RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01933
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060213

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

CI CONTENTION:  “I was only rated for my back and shoulders, my medical board was done so fast there wasn’t time to really go through my records.”  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20051216	VARD - 20060808	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5243	10%	Low Back Strain	5237	20%	20060328	
Bilateral Shoulder Pain	5099-5003	0%	Impingement Syndrome, Left	5099-5024	10%	20060328	
			Impingement Syndrome, Right	5099-5024	10%	20060328	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Low Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began in February 2004 without evidence of trauma or injury.  A March 2005 MRI showed a herniated disc at L5-S1 with mass effect on the S1 lateral recess, but neurosurgery did not feel that surgery would be beneficial.  The 1 August 2005 orthopedic range of motion (ROM) evaluation showed 60 degrees of flexion (normal 90) and 10 degrees of extension (normal 30), with pain in both planes of movement.  The 30 August 2005 physical therapy (PT) ROM evaluation, after repetition, showed pain-limited flexion of 45 degrees and combined ROM of 170 degrees (normal 240).  

The 5 December 2005 MEB NARSUM examination, 2 months prior to separation, noted complaints of radiating back pain.  Physical examination showed tenderness and spasm, but there was no evidence of abnormal gait or spinal contour.  The ROM evaluation showed flexion of “about” 60 degrees and extension of “about” 10 degrees.  Straight leg raise testing was negative and the CI had normal motor strength and reflexes.  

At the 28 March 2006 VA Compensation and Pension (C&P) examination, 2 months after separation the CI reported constant 7/10 back pain elicited by physical activity, walking or prolonged standing.  The examiner noted three incidents of incapacitation for a total of 10 days.    Physical examination showed normal gait and spinal curvatures without spasm, but there was evidence of tenderness.  The ROM examination showed flexion of 80 degrees, with pain starting at 60 degrees, and combined thoracolumbar ROM of 230 degrees.  Although the examiner mentioned the joint function of the spine was additionally limited by pain after repetitive use, the amount of limitation was 0 degrees.  The spine function was not additionally limited after repetitive use by fatigue, weakness, lack of endurance or incoordination.  Straight leg raise testing was negative bilaterally and there was no ankylosis of the lumbar spine.  Lower extremity motor strength, reflexes and sensation were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5243 (intervertebral disc syndrome), citing pain-limited motion and tenderness.  The VA rated the back condition 20% coded 5237 (lumbosacral strain), based on the C&P examination, citing that even though the ROM falls within the criteria for a 10% percent rating, her back was rated at 20% based on subjective complaints of pain and pain starting at 60 degrees of flexion.  

The panel considered the somewhat disparate ROM evaluations and noted all of the pre-separation ROM evaluations were between 45 and 60 degrees of flexion.  The post-separation VA examination was an outlier, but still showed painful flexion starting at 60 degrees.  The panel agreed that a 20% rating, but no higher, was justified for limitation of flexion greater than 30 degrees but not greater than 60 degrees.  There was no significant evidence of intervertebral disc syndrome which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under that alternate VASRD formula.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the back condition, coded 5243.  

Bilateral Shoulder Pain.  The PEB combined the left and right shoulder conditions under a single disability rating, coded analogously to 5003 (degenerative arthritis) and rated 0% with application of the US Army Physical Disability Agency (USAPDA) pain policy.  This approach by the PEB reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The panel 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 panel’s initial charge in this case was therefore directed at determining if combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel 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 panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the left and right shoulder conditions are presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the STR and MEB NARSUM, the right-hand dominant CI complained of left greater than right shoulder pain in March 2002 after an automobile accident.  Radiographic studies in September 2004 showed normal shoulder and acromioclavicular joints.  Although the left shoulder MRI showed no surgical pathology, orthopedics thought the CI would benefit from left shoulder arthroscopy with acromioplasty, but this was never performed.  The 8 September 2005 PT ROM evaluation, after repetition, showed left shoulder flexion of 120 degrees (normal 180) and abduction of 112 degrees (normal 180); and right shoulder flexion of 110 degrees and abduction of 113 degrees.  There was painful limitation of motion bilaterally during both active and passive ROM testing.  

During the MEB NARSUM examination, 2 months prior to separation, the CI complained of bilateral shoulder pain with repetitive use, reaching, activity or overhead activity.  Physical examination showed no evidence of instability.  The examiner indicated the shoulders were globally tender with abduction and flexion causing the most pain.  Forward flexion was “about” 150 degrees and abduction was “about” 160 degrees.  The examiner noted the ROM was good, but painful; however, did not specify if the ROM measurements were applicable to the right, left or both shoulders.  

At the C&P examination the CI reported 5/10 bilateral shoulder pain elicited by physical activity.  She denied incapacitation and her medical history showed no reported functional impairment.  The ROM evaluation showed 180 degrees of right and left shoulder flexion with pain starting at 150 degrees bilaterally and 180 degrees of right and left abduction with pain starting at 160 degrees bilaterally.  Shoulder joint function on the left and right was not additionally limited following repetitive motion due to fatigue, weakness, lack of endurance or incoordination.  Provocative testing for rotator cuff impingement signs (equivalent to painful motion) was positive bilaterally.  

The panel first considered if the left and right shoulder conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Panel members agreed the evidence reasonably justified that the functional limitations of the left and right shoulder conditions contributed to the CI’s inability to perform her military duties, and accordingly separate disability ratings for each shoulder are recommended.  

The panel directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB assigned a 0% rating for the bilateral shoulder condition analogous to the 5003 code, citing frequent and minimal pain IAW the USAPDA pain policy.  The VA assigned 10% ratings for both the left and right shoulders using the analogous 5024 code (tenosynovitis) for each, citing painful motion of a major joint for each shoulder.  

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 in both arms.  However, panel members agreed that a 10% rating for each shoulder joint was justified with application of VASRD §4.59 (painful motion).  Coding analogous to 5024 was predominant.  There was no malunion or recurrent dislocation of the humerus and no dislocation or nonunion of the clavicle or scapula for either shoulder 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 the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends disability ratings of 10% for the right shoulder condition and 10% for the left shoulder condition, each coded 5099-5024.  

BOARD FINDINGS:  In the matter of the back condition, the panel recommends a disability rating of 20%, coded 5243 IAW VASRD §4.71a.  In the matter of the bilateral shoulder condition, the panel recommends that each joint be separately adjudicated as follows: an unfitting right shoulder condition coded 5099-5024 and rated 10%, and an unfitting left shoulder condition, coded 5099-5024 and rated 10%, both 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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Low Back Pain	5243	20%	
Left Shoulder Pain	5099-5024	10%	
Right Shoulder Pain	5099-5024	10%	
COMBINED	40%	

AR20180015092, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

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