RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01596
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20050318

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E4, Wheeled Vehicle Repairer, 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:  “Review all conditions.”  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 progression or complications of service-connected conditions after separation.  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 - 20041220	VARD - 20051212	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	L5 Marginal Fracture with Disc Herniation at L4-5 and L5-S1	5243	10%	20050712	
Chronic Right Shoulder Pain	5201	0%	Right Shoulder Impingement	5299-5203	10%		
Post-Traumatic Stress Disorder	Not Unfitting	Posttraumatic Stress Disorder	9411	30%	STR	
Polysubstance Dependence	Not Ratable 	Alcohol Dependence	9499-9440	Willful Misconduct, Substance Abuse	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  80% 	

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 July 2003 after falling out of a military vehicle.  Lumbar spine neuroimaging showed marginal fracture of the L4 vertebra with disc herniation at L4-5 and L5-S1.  The 2 December 2004 MEB NARSUM examination, 4 months prior to separation, noted CI complaints of chronic, dull, occasionally sharp pain relieved with heat and rest.  He was taking an anti-inflammatory pain medication twice daily and continued to receive physical therapy.  Physical examination did not reference gait and posture.  Range of motion (ROM), pain on motion, tenderness, swelling, atrophy, strength and neurological findings were also not addressed, but the examiner noted pain was “intermittent and mild in intensity.”  

At the 12 July 2005 VA C&P evaluation, 4 months after separation, the CI reported his lower back was constantly uncomfortable with occasional radiation into his left leg as far as the knee, and that he could not walk more than 100 yards before pain increased.  The pain was more pronounced in the morning shortly after getting out of bed, and it was difficult for him to bend over and remove his shoes and socks.  Coughing and sneezing aggravated his pain, and flare-ups occurred after prolonged sitting or driving.  He did not wear a back brace, denied lower extremity numbness and tingling, and used pain medications which helped to a limited degree.  Physical examination showed midline lumbosacral tenderness with flexion to 70 degrees (normal 90) and extension to 15 degrees (normal 30).  Straight leg raise testing was normal bilaterally with sensory and motor functions intact.  

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 worsened by prolonged sitting or standing, neuroimaging indicating marginal L4 vertebrae with L4-5 and L5-S1 disc herniation, and electromyelogram showing evidence of a left L5 radiculopathy.  The VA rated the back condition 10%, coded 5243, (intervertebral disc syndrome), based on the C&P examination 4 months after separation, citing limitation of motion.  Members noted the limited documentation from the NARSUM regarding LBP and thus placed higher probative value on the C&P evaluation, with 70 degrees of flexion warranting a 10% rating but no higher.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, and no evidence of sensory loss in either lower extremity to meet the next higher 20% rating.  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 chronic LBP condition.

Chronic Right Shoulder Pain.  According to the STR and MEB NARSUM, the CI’s chronic shoulder pain condition also began in July 2003 after his fall from of a military vehicle.  Cervical spine neuroimaging showed diffuse spondyloarthropathy especially around C5-C7 with neuroforaminal stenosis.  The 2 December 2004 MEB NARSUM examination noted CI complaints of right shoulder pain worsening with exposure to cold weather, lifting, overhead activities and house cleaning; he took an anti-inflammatory pain medication twice daily.  Physical examination showed mild tenderness in the bicipital grove, no swelling or redness, and normal neurological findings.  Active ROM (documented as “left shoulder” but most likely an error since right shoulder was referenced throughout the examination) was decreased due to pain with flexion to 120 degrees (normal 180), abduction to 118 degrees (normal 180), internal rotation to 50 degrees and external rotation to 40 degrees.  

At the 12 July 2005 VA C&P evaluation the CI reported laxity and “popping” of the right shoulder, but modified his movements to avoid this sensation.  He also did not lift items weighing more than 25 pounds and refrained from recreational activities that put his right upper extremity at risk.  Physical examination showed the right shoulder was not dissimilar to the left, with both appearing to be at the same level and no loss of deltoid muscle.  The right acromioclavicular joint was prominent with tenderness in the subacromial and subcoracoid shoulder regions.  Flexion was to 115 degrees and active abduction to 100 degrees with increased intensity beyond this point; bringing the arm beyond the horizontal level caused discomfort and increased fatigue.  There was a sense of impending dislocation with the right shoulder in a position of abduction and external rotation, but no indication of grinding or crepitation on passive motion of the joint. There were no episodes of outright dislocation requiring manipulation.  
The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder condition 0%, coded 5201 (arm, limitation of motion), citing pain,  passive ROM of 150 degrees abduction and 170 degrees flexion, and a normal neurological examination.  The VA rated the right shoulder condition 10%, analogously coded 5203 (clavicle or scapula, impairment of), based on the C&P examination 4 months after separation, citing pain in the joint after activity.  The NARSUM noted non-compensable active limitation of ROM, but members agreed there was decreased ROM due to painful shoulder motion warranting a 10% rating (based on §4.59).  Neuroimaging showed arthropathy and stenosis at C5-C7 to be the likely source of the shoulder pain, and the panel determined the condition was most appropriately coded as 5299-5003 (analogous to arthritis, degenerative).  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 chronic right shoulder pain condition, coded 5299-5003.  

Contended PEB Conditions:  PTSD and Polysubstance Dependence.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.    The June 2004 MEB NARSUM psychiatric examination noted stressors from the CI’s recent deployment and geographical separation from family. He reported improved mood and decreased irritability since beginning medication (anti-anxiety, anti-depression, and sleep aid) with anxiety slightly improved, and panic attacks less frequent and severe.  While nightmares had decreased in frequency and intensity, he still had difficulty sleeping.  Flashback frequency had also decreased with occasional, less severe auditory hallucinations.  The examiner put the CI on an S4 profile and diagnosed PTSD and polysubstance dependence, both medically unacceptable, with a Global Assessment of Functioning score of 55 (moderate symptoms).  

While the NARSUM and MEB determined the PTSD condition was medically unacceptable, the October 2004 commander’s statement noted the CI was an outstanding soldier, highly motivated and mission oriented.  The 1 December 2004 psychiatry memo to the PEB reported significant improvement in mood and anxiety symptoms that included improved sleep, resolved panic attacks and no nightmares or flashbacks for several weeks.  He continued to attend his substance abuse treatment appointments, and while he still experienced symptoms of isolation, crowd avoidance, hypervigilance, paranoia, and exaggerated startle response at times, the examiner opined he could tolerate work requiring minimal concentration with mild stress levels and infrequent loud noises.  Members agreed there was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  

Polysubstance dependence does not constitute a physical disability and is not ratable IAW DoDI 1332.38.  After due deliberation, the panel concluded 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 low back pain 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 5299-5003 IAW VASRD §4.71a.  In the matter of the contended PTSD and polysubstance dependence conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting. 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 Low Back Pain	5237	10%	
Chronic Right Shoulder Pain	5299-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

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

AR20180002362, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

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