RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02230
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070815

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an O3 Reserve, Medical Surgical Nurse, medically separated for “chronic low back pain,” right shoulder pain,” “chronic cervicalgia,” and “chondromalacia left knee, with left knee pain” rated 10%, 0%, 0%, 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 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 - 20070703	VARD – 20080528	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Chronic Lower Back Pain	5237	NSC	20071119	
Right Shoulder Pain	5024	0%	Tendonitis, Right Rotator Cuff	5024	10%	20071119	
Chronic Cervicalgia	5237	0%	Degenerative Disc Disease C5-6	5237	10%	20071119	
Chondromalacia Left Knee 	5099-5003	0%	Osteoarthritis of the Left Knee Status Post Arthroscopy w/Scars	5260	NSC	20071119	
Occupational Problem	Not Unfitting	Dysthymia & Personality Disorder	9433	NSC	20080117	
Asthma, Moderate	Not Unfitting	Asthma, Moderate	6602	NSC	20071119	
Urge Incontinence	Not Unfitting	Urinary Incontinent	7512	20%	20071119	
Coronary Artery Spasms	Not Unfitting	Prinzmetal Angina 	7099-7005	NSC	20071119	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS:  40% 	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s low back condition began in March 2003 after a fall during night training.  A CT scan on 8 November 2004 showed bilateral spondylolysis (defect or fracture of pars interarticularis of the vertebral arch) at L5, and left spondylolysis at L4, without any spondylolisthesis (anterior movement of a vertebra on the vertebra below).  In physical therapy (PT) on 12 December 2005, she reported being pain-free since starting prescribed home back exercises.  However, she complained of annoying back pain, despite good range of motion (ROM), at a primary care visit on 22 May 2006, after re-injuring her back a couple months before. 

At the 23 March 2007 MEB NARSUM examination, 5 months prior to separation, the CI reported daily low back pain, aggravated by bending, moving, and twisting.  Physical examination showed tenderness and muscle spasms from L4-S1, but no neurological deficits.  Thoracolumbar ROM was measured by PT on the same day, and flexion was to 65 degrees (normal 90) and combined ROM was 210 degrees (normal 240) after repetition, with painful motion noted.

At the 19 November 2007 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported back pain and stiffness without weakness, but that she could function with medication; she denied any incapacitation.  Physical examination showed a normal gait and no muscle spasm, tenderness, or abnormal spinal curvature. There was no radiating pain with movement, and straight leg raise (SLR) testing to elicit radicular symptoms was negative.  Thoracolumbar flexion was to 90 degrees and combined ROM was 240 degrees, with joint function additionally limited by pain after repetition, but without additional loss of motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5237 (lumbosacral strain), citing tenderness.  The VA denied service connection for the back condition, based on the C&P examination, citing no permanent residual or chronic disability.  Panel 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), as reported on the PT ROM examination.  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 (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 low back condition.  

Right Shoulder Pain.  According to the STR and MEB NARSUM, the CI’s right shoulder pain also began in March 2003 after the same fall noted above.  She was initially treated with anti-inflammatory medication and stretching exercises, and an MRI on 21 August 2006 was negative.  At an orthopedic examination on 4 December 2006, the provider indicated the shoulder pain was an inflammatory process and recommended continued PT and activity limitations.  At an orthopedic follow-up visit on 5 January 2007, the CI reported doing well.  Physical examination showed “almost complete range of motion lacking only a few degrees of overhead elevation.”  A slow transition back to normal activities was recommended.  

The MEB NARSUM examination noted complaints of daily right shoulder pain aggravated by activity, especially when raising the arm above the shoulder. The examiner noted pain with limited abduction.  Shoulder ROM, measured by PT the same day, revealed flexion to 138 degrees (normal 180) and abduction to 101 degrees (normal 180) after repetition, with painful motion.

At the C&P examination, the CI reported right shoulder pain, weakness, and stiffness, which was worsened by activity; but she could function with pain medication.  The examiner noted that she was right-hand dominant and had shoulder tenderness without swelling, weakness, guarding of movement or subluxation.  Shoulder flexion and abduction were both to 180 degrees, with painful motion, but no additional loss of ROM after repetition.  Shoulder X-rays showed soft tissue calcifications, with no other abnormalities identified.  
The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder condition 0%, coded 5024 (tenosynovitis), citing no mechanical loss of motion.  The VA initially deferred rating the right shoulder condition, but the 28 May 2008 VARD rated right rotator cuff tendonitis 10%, also coded 5024, based on the C&P examination, citing painful or limited motion of a major joint.  Panel members noted that the VASRD §4.71a threshold for rating ROM impairment under 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, the panel agreed that a 10% rating was supported under code 5024 for painful, limited 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 recommends a disability rating of 10% for the right shoulder condition, coded 5024.  

Chronic Cervicalgia.  According to the STR and MEB NARSUM, the CI’s neck condition also began after the fall in March 2003.  She was initially treated conservatively, however the pain continued and she developed radicular symptoms down the right upper extremity (RUE).  A cervical spine MRI on 14 February 2005 showed degenerative disc disease from C5-C7, without significant central spinal canal or neuroforaminal stenosis.  A repeat MRI on 20 June 2006 was unchanged.  

The MEB NARSUM examination noted CI complaints of neck pain aggravated by bending, twisting or sudden movements of the neck, as well as intermittent numbness and tingling in the RUE.  Physical examination showed neck pain with flexion and extension and tingling down the RUE.  Cervical ROM measured by PT the same day revealed normal flexion (normal 45) and a combined ROM of 265 degrees (normal 340) after repetition, with painful motion.  

At the C&P examination, the CI reported constant neck pain and weakness, but that she could function with medication and did not have incapacitating episodes.  Physical examination showed tenderness without muscle spasm, and no evidence of radiating pain with movement.  Cervical spine flexion was to 45 degrees and combined ROM was 340 degrees.  There was painful motion with repetition, but no additional loss of motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the cervical spine condition 0%, coded 5237, citing no mechanical loss of motion.  The VA rated the cervical spine condition 10%, also coded 5237, based on the C&P examination, citing joint function limited by pain.  Panel members agreed that a 10% rating, but no higher, was justified for limitation of combined ROM (greater than 170 degrees but not greater than 335 degrees), as reported on the PT examination and/or tenderness noted at the VA examination.  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 evidence of IVDS which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under that alternate 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 cervical spine condition, coded 5243.  

Left Knee Chondromalacia.  According to the STR and MEB NARSUM, the CI’s left knee pain began after the fall noted above.  Arthroscopy on 2 December 2003 showed degenerative changes of the patella (chondromalacia patella), without meniscal tears or ligament damage.  The CI underwent a second arthroscopy on 10 January 2005 with debridement of the patella; no tears of either meniscus were noted and ligaments were intact.  An injection with artificial joint fluid (Synvisc) provided some benefit, but daily pain continued.  

The MEB NARSUM noted complaints of knee pain increased by activities, and the examiner documented full extension and no effusion or laxity.  Left knee ROM measured by PT the same day revealed flexion to 127 degrees (normal 140) and hyperextension to 7 degrees after repetition, with painful motion.  

At the C&P examination, the CI reported she was diagnosed with osteoarthritis of the left knee, and that about 4 times a week, she had knee pain, giving way, and locking with activity.  Physical examination showed tenderness, but no locking pain, genu recurvatum, crepitus, instability or evidence of meniscal pathology.  Knee flexion was to 140 degrees and extension to 0 degrees, with painful motion after repetition, but no additional limitation of motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 0%, analogously coded 5099-5003 (arthritis, degenerative), citing no mechanical loss of motion.  The VA initially deferred a rating on the left knee condition, but the 28 May 2008 VARD denied service connection for chronic left knee pain, based on C&P examination, citing no permanent residual or chronic disability.  Panel members agreed there no limitation of flexion or extension (5260 or 5261) which warranted a compensable rating, however, there was evidence of painful motion with functional loss warranting a 10% rating (based on §4.59, §4.40 and §4.45).  Additionally, there was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258); history of surgery to remove a meniscus (5259); or fracture, nonunion or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  There was therefore no rating higher than a 10% supported under any applicable VASRD code.  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 left knee condition, coded 5299-5260.  

Contended PEB Conditions:  Asthma; Urge Incontinence, and Coronary Artery Spasms.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  The asthma and urge incontinence were profiled and did not meet retention standards.  The commander’s statement dated 20 April 2007 indicated the CI’s profile for asthma, neck, back, and shoulder pain impaired the successful performance of her duties.  The coronary artery spasms were not profiled or implicated in the commander’s statement and met medical retention standards.  

Asthma.  Panel members agreed that a preponderance of the evidence supports recommending the asthma as unfitting at separation and eligible for disability rating.  According to the STR and MEB NARSUM, the CI’s asthma began in 2003.  At a primary care visit on 7 February 2003, she had difficulty breathing and peak flow measures increased from 64% to 86% of predicted normal after treatment with bronchodilator (BD) medication.  

The MEB NARSUM documented that the CI was officially diagnosed with asthma in 2004 while in Germany and treated with a daily anti-inflammatory inhaler (Azmacort), daily oral BD medication (Singulair), and a BD inhaler (albuterol) as needed.  On 15 April 2005, 7 months prior to separation, she was seen in the emergency room (ER) for shortness of breath (SOB), coughing, and chest pain.  She was treated with BD medication which resolved the respiratory difficulties.  At an evaluation for ER follow-up, baseline pulmonary function testing (PFT) was normal, but the provider noted the CI was taking Azmacort at the time.  

When the CI was transferred to Arizona, her asthma worsened and required nebulization treatment 1-2 times a week, and she reported going on oral prednisone approximately every 6 months.  At a primary care visit on 20 September 2006, she reported cough, chest tightness, and SOB for a few days.  Physical examination showed scattered wheezes in the lungs, and she underwent a nebulization treatment for acute asthma exacerbation.  She was subsequently placed on a new daily anti-inflammatory/BD inhaler combination (high dose Advair), a BD inhaler (Xopenex), and allergy medications.  On 19 January 2007, PFTs showed pre-medication values for forced expiratory volume in one second (FEV-1) of 70% and FEV-1/forced vital capacity (FVC) of 74% and decreased values after BD use, leading to an interpretation of moderate obstruction.  

At the MEB NARSUM examination, the CI reported asthma exacerbations 2-3 times per week and that she used a home nebulizer.  She denied ever being intubated or hospitalized overnight for asthma.  Physical examination of the heart and lungs was normal.  The PEB requested additional information on the asthma diagnosis with a specialist evaluation.  On 7 June 2007, 5 months prior to separation, baseline PFTs were normal and methacholine challenge testing was negative.  At a pulmonary consult the same day, the provider indicated that he could not prove or disprove a diagnosis of asthma in one visit, but that the CI’s normal PFT and methacholine challenge did not provide support for a diagnosis of asthma.  He noted the CI had taken Advair [high dose] within 6 hours of the test which may have contributed to the negative result.  Other possible diagnoses included vocal cord dysfunction or anxiety.  In the year before separation there were four visits noted in the STR for acute treatment of asthma exacerbations, with two visits being to the ER.  At the ER visit on 11 May 2007, the CI was treated with intravenous steroids and was discharged on a tapering course of oral steroids.  

At the C&P examination, the CI reported productive cough and SOB when walking two blocks, as well as weekly asthma attacks.  She visited a physician for asthma management 4 times a year, and required daily use of inhaled anti-inflammatory and BD medications.  She denied use of oxygen, immunosuppressive medication, steroid therapy or BD medication by mouth.  Heart and lung examinations were normal, and PFT results before BD were normal with an FEV-1 of 116% predicted normal and an FEV-1/FVC of 84% (thus no post-BD test was performed).  

The panel directed attention to its rating recommendation based on the above evidence.  The VA did not service connect the asthma, citing no evidence of a chronic disability.  Panel members considered the pulmonary consult 4 months prior to separation, and noted that although normal spirometry and methacholine challenge results did not support an asthma diagnosis, the CI had taken asthma medication that day and the provider could not rule out asthma in one evaluation.  Additionally, she was first diagnosed with asthma in Germany, but those diagnostic records were not in record.  A PFT on 19 January 2007 demonstrated moderate obstruction based on the FVC values, and there were multiple visits recorded for typical asthma attacks for which the CI was treated with and responded to asthma medications over a period of years.  

A 30% rating stipulates “FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication.”  Panel members considered that the examinations in evidence reported a current prescription and use of daily BDs and inhaled anti-inflammatories.  Panel members agreed that the threshold for a 30% rating was reasonably satisfied in this case on the basis of BD and/or inhalational anti-inflammatory medication use.  A 60% rating was not justified in the absence of at least monthly visits to a physician for required care of exacerbations, or intermittent (at least three per year) courses of systemic corticosteroids.  There was no PFT evidence to support the next higher 60% rating.  After due deliberation, the panel agreed the preponderance of the evidence with regard to the functional impairment of the asthma favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 6602, and meets the VASRD §4.97 criteria for a 30% rating based on use of anti-inflammatory medications.  

Urge Incontinence And Coronary Artery Spasms.  As mentioned above, urge incontinence was listed on the permanent profile and did not meet retention standards, but was not implicated in the commander’s statement as impairing the CI’s duty performance.  The coronary artery spasm condition was not profiled or implicated in the commander’s statement and did meet retention standards.  There was no performance-based evidence from the record that either of these 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 the urge incontinence and coronary artery spasm conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the low back condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the right shoulder condition, the panel recommends a disability rating of 10%, coded 5024 IAW VASRD §4.71a.  In the matter of the neck condition, the panel recommends a disability rating of 10%, coded 5243 IAW VASRD §4.71a.  In the matter of the right knee condition, the panel recommends a disability rating of 10%, coded 5299-5260 IAW VASRD §4.71a.  In the matter of the contended asthma, the panel agrees it was unfitting and recommends a disability rating of 30%, coded 6602 IAW VASRD §4.97.  In the matter of the contended urge incontinence and coronary artery spasms, the panel 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; 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 Low back Pain 	5237	10%	
Right Shoulder Pain	5024	10%	
Chronic Cervicalgia	5243	10%	
Chondromalacia	5299-5260	10%	
Asthma	6602	30%	
COMBINED	50%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170225, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20190008064, XXXXXXXXXXXXXXXXXX 

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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 50% 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.  Inquiries 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.