RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXX	CASE:  PD-2017-03184
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20080401

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Aerospace Propulsion Journeyman, medically separated for “low back pain” and “right knee pain,” rated 10% each, with a combined  disability rating of 20%.

CI CONTENTION:  Requested review of all conditions in addition to PTSD, neck and right ankle 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 - 20080122	VARD - 20091113	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5235	10%	Chronic Low Back Pain…	5237	20%	20080709	
Right Shoulder Status Post Arthroscopic Surgery	5003	10%	Right Shoulder Pain…	5203	10%		
Tobacco Abuse	Category III	No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:

Low Back Pain (LBP).  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s LBP began in June 2006 when a roof collapsed on him during a storm and caused a spinal fracture.  A July 2006 spine MRI documented a healing T12-L1 small trabecular fracture of the medullary bone in the vertebral body.  A follow-up lumbosacral CT scan in October 2006 was normal, and surgery was not recommended.  During the 19 June 2007 MEB NARSUM, 10 months prior to separation, the CI reported chronic LBP aggravated by bending, lifting and running.  Physical examination revealed a normal gait and no spinal tenderness.  “Back” flexion was to 80 degrees (normal 90) and combined range of motion (ROM) was 210 degrees (normal 240).  Painful motion, gait, posture, guarding and spinal spasm were not addressed.  

The 14 November 2007 MEB physical therapy (PT) examination, 5 months before separation, noted CI complaints of constant back pain aggravated by lifting, bending, and running.  Physical examination showed back flexion at L1 of 70 degrees and L5 flexion was 40 degrees.  A forward bend functional test showed reaching [finger tips] to 12 inches from the floor (approximately 70 to 80 degrees of normal 90 degrees).  Painful motion, gait, posture, guarding, spinal tenderness and spasm were not addressed.  The 13 December 2007 MEB NARSUM addendum, 4 months prior to separation, documented the CI’s mid back pain and inability to run, perform high impact activities, and lift heavy objects.  Current limitations indicated ROM “in the mid back is limited making twisting difficult,” and the examiner referenced the MEB PT physical findings.  

At the 9 July 2008 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported LBP.  Physical examination noted a normal gait with spinal tenderness and muscle spasm.  Goniometrically measured lumbar flexion was to 90 degrees and combined ROM was 230 degrees, with painful motion, but no additional ROM loss following repetitive use.  Posture, guarding and spinal contour were not addressed.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP 10%, coded 5235 (vertebral fracture or dislocation).  The VA rated the LBP n 20%, coded 5237 (lumbosacral strain), based on the C&P examination, citing muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis.  Panel members agreed that the NARSUM and PT examinations best aligned with the preponderance of the evidence and were adjudged to have the highest probative value for rating at separation.  The panel 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/NARSUM examinations.  The VA examination also documented combined ROM, painful motion and muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour to support the 10% rating.  Although there was muscle spasm at the VA examination, it was not 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 concluded there was insufficient cause to recommend a change in the PEB adjudication for the LBP condition.

Right Shoulder Status Post Arthroscopic Surgery.  According to the STR and MEB NARSUM, the CI’s right (dominant) shoulder condition also began during the aforementioned roof collapse.  He underwent right shoulder surgery (biceps tendon debridement) in May 2007, and an X-ray in October 2007 was normal.  The MEB NARSUM addendum documented that the CI was not able to lift objects overhead due to the right shoulder, and that repeat orthopedic evaluations revealed a persistent concern for the right shoulder labrum.  A repeat right shoulder surgery was a possibility, but continued PT was recommended at that time, and no right shoulder examination performed.  At a family practice examination on 20 February 2008, 1 month before separation, the CI complained of right shoulder pain with flexion, and “grinding and popping” during cross-chest movement.  Physical examination showed no bilateral shoulder tenderness, but pain was elicited during impingement and  tests, indicative of a labral impairment.  Bilateral shoulder ROM was “full,” but painful motion was not addressed.  

At the C&P examination, the CI reported constant right shoulder pain with some weakness, but denied any dislocation, recurrent subluxation and locking.  He experienced flare-ups during overhead work and lifting, but no incapacitating episodes over the last 12 months.  Physical examination revealed right shoulder tenderness without gross edema or deformity.  Goniometrically measured right shoulder flexion was to 180 degrees (normal) and abduction to 145 degrees (normal 180), with painful motion and no additional ROM loss following repetitive use.  Motor strength, sensory and subluxation were not addressed.  A right shoulder X-ray showed a widened acromioclavicular [joint] distance compatible to a right shoulder sprain. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder condition 10%, coded 5003 (degenerative arthritis).  The VA rated the right shoulder condition 10%, coded 5203 (clavicle or scapula, impairment), based on the C&P examination, citing clavicle or scapula malunion.  Panel members agreed 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 STR and VA ROM evidence did not demonstrate motion limited to this level to support a 20% rating.  However, there was satisfactory evidence of painful motion (VASRD §4.59), as recorded in STR entries and on the VA examination to support a 10% rating.  The panel also agreed there was no fibrous union or nonunion of the humerus (5202), or clavicle or scapula impairment (5203) to support a higher rating.  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 right shoulder condition.

Contended PEB Condition:  Tobacco Abuse.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition does not constitute a physical disability, therefore, the panel has no basis for recommending it as unfitting.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination  for the contended condition and so no additional disability rating is 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 and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended tobacco abuse condition, the panel agrees it cannot recommend it for additional disability rating.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

SAF/MRB

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Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case NumberPD-2017-03184.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.