RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00980
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061228

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Maintenance Support Specialist, medically separated for “chronic low back pain…” and “intermittent right shoulder pain,” rated 0% each, with a combined disability rating of 0%.  

CI CONTENTION:  “My back and shoulders are worse.  Acne is horrible.  I am having sleeping problems.”  The CI’s complete submission is at Exhibit A.

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on 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(s) at the time of separation.  The panel 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 panel 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 - 20061107	VARD - 20070918	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain Secondary to Degenerative Disc Disease	5237	0%	Degenerative Disc Disease, Lumbar Spine 	5242	20%	20070627	
Intermittent Right Shoulder Pain	5099-5003	0%	Residuals, Right Shoulder Injury, Chronic Rotator Cuff
Tendinitis with Internal Derangement	5024-5203	10%	20070627	
Acne	Not Unfitting	Chronic Acne	7899-7806	10%	20070831	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain Secondary to Degenerative Disc Disease (DDD).  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back condition began in approximately May 2004 after lifting heavy equipment.  Radiographic imaging showed early degenerative disc disease.  He was treated with physical therapy (PT), medication, biofeedback and epidural steroid injections. 

At an unspecified clinic visit on 26 September 2006 (3 months prior to separation), lumbar flexion was 80 degrees (normal 90 degrees) and combined range of motion (ROM) was 230 degrees (normal 240 degrees).  Painful motion was present but there was no tenderness, spasm or deformity.  A test for nerve root irritation was negative.  Gait and posture were normal.

The MEB NARSUM examination on 11 October 2006 (3 months prior to separation) noted complaints of low back pain present 40% of the time, with an average pain level of 5 out of 10 in severity.  Once per week the pain radiated into the left buttock and left posterior thigh, and was associated with tingling in the plantar aspect of the left foot.  The pain prevented any running, and was exacerbated by walking more than 1 mile, lifting more than 30 pounds, standing or sitting more than 20 minutes, or performing sit-ups or biking.  Physical examination findings were identical to those of 26 September 2006.

At the 27 June 2007 VA Compensation and Pension (C&P) evaluation, performed 6 months after separation, the CI reported chronic, daily low back pain and stiffness which frequently radiated into the buttocks region bilaterally but not necessarily down his lower extremities.  Numbness and tingling of the left foot occurred intermittently.  He did not use a back brace or ambulatory aid, but reported difficulty with walking long distances and prolonged standing.  There was 2 episodes during the previous year when he stayed in bed for 1-2 days due to back pain.  The examination noted no scoliosis or abnormal spinal curvatures.  His gait was normal.  Lumbosacral tenderness and mild spasm were present bilaterally.  Thoracolumbar flexion was 80 degrees and combined ROM was 210 degrees.  Painful motion was present.  Repetitive motion caused increased pain with fatigability. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 0%, coded 5237 (lumbosacral strain).  The VA rated the condition 20% under the 5242 code (degenerative arthritis of the spine), citing findings of painful motion and mild muscle spasm as a rationale.  The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) or for combined ROM (greater than 120 but not greater than 225 degrees).   The presence of tenderness and muscle spasm were alternate routes to a 10% rating.  There was no history or evidence of vertebral body fracture with loss of 50 percent or more of the height, nor was there evidence of additional functional loss that would impact functioning in the average civil occupation.  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 also no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS).  There was therefore no VASRD §4.71a route to a higher rating under any applicable code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the low back condition, coded 5237.  

Intermittent Right (Non Dominant) Shoulder Pain.  According to the STR and the MEB NARSUM, the CI’s right shoulder pain condition began in December 2004 after doing push-ups.  Although imaging studies in June 2005 noted a possible loose body and possible tendon tear, findings at the time of surgical arthroscopy in September 2005 were remarkable only for abundant inflamed synovium (joint lining), which was debrided.

The MEB NARSUM examination on 11 October 2006 (3 months prior to separation) noted complaints of sharp right shoulder pain during overhead activities.  Physical examination showed no weakness of the rotator cuff musculature.  Painful motion was present, but instability signs were negative.  Right shoulder flexion was 170 degrees (normal 180), and abduction was 175 degrees (normal 180).

At the 27 June 2007 C&P evaluation, 6 months after separation, the CI reported 4-5/10 pain severity and some weakness.  Recurrent dislocation or subluxation was denied.  Physical examination showed diffuse tenderness and crepitus (grinding sensation), but no instability.  Flexion was 130 degrees and abduction was 130 degrees.  Painful motion was present.  Repetitive motion caused pain and fatigability, but additional limitation of motion was not reported.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder pain condition 0%, coded analogously to 5003 (arthritis, degenerative).  The VA rated the condition 10% under a combination 5024-5203 code (tenosynovitis; clavicle or scapula, impairment of), citing limitation of function due to painful motion.  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, panel 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 and no dislocation or nonunion of the clavicle or scapula to justify a higher rating under the 5202 (humerus, other impairment of) or 5203 codes.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the right shoulder pain condition, coded 5099-5003.  

Contended PEB Conditions:  Acne.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The acne 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 panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended acne condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the low back condition, the panel unanimously recommends a disability rating of 10%, coded 5237 IAW VASRD §4.71a.  In the matter of the right shoulder pain condition, the panel unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the contended acne condition, the panel unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the panel’s scope of review for consideration.  The panel 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	
Chronic Low Back Pain Secondary to Degenerative Disc Disease	5237	10%	
Intermittent Right Shoulder Pain	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150608, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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Dear XXXXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction. 

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

Sincerely,	
Enclosure