RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01898
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070423

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Infantryman, medically separated for “chronic neck pain” and “left shoulder pain,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  The CI contends his disabilities were evaluated at 80% by the VA and they continue to worsen and impact his daily activities.   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 - 20070118	VARD - 20150602	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain	5237	10%	Cervical Strain and DDD…	5237	30%	20150225	
Left Shoulder Pain	5099-5003	0%	Left Shoulder Strain…	5201-5019	10%		
Left Upper Extremity Radicular Symptoms	Not Unfitting	Left Upper Extremity Radiculopathy…	8512	30%		
Myofascial Pain	Not Unfitting	Multiple VA Entries				
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Chronic Neck Pain.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s neck pain began in July 2004 after a parachute landing.  During the 27 March 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 13 months prior to separation, the CI reported his neck/back pain had not recovered.  Physical examination revealed tenderness and limitation of motion of the neck with pain.  The 15 September 2006 MEB NARSUM examination, 6 months prior to separation, noted complaints of continued pain and paresthesias (numbness and/or tingling) and an inability to perform duties.  Electrodiagnostic studies showed no evidence of radiculopathy, peripheral neuropathy or plexopathy (dysfunction of the brachial plexus nerves).  The examiner’s diagnosis was cervical pain secondary to a herniated intervertebral disc at C6/7.  The 7 April 2006 physical therapy examination recorded flexion at 15 degrees (normal 45) and combined ROM at 150 degrees (normal 340), with all planes of motion limited by pain.  There was no VA examination proximate to separation, and the remote 25 February 2015 VA Compensation and Pension (C&P) evaluation (94 months after separation) had no probative value in panel deliberations.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic neck pain condition 10%, coded 5237 (cervical strain), citing cervical ROMs limited by pain.  The VA rated the chronic neck pain condition 30% coded 5237, based on the remote C&P examination almost 8 years after separation, citing forward flexion of the cervical spine 15 degrees or less.  The panel agreed that a 30% rating, but no higher, was justified for limitation of flexion (forward flexion of the cervical spine 15 degrees or less) as reported on the NARSUM examination.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the chronic neck pain condition, coded 5237.  

Left Shoulder Pain.  According to STR and the MEB NARSUM, the CI’s left shoulder pain began in July 2004 after a parachute landing.  He reinjured his shoulder on 23 August 2004 after a ruck march.  During the 27 March 2006 MEB examination the CI reported the shoulder pain had not recovered.  Physical examination revealed no tenderness of the left shoulder joint or deltoid, but there was loss of motion of the shoulder joint with associated pain.  Motor strength of the left deltoid muscle and biceps was 4/5, which was limited due to pain.  The MEB NARSUM examination noted complaints of pain and paresthesias.  Physical examination revealed the left shoulder was without focal dysfunction or deformities.   Biceps and deltoid motor function was 4/5 on the left compared to the right.  There was no additional motor or sensory dysfunction.  The left shoulder active ROM was 180 degrees (with no detail regarding flexion and/or abduction).  The examiner’s diagnosis was left shoulder pain s/p Hill Sachs injury.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder pain condition 0%, coded 5099-5003 (arthritis, degenerative), citing abduction to 180 degrees.  The VA rated the left shoulder pain condition 10% coded 5201-5019 (arm, limitation of motion-bursitis), based on the C&P examination 8 years after separation, citing painful motion of the shoulder.  There was no limitation of motion of the shoulder to support a rating under diagnostic code 5201 (arm, limitation of motion of).  The MEB NARSUM  examination did not note findings such as swelling, muscle spasm, satisfactory evidence of painful motion or other evidence of functional loss to support a 10% rating IAW VASRD §4.59, §4.40 or §4.45.  While the VA examination noted painful motion, the examination was remote from separation, so it held no probative value for panel deliberations or rating purposes.  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).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left shoulder pain condition.  

Contended PEB Conditions:  Left Upper Extremity Radicular Symptoms and Myofascial Pain.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  Neither of the conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.   There was no performance-based evidence from the record that either of the conditions 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 any of the contended conditions; and so, no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the chronic neck pain condition, the panel unanimously recommends a disability rating of 30%, coded 5237 IAW VASRD §4.71a.  In the matter of the left shoulder pain condition the panel recommends no change in the PEB's 0% rating.  In the matter of the contended radicular symptoms and myofascial pain conditions, the panel unanimously recommends no change from the PEB determinations 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; 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 Neck Pain	5237	30%	
Left Shoulder Pain	5099-5003	0%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150707, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170009258, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	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 30% 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), XXXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs and to the counsel you listed on your application, XXXXXXXXXXXXXXXXXXX.

Sincerely,					      
Enclosure