RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00674
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040530

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty  E4, Infantryman, medically separated for “chronic low back pain” and “chronic right shoulder pain” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  His condition continues to worsen and the VA rated him higher. The 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 - 20040318	VARD - 20040721	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Early Degenerative Changes to the Lumbar Spine	5242	10%	20040427	
Chronic Right Shoulder Pain	5099-5003	0%	Status Post Traumatic Right Shoulder Dislocation…	5201-5024	10%	20040427	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40% 	

ANALYSIS SUMMARY:

Chronic Low Back Pain (LBP).  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in March 2002 after a roll-over motor vehicle accident (MVA).  He was treated with physical therapy (PT) and medications but his pain persisted.  X-ray studies in April and December 2002 were within normal limits.  At a PT appointment on 20 March 2003, 14 months prior to separation and 1 year after the MVA, the CI reported pain in the region of the right sacroiliac joint (SIJ), aggravated by activity as well as prolonged sitting and standing.  The gait was mildly antalgic (abnormal due to pain), but the range of motion (ROM) was full.  Extension was painful.  Provocative testing for nerve root irritation and SIJ irritation was negative.  As the CI had been on a profile for over 1 year, he was entered into the MEB process.

At the 12 November 2003 orthopedic clinic appointment, 7 months prior to separation, the CI reported persistent LBP but denied any numbness or weakness in his lower extremities.  His pain was aggravated by activity but he was able to work in the mail room without “too much difficulty.”  Physical examination showed no spinal tenderness and a normal neurological evaluation.  It was noted that X-ray and MRI studies were within normal limits.  The examiner also noted the back condition was stable and “from an orthopedic standpoint, the patient meets retention criteria in accordance with AR 40-501.”  

The CI was referred to physical medicine, seen the same day, and thought to have myofascial pain.  X-rays of the lower back were normal other than a congenital finding at S1.  X-rays of the hips and SIJs were also normal.  The same examiner prepared the MEB NARSUM examination (12 November 2003) based on this evaluation.  The CI reported constant dull LBP, without radiation to the lower extremities.  Physical examination showed ROM was limited by 30 percent for extension (which equated to an extension of 20 degrees (normal 30) with painful motion.  There were no other ROM measurements reported during the examination for the back implying that these were normal, but this was not explicitly stated.  There was pain with extension and with bilateral rotation.  There was tenderness but spasm was not recorded and provocative testing for nerve root irritation was negative.  The neurological examination was normal.  The MRI was noted to show mild degenerative disc disease at T12-L1.  The examiner noted the CI’s report that his overall symptoms had been stable since April 2002.  The examiner also noted the CI met retention criteria, and “in regard to low back pain, the service member should be returned to duty.”  A whole body scan on 17 November 2003 showed changes consistent with minimal overuse or stress-related changes without evidence for a fracture.  

On 13 January 2004 an updated MEB NARSUM, 5 months prior to separation, was updated by a different examiner.  The prior examination and AR 40-501, Chapter 3-41e(1) were cited in the notations that the CI failed retention criteria due to a combination of conditions (LBP and right shoulder pain) that resulted in interference with satisfactory performance of duty.  

At the 27 April 2004 VA Compensation and Pension (C&P) evaluation, 1 month before separation, the CI reported continued LBP on a daily basis, with no complaints of radiation or associated symptoms.  Incapacitation was not recorded.  No assistive device was in use.  Physical examination showed a limp associated with LBP caused by placing weight on the right foot.  There was normal curvature of the spine.  Tenderness was present but muscle spasm absent.  ROM was flexion to 85 degrees (normal 90) and the combined ROM was 235 degrees (normal 240) with painful motion.  There were normal reflexes and strength of the lower extremities.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain), citing pain limited motion and spinal tenderness.  The VA also rated the back condition 10%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination 1 month before separation, citing painful motion.

The panel agreed a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and for combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the PT, orthopedic, MEB NARSUM, and VA examinations 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 with incapacitating episodes which would provide for a higher rating under that formula.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the LBP condition.  

Chronic Right Shoulder Pain.  According to the STR and MEB NARSUM, the CI’s right shoulder condition also began in March 2002 after the aforementioned roll-over MVA.  The CI reported a dislocation which he was able to reduce himself at the scene of the accident.  X-ray studies in April 2002 were within normal limits.  He was treated with medications, PT, and duty limitations but his pain persisted.  Electrodiagnostic studies of the right upper extremity performed in May 2002 were normal.  An MRI in August 2002 showed some inflammation of the infraspinatus tendon (part of the rotator cuff) and early degenerative changes were described at the acromioclavicular (AC) joint (between the collar bone and shoulder blade).

During the 12 November 2003 orthopedics examination, 7 months prior to separation the CI reported persistent right shoulder pain with overhead activity and lifting heavy objects.  He denied any prior dislocations of his right shoulder (which is different from the history above).  Physical examination showed minimal tenderness over the acromioclavicular joint area and ROM was flexion to 175 degrees (normal 180) and abduction to 175 degrees (normal 180) with painful motion.  There was normal strength, reflexes, and sensation.  Signs of impingement were absent.  The examiner reported that X-ray study showed a type II acromion and minimal AC joint degenerative disease without other significant pathology.  An MRI did not show a rotator cuff tear but did show minimal AC joint degenerative disease.  The examiner reported the CI’s right shoulder condition as stable and “from an orthopedic standpoint, the patient meets retentions criteria.” 

The MEB NARSUM examination (also dated 12 November 2003) noted complaints of aching pain at the right shoulder, occasionally radiating to the right biceps region, and intermittent numbness of the entire right hand.  His symptoms were aggravated with prolonged use of the right upper extremity.  The shoulders blades demonstrated asymmetric motion.  There was no ROM for flexion or abduction reported.  There was tenderness at the AC joint region, and mild to moderate tenderness at the anterior right greater tuberosity region.  The 13 January 2004 MEB NARSUM update, 5 months prior to separation, noted the CI failed retention criteria due to combined conditions as discussed above.

At the C&P evaluation the CI reported continued right shoulder discomfort.  He also reported an initial dislocation of the shoulder at the time of the injury in March 2002, and that no further dislocations had occurred.  Physical examination showed some tenderness at the clavicular sternal joint.  The ROM was flexion and abduction to 180 degrees with painful motion.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder condition 0%, analogously coded 5003 (degenerative arthritis), citing impingement syndrome.  The VA rated the right shoulder condition 10%, analogously coded 5201-5024 (arm limitation of motion-tenosynovitis), based on the C&P examination 1 month before separation, citing 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) using the code 5003 (degenerative arthritis) noting that the ROM was reduced, but not compensable, on the MEB orthopedic examination and degenerative changes were present on X-ray.  There was also evidence to support the use of the 5203 (clavicle or scapula, impairment of) codes due to tenderness and an abnormal X-ray of the AC joints on multiple examinations.  This code better described the underlying pathology demonstrated during examinations and is recommended for use.  Neither code provides a rating advantage over the other.  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 condition coded 5203.

BOARD FINDINGS:  In the matter of the chronic LBP condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the chronic right shoulder pain condition, the panel unanimously recommends a disability rating of 10%, coded 5203 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends 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 LBP	5237	10%	
Chronic Right Shoulder Pain	5203	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160913, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170016918, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	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