RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01940
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080327

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

CI CONTENTION:  Review all conditions.  The CI also requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20080402	VARD - 20080331	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5299-5237	10%	Degenerative Arthritis of the Lumbar Spine	5242	10%	20080109	
Bilateral Shoulder Impingement Syndrome	5099-5003	0%	Left Shoulder Tendinopathy	5024-5203	10%	20080109	
			Right Shoulder Bursitis	5024-5203	10%	20080109	
Migraine Headaches	Not Unfitting	Migraine Headaches	8100	0%	20080109	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began in August 2006 without injury or trauma.  X-rays showed thoracic and lumbar scoliosis and a thoracic spine MRI showed multiple wedge shaped deformities, dehydrated intervertebral disks and a central Schmorl’s node (protrusion at T11).  At the 2 November 2007 MEB NARSUM examination, 5 months prior to separation, the CI reported upper back pain aggravated by carrying groceries or moving things.  Physical examination showed a normal gait, but there was slight spasms in the lower lumbar region and the back showed a slight hump on the left thoracic spine, which was visible when bending.  Motor strength, reflexes and sensation were normal, and straight leg raise testing was negative.  The range of motion (ROM) evaluation showed flexion of 75 degrees (normal 90) and combined thoracolumbar ROM of 195 degrees (normal 240) with painful motion.  

At the 9 January 2008 VA Compensation and Pension (C&P) examination, 3 months before separation, the CI reported stiffness in the mornings, weakness with heavy lifting and 8/10 back pain elicited by physical activity.  The CI also reported back pain with prolonged standing, bending and sitting, but denied incapacitation.  Physical examination showed no evidence of radiating pain on movement and no spasm or tenderness.  The spinal contour was normal and there were no signs of intervertebral disc syndrome (IVDS).  Straight leg raise testing was negative bilaterally and the CI’s gait, motor strength, sensation and reflexes were normal.  The ROM evaluation showed flexion of 90 degrees and combined thoracolumbar ROM of 240 degrees with pain on extension.  The spine was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetition.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5299-5237 (analogous to lumbosacral strain), citing spasm and pain limited motion.  The VA also rated the back condition 10%, analogously coded 5242 (degenerative arthritis of the spine), based on the C&P examination, citing painful motion.  

The panel considered the somewhat disparate examinations and agreed the VA examination held more probative value for rating because it was more proximate to separation and complete.  The panel agreed that a 10% rating, but no higher, was justified for evidence of painful motion.  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 IVDS with incapacitating episodes which would provide for a higher rating under that formula.  After due deliberation, considering all 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 back condition.  

Bilateral Shoulder Impingement Syndrome.  The PEB combined the right and left shoulder conditions under a single disability rating, coded analogously to 5003 (degenerative arthritis) and rated 0%.  This approach by the PEB reflected its judgment 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 right and left 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-handed CI’s bilateral shoulder conditions began in March 2006 without injury or trauma.  Early consultation to physical therapy (PT) revealed multiple positive tests for bilateral glenohumeral multi-directional laxity (bilateral positive NEERS, anterior load & shift, sulcus; grinding with pain, and mild weakness).  Radiographic studies of each shoulder were negative.  

At the MEB NARSUM examination, 5 months prior to separation, the CI reported diminished bilateral shoulder pain, aggravated by carrying groceries or moving things.  Physical examination showed normal PT ROMs for both the right and left shoulders without weakness or pain.  However, the 25 October 2007 PT ROM study documented right shoulder flexion limited to 170 degrees (normal 180), with bilateral internal and external rotations limited by 4 to 5 degrees; and left shoulder internal and external rotations limited by 10 degrees.  

During the C&P examination, 3 months before separation, the CI reported stiffness in the mornings, weakness with heavy lifting, giving way with overhead lifting and 8/10 bilateral shoulder pain elicited by physical activity.  The CI denied swelling, heat, redness, lack of endurance, locking, fatigability, dislocation or shoulder pain while resting.  Physical examination showed no signs of edema, effusion, weakness, tenderness, redness, heat, subluxation or guarding of movement in either shoulder.  The ROM evaluation showed bilateral shoulder flexion of 175 degrees (normal 180) and abduction of 180 degrees (normal) with pain on abduction and external rotation.  Although the examiner indicated that joint function was additionally limited by pain for each shoulder, the limitation was 0 degrees.  There was no additional limitation to either shoulder due to fatigue, weakness, lack of endurance or incoordination.  Bilateral shoulder X-rays were normal.  The diagnoses were right shoulder bursitis and left shoulder tendinopathy.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral shoulder condition 0%, coded 5099-5003 (analogous to degenerative arthritis), citing full ROM of both shoulders.  The VA rated each shoulder 10%:  the right shoulder was dual coded 5019-5203 (bursitis due to clavicle or scapula impairment) and the left was dual coded 5024-5203 (tenosynovitis due to clavicle or scapula impairment), based on the C&P examination, citing painful motion of each shoulder.  

The panel first considered if the right and left shoulder conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The NARSUM and profile indicated bilateral shoulder pain, the MEB diagnosis was “bilateral shoulder pain due to impingement,” and the commander’s statement noted “severe shoulder pain” without any mention of lateralization.  Panel members concluded there was not a preponderance of evidence in the service records which overcame the panel’s presumption that the unbundled right or left shoulder conditions were reasonably considered separately unfitting.  Panel members also agreed the evidence reasonably justified that the functional limitations of each shoulder contributed to the CI’s inability to perform her military duties, and accordingly separate disability ratings are recommended.  The panel then considered its rating recommendation for the unfitting right and left shoulder conditions at the time of separation.  

The panel considered the somewhat disparate examinations and the majority agreed the pre-separation VA examination held more probative value for rating because it was more proximate to separation, more complete, included an assessment of ROM after repetition and considered the DeLuca criteria.  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), but the examinations in evidence demonstrated motion above this level.  Some STR examinations documented “full” painless shoulder ROM, but there were multiple STR entries documenting painful motion and functional loss of each shoulder.    Therefore, the panel consensus was that a 10% rating was justified for each shoulder joint 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 with loose movement to justify a higher rating under the 5202 (humerus, other impairment of) or 5203 (clavicle or scapula, impairment of) codes for either shoulder.  As there was no imaging documentation of degenerative changes in the shoulders, the clinical evidence of impingement coding under 5024-5203 was predominate.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 10% for the right shoulder condition, coded 5024-5203, and a disability rating of 10% for the left shoulder condition, coded 5024-5203.  

Contended PEB Condition:  Migraine Headaches.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The contended condition was not profiled, 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 there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the bilateral shoulder condition, the panel majority recommends that each joint be separately adjudicated as follows:  an unfitting right shoulder condition coded 5024-5203 and rated 10%, and an unfitting left shoulder condition, coded 5024-5203 and rated 10%, both IAW VASRD §4.71a.  The single voter for dissent recommends no change and did not elect to submit a minority opinion.  In the matter of the contended migraine headaches, the panel recommends no change from the PEB determination 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; 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	
Chronic Back Pain	5299-5237	10%	
Right Shoulder Impingement Syndrome	5024-5203	10%	
Left Shoulder Impingement Syndrome	5024-5203	10%	
COMBINED	30%	

AR20180016327, 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 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), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557.
A copy of this decision has also been provided to the Department of Veterans Affairs.