi-Channel Transmission Systems Operator, medically separated for “chronic low back pain,” “bilateral shoulder impingement syndrome,” “right trochanteric bursitis,” and “cubital tunnel syndrome,” rated 10%, 0%, 0%, and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  The CI contends that his rating (presumably his VA rating) did not include his shoulders, hips, and back.  The 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 - 20040326	VARD - 20041013	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Chronic Low Back Pain	5299-5237	NSC	20040921	
Bilateral Shoulder Impingement Syndrome	5099-5003	0%	Bilateral Shoulder Impingement	5203	NSC		
Right Trochanteric Bursitis	5019	0%	Right Trochanteric Bursitis	5019	NSC		
Cubital Tunnel Syndrome Left Arm (Minor)	5099-5003	0%	Cubital Tunnel Syndrome Left of the Left Arm	8616	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in 2001 without any specific injury or trauma.  At a primary care (PC) visit in June 2003 the CI reported localized intermittent low back pain for 2 years, aggravated by standing and physical training.  Lumbosacral spine X-rays were normal.  The MEB forwarded “low back and thoracic pain” for PEB adjudication.  

The range of motion (ROM) examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Thoracolumbar ROM
(Degrees)	MEB ~4 Mo. Pre-Sep
	VA C&P ~3 Mo. Post-Sep
	
Flexion (90 Normal)	90	90 (100)	
Combined (240)	235	240	
Comments	Tenderness		
§4.71a Rating	10%	0%	

During the MEB examination (recorded on DD Forms 2807 and 2808) dated 9 January 2004, 4 months prior to separation, the CI reported that he had been treated for back pain and muscle spasms since 2001.  Physical examination showed “restricted ROM due to hip pain” and tenderness to palpation of the thoracolumbar spine.  

The MEB NARSUM examination on 23 January 2004 (4 months prior to separation) showed limitation of combined motion as noted in the above chart.  The examination was silent in regards to pain with motion testing.  He had tenderness, but there was no mention of spasm or guarding.  He had a normal gait, spinal contour, motor strength, reflexes and sensation.
 
At the 21 August 2004 VA Compensation and Pension (C&P) evaluation, performed 3 months after separation, the CI reported that he had fallen approximately 10 feet on his back 2.5 years ago with no acute injury note at the time.  Since then he occasionally had soreness of the whole spine with no radiation of pain to his extremities, no numbness or paresthesias, and no therapy or treatment of his back condition.  Physical examination showed a normal gait and there was no spinal tenderness.  The examination was silent in regards to the presence of spasm, guarding or abnormal spinal contour.  His ROM was normal as indicated in the chart above.  Testing for radicular signs were negative and his reflexes were normal.  Lumbar and thoracic spine X-rays were normal.  The VA examiner did not provide a diagnosis of the back condition and noted the CI had “vague musculoskeletal complaints” and “otherwise all of his joints are normal other than just the occasional soreness that occurs with life.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10% coded 5237 (lumbosacral strain).  The VA did not service connect the low back condition based on the VA C&P examination 3 months after separation, citing no diagnosis of a chronic condition.  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 MEB NARSUM examination proximate to separation.  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 documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS), or evidence of ratable peripheral nerve impairment which would provide for additional rating.  After due deliberation, and 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 back condition.

Bilateral Shoulder Impingement Syndrome.   The permanent profile dated 5 January 2004 listed bilateral shoulder pain, right hip pain, chronic low back pain, and cubital tunnel syndrome.  The commander’s statement indicated that the CI’s “medical conditions and his physical profile” rendered him unable to perform his assigned duties.  The MEB NARSUM determined that the CI failed to meet retention standards for the bilateral shoulder pain, right greater than left, greater trochanteric bursitis, right, low back and thoracic pain, and cubital tunnel syndrome.  The Board first considered if the right and left shoulder conditions, having been de-coupled from the combined PEB adjudication, each remained separately unfitting as established above.  The permanent profile listed bilateral shoulder pain and the physical profile noted limitations of no swimming, no push-ups and no lifting greater than 70 pounds which implicated the shoulder conditions.  The NARSUM determined that the bilateral shoulder pain contributed to the CI’s failure to meet retention standards.  The Board concluded that there was not a preponderance of evidence of the service records that overcame the Board’s presumption that the bundled shoulder conditions were each reasonably considered separately unfitting.  The Board then considered its rating recommendation for the unfitting right and left shoulder conditions at the time of separation.

Right shoulder.  According to STRs and the MEB NARSUM, the right hand dominant CI reported bilateral shoulder pain since at least August 2001, with right shoulder symptoms greater than the left.  A PC note in June 2003 noted right shoulder pain and X-rays showed acromioclavicular degenerative joint disease.  A bone scan was normal and a magnetic resonance imaging of the right shoulder did not show evidence of degenerative joint disease and no definite injury to the joint cartilage, though noted the study “was not tailored” to identify such injury.  The CI was referred for an orthopedic consult in July 2003 for persistent right shoulder pain, but there were no notes regarding the right shoulder in record after this.  The MEB forwarded “shoulder impingement syndrome, right greater than left” for PEB adjudication.

At the MEB examination (recorded on DD Forms 2807 and 2808) dated 9 January 2004, 4 months prior to separation, the CI reported right shoulder pain since 2001 and left shoulder pain with history of three dislocations since being in the service.  Physical examination showed restricted ROM of shoulders, but the examiner did not mention the degree of restriction or whether or not the ROM was painful.  

At the MEB NARSUM evaluation on 23 January 2004 (4 months prior to separation) the CI complained of bilateral shoulder pain with “pain at the anterior aspect of his shoulder” with overhead work, heavy lifting, and certain aspects of the fitness test.  The physical examination did not address the right shoulder.  

At the 21 August 2004 VA Compensation and Pension (C&P) examination, performed 3 months after separation, the CI reported right greater than left shoulder pain.  He reported painful popping of his right shoulder and posterior pain in the muscles without any known injury. Physical examination showed full and equal range of motion with forward flexion of 180 degrees (normal 180) and abduction of 180 degrees (normal 180).  There was tenderness to palpation of his right trapezius muscle, but limited testing for signs of impingement or instability was negative.  Bilateral shoulder X-rays showed no evidence of significant degenerative changes.  The VA examiner did not provide a diagnosis of the right shoulder condition on the same basis as noted above.  

Outpatient orthopedic treatment notes indicated the CI sought care for his shoulders in September 2005 (17 months after separation).  The CI reported constant right shoulder symptoms with painful motion, not helped by medications, physical therapy or injections.  The orthopedic treatment notes also indicated a past medical history of rheumatoid arthritis, but no regular medications. The CI underwent arthroscopic surgery for right shoulder impingement in October 2005.  At the time of the decompression surgery for impingement a labral tear (SLAP lesion) was also noted and debrided.  

The Board directed attention to its rating recommendation for the right shoulder based on the above evidence.  The PEB combined the right and left shoulder conditions as a single unfitting condition coded 5099-5003 (analogous to degenerative arthritis) and rated 0%.  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The Board also noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining the shoulder conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB. 

The PEB assigned the bilateral shoulder condition a 0% rating under an analogous 5003 code (degenerative arthritis), citing “degenerative arthritis without loss of shoulder motion attributable to pain alone.”  The VA did not service connect the right or left shoulder based on the VA C&P examination conducted 3 months after separation, citing no diagnosis of a chronic condition of either shoulder.  

The orthopedic treatment notes in record were not VA records and were beyond the 12 month period post-separation defined by DoDI 6040.44 for special consideration in the Board’s rating recommendation and therefore have reduced probative value regarding the CI’s disability at the time of separation.  The orthopedic notes and surgery on the right shoulder approximately 18 months after separation demonstrate the right shoulder pain reported prior to separation, persisted after separation and justified eventual surgical intervention.  The orthopedic records also indicated that the CI had a past history of rheumatoid arthritis (RA), but he was on no medications at the time.  There was no evidence of a well-established diagnosis of RA at the time of separation and there was no other expansion on this diagnosis in record after separation.  According to the VASRD, without evidence of an active process, RA (5002) is rated according to the same criteria as 5003.  There was no limitation of motion of the right shoulder to support a rating under diagnostic code 5201 (arm, limitation of motion of).  However, there was evidence of limited motion with X-ray evidence of acromioclavicular degenerative arthritis supporting a 10% rating (based on §4.59, §4.40 and §4.45) coded as 5003.  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 disability rating of 10% for the right shoulder condition.  

Left shoulder.  As noted above, the CI had bilateral shoulder pain since August 2001, with the right shoulder symptoms greater than the left.  There were only two notes in the STR prior to the MEB regarding shoulder pain at which the CI reported right shoulder pain only.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated 9 January 2004, 4 months prior to separation, the CI reported left shoulder pain with a history of three dislocations since being in the service.  Physical examination showed restricted ROM of shoulders, but the examiner did not mention the degree of restriction or whether or not the ROM was painful.  

At the MEB NARSUM evaluation on 23 January 2004 (4 months prior to separation) the CI complained of bilateral shoulder pain with “pain at the anterior aspect of his shoulder” with overhead work, heavy lifting, and certain aspects of the fitness test.  The physical examination did not address the left shoulder.  

A left shoulder X-ray in April 2004 noted a superior off-set of the distal clavicle, a possible normal variant, but recommended correlation with any history of past injury.  

At the 21 August 2004 VA Compensation and Pension (C&P) examination, performed 3 months after separation, the CI reported right greater than left shoulder pain.  He reported that he “subluxated his left shoulder” a year and a half ago while shoveling and had had occasional pain since.  He had not required medical intervention to reduce the shoulder.  Physical examination showed full range of motion with forward flexion of 180 degrees (normal 180) and abduction of 180 degrees (normal 180).  Limited tests for signs of impingement and instability were negative.  The VA examiner did not provide a diagnosis of the left shoulder condition on the same basis as noted above.  

Outpatient orthopedic treatment notes indicated the CI sought care for his shoulders in September 2005 (17 months after separation).  The CI reported the same symptoms of the left shoulder as the right.  He underwent arthroscopic surgery for left shoulder impingement in November 2005, following the right shoulder surgery noted above.  

The Board directed attention to its rating recommendation for the left shoulder based on the above evidence.  The PEB and VA ratings for the left shoulder were as summarized above under the right shoulder discussion.  

There was no limitation of motion of the left shoulder to support a rating under diagnostic code 5201 (arm, limitation of motion of) and there was not satisfactory evidence of painful motion with functional loss to support a 10% rating (based on §4.59, §4.40 and §4.45) coded as 5099-5024.  Although the remote clinical evidence in record noted surgery on the left shoulder at approximately 18 months post-separation, this may have been due to worsening of the left shoulder condition.  According to the available STR, the CI did not report symptoms of the left shoulder from June 2003 until the MEB process and the VA exam 3 months after separation noted normal exam of the left shoulder.  There was no malunion, deformity, or recurrent dislocation of the humerus to justify a rating under the 5202 code (humerus, other impairment of); and no nonunion or malunion of the clavicle or scapula to warrant any rating under the 5203 code (clavicle or scapula, impairment of).  There was no higher than a 0% rating supported for the left shoulder at separation under any applicable VASRD code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 0% for the left shoulder condition.  

Right Trochanteric Bursitis.  According to STRs and the MEB NARSUM, the CI’s right greater trochanteric (hip) pain condition began in approximately June 2001.  At a PC visit in June 2003 the CI reported hip pain for 2 years.  A bone scan (BS) was negative.  In April 2003 a Primary Care (PC) visit noted chronic right hip pain with negative BS and planned referral to orthopedics.  There were no treatment notes for the hip in record beyond this date.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated January 2004, 4 months prior to separation, the CI reported hip pain.  Physical exam noted “restricted range of motion d/t [due to] hip pain.”  
At the MEB NARSUM evaluation on 23 January 2004 (4 months prior to separation) the CI reported right hip pain.  He reported difficulty doing physical fitness tests due to pain.  He was unable to run.  He was able to complete the test as a walk.  Physical exam showed hip ROM of 110 degrees flexion (normal 125) and extension 10 degrees (normal 20) with mild pain.  There was tenderness to palpation over the right hip.  The CI had a normal gait and strength, sensation, and reflexes of the lower extremities were normal.  
At the VA Compensation and Pension (C&P) examination in August 2004, performed 3 months after separation, the CI reported occasional painful snapping hip on the right side and tightness, with no specific injury.  Physical exam showed a normal gait.  Hip ROM was noted to be full, but reported as flexion of 100 degrees, with otherwise full ROM with no snapping reproduced.  Right hip and pelvis X-rays were normal.  The VA examiner did not provide a diagnosis of the right hip condition on the same basis as noted above for all the other musculoskeletal conditions addressed.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under a 5019 code (bursitis).  The VA did not service connect the right hip condition based on the VA C&P examination 3 months after separation, citing no diagnosis of a chronic condition after separation.  

There was evidence of pain with use of the hip in the STR and there was limited hip ROM with tenderness and mild pain noted at the MEB NASRUM examination to support a 10% rating for painful hip motion for functional loss due to pain with use coded as 5099-5019 or 5299-5252 (based on §4.59, §4.40 and §4.45).  There was no limitation of motion which supported a higher rating under the diagnostic codes for limitation of thigh flexion or extension, or thigh impairment (5251, 5252, 5253).  There was no evidence of hip ankyloses, flail hip joint, or femur impairment (5250, 5254, 5255) for a rating under the respective codes.  There was therefore no route to a rating higher than the 10% under any applicable VASRD §4.71a code.  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 right hip condition, coded 5099-5019.  

Cubital Tunnel Syndrome Left Arm (Minor).  According to STRs and the MEB NARSUM, at the MEB NARSUM examination the CI reported paresthesia of the non-dominant left arm into the fourth and fifth fingers, with difficulty grasping items.  He had tried a night splint without resolution and anti-inflammatory medications were helpful.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated January 2004, 4 months prior to separation, the CI reported tingling in the left hand and last two fingers and that he was treated at occupational therapy in November 2003.  Physical exam showed a positive Tinel’s sign (evidence of nerve entrapment) over the cubital tunnel on the left (course of the ulnar nerve at the elbow).

At the VA Compensation and Pension (C&P) examination in August 2004, performed 3 months after separation, the CI reported a one year history of the left upper extremity symptoms.  Physical exam showed full ROM of the elbow.  There was a positive Tinel’s sign at the ulnar nerve at the elbow.  There was decreased sensation in the fourth and fifth digits.  There was normal muscle strength of the hand with full grip strength and no muscle atrophy.  The VA examiner noted a diagnosis of cubital tunnel syndrome of the left elbow.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under an analogous 5003 code (degenerative arthritis), citing AR 635-40, paragraph B-15.  The VA assigned a 10% rating coded 8616 (ulnar nerve neuritis) based on the VA C&P examination 3 months after separation, citing mild neuritis.  

There was evidence of mild ulnar nerve irritation due to cubital tunnel syndrome with symptoms of tingling, numbness in the nerve distribution and decreased sensation noted on the VA exam for a 10% rating for “mild” neuritis of the ulnar nerve coded analogous to ulnar nerve neuritis (8699-8616), an analogous code for cubital tunnel syndrome.  There was no evidence of loss of reflexes, muscle atrophy or “constant pain, at times excruciating” to support higher rating for “moderate” neuritis.  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 cubital tunnel syndrome, coded 8699-8616.   

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral shoulder impingement syndrome, the Board unanimously recommends a disability rating as follows:  an unfitting right shoulder condition rated 10%, coded 5003 and an unfitting left shoulder condition rated of 0%, coded 5099-5024 IAW VASRD §4.71a.  In the matter of the right trochanteric bursitis condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5019 IAW VASRD §4.71a.  In the matter of the left cubital tunnel syndrome, the Board unanimously recommends a disability rating of 10%, coded 8699-8616 IAW VASRD §4.124a.  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 re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Low Back Pain	5237	10%	
Right Shoulder Impingement Syndrome	5003	10%	
Left Shoulder Impingement Syndrome	5099-5024	0%	
Right Trochanteric Bursitis	5099-5019	10%	
Left Cubital tunnel Syndrome	8699-8616	10%	
COMBINED	40%	

The following documentary evidence was considered:

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

AR20170005268, XXXXXXXXXXXXXXXXXX

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XXXXXXXXXXXXXXXXXX
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Dear XXXXXXXXXXXXXXXXXX:

	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 40% 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), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,					       
Enclosure