RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02110
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20061216

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E6, Concrete and Asphalt Equipment Operator, medically separated for “chronic pain right shoulder status post surgical repair” and “chronic back pain due to degenerative disc disease [DDD],” rated at 10% and 0%, respectively, with a combined disability rating of 10%.  

CI CONTENTION:  Review requested of arm right arm and back as well as 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 the 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 – 20060628	VARD – 20070209	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Shoulder Pain… 	5099-5003	10%	Rotator Cuff Repair Right Shoulder	5201	20%	20060919	
Chronic Back Pain… 	5299-5242	0%	Spondylosis of the Lumbar Spine 	5242	10%	20060919	
Anxiety Disorder with Sleep Deprivation	Not Unfitting	Post Traumatic Stress Disorder 	9411	10%	20060913	
Hypertension	Not Unfitting	Hypertension	7101	0%	20060919	
Impaired Fasting Glucose	Not Unfitting	Impaired Fasting Glucose	7913	NSC	20060919	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Right Shoulder Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI hyper flexed his right (dominant) shoulder in June 2004 after slipping on a wet surface when he dismounted a tactical vehicle.  He was profiled and treated with medications, and upon redeployment, he was diagnosed with a right shoulder rotator cuff tear and a superior labral anterior posterior tear.  He underwent surgical repair on 28 July 2005, but symptoms persisted despite post-operative management, temporary profiles, physical therapy (PT) rehabilitation and use of various medications.  

The 14 April 2006 MEB NARSUM examination, 8 months prior to separation, noted CI complaints of right shoulder pain.  Physical examination showed well-healed surgical scars over the anterior and lateral aspect of the shoulder with no edema, erythema or atrophy.  Active range of motion (ROM) measurements revealed forward flexion to 170 degrees (normal 180) and abduction to 165 degrees (normal 180), with painful motion.  There was slight supraspinatus weakness (4/5) with normal strength in the subscapularis, infraspinatus and teres minor.  A PT treatment note on 11 May 2006 documented full right shoulder flexion and abduction, with painful motion and slight muscle weakness.  

At the 19 September 2006 VA Compensation and Pension (C&P) examination, 3 months before separation, the CI reported deep-seated right anterior/inferior acromioclavicular joint pain, rated at 4/10, and increased with overhead motion; flare-ups occurred about every 2 weeks and lasted 2 hours.  Shoulder X-rays showed post-traumatic or degenerative changes, and the examiner recorded forward flexion to 150 degrees and abduction to 135 degrees, with painful motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder condition 10%, analogously coded 5099-5003 (degenerative arthritis), citing application of the US Army Physical Disability Agency Policy and slight pain not requiring daily narcotic therapy.  The VA rated the right shoulder condition 20%, coded 5201 (arm, limitation of motion of), based on the C&P examination, citing arm motion limited by pain at the shoulder level.  Members noted that the VASRD §4.71a threshold for rating ROM impairment under code 5201 is “at shoulder level” (approximately 90 degrees from the side), and that all ROM evaluations demonstrated motion above this level.  However, the panel agreed that a 10% rating was justified for application of VASRD §4.59 (painful motion).  There was no malunion or recurrent dislocation of the humerus to justify a rating under code 5202 (humerus, other impairment of), and no nonunion with loose movement of the clavicle to warrant the next higher 20% rating under code 5203 (clavicle or scapula, impairment of).  After due deliberation, considering all 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 right shoulder condition.

Chronic Back Pain.  According to the STR and MEB NARSUM, the CI injured his back during the same fall causing the shoulder pain.  A lumbar spine MRI on 14 Sep 2005 showed multi-level DDD with nerve impingement at L3-4 level without evidence of spinous fracture.  His back pain did not improve and he was unable to pass the physical fitness test or perform military specialty duties.  The 20 March 2006 MEB NARSUM examination, 9 months prior to separation, noted CI complaints of low back pain that would start after ROM activities.  Physical examination showed normal motor and sensory functions as well as symmetrical and normal deep tendon reflexes throughout.  Thoracolumbar “mechanical” ROM showed flexion of 90 degrees (normal) and combined ROM of 240 degrees (normal) after repetition.  Gait and heel/toe-walk were normal with a negative straight leg raise test and no non-physiologic findings.  There was no bowel or bladder incontinence, swelling, erythema, warmth, or deformity.  

At the 19 September 2006 VA Compensation and Pension (C&P) examination, 3 months before separation, the CI reported low back pain.  Physical examination revealed thoracolumbar flexion of 85 degrees, flattening of lumbar segments, and combined ROM of 230 degrees; ROM was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use.  Gait and posture were within normal limits, and there was no tenderness, spasm, or signs of intervertebral disc syndrome.  Spine X-rays demonstrated spondylosis, and the examiner diagnosed “spondylosis, lumbosacral spine without lower extremity radiculopathy.”  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 0%, coded 5299-5242 (degenerative arthritis of the spine), citing combined thoracolumbar ROM of 240 degrees.  The VA rated the back condition 10%, coded 5242, based on the C&P examination, citing combined thoracolumbar ROM greater than 120 degrees but not greater than 235 degrees. Members noted that the MEB NARSUM measurements specified “mechanical” ROM rather than active ROM (possible passive or not noting painful limitation by the CI), did not address DeLuca criteria, and was more distant from separation.  The C&P examination was most proximate to separation and noted repetition and DeLuca criteria, and thus the panel placed more probative value on the VA ROM measurements.  Members agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and/or combined ROM (greater than 120 degrees but not greater than 235 degrees).  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 the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the back condition, coded 5299-5242.  

Contended PEB Conditions:  Anxiety Disorder, Hypertension, and Impaired Fasting Glucose.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  None of the conditions were profiled or failed retention standards.  The commander’s statement specified shoulder and back pain leading to medical retention processing and mentioned the CI “also reports that he now has anxiety attacks, Type II diabetes and hypertension that have worsened since his tour to Iraq.”  There was no performance-based evidence from the record that any of the conditions 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 any of the contended conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the shoulder condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the back condition, the panel recommends a disability rating of 10%, coded 5299-5242 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 the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Pain Right Shoulder Status Post-Surgical Repair	5099-5003	10%	
Chronic Back Pain, Due to Lumbar Degenerative Disc Disease, without Neurologic or Electro diagnostic Abnormality	5299 5242	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160224, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20190005967, 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