RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03383
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080513

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E8, Recruiting and Retention Non-Commissioned Officer, medically separated for “chronic right shoulder pain,” “chronic left shoulder pain,” and “chronic low back pain,” rated 10%, 10% and 0%, respectively, with a combined disability rating of 20%.  

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 - 20080225	VARD – 20090505	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Shoulder Pain	5099-5003	10%	Right Shoulder Impingement	5201-5024	10%	20090304	
Chronic Left Shoulder Pain	5099-5003	10%	Left Shoulder Impingement	5201-5024	10%	20090304	
Chronic Low Back Pain	5299-5243	0%	Lumbosacral Strain Status Post Microdiskectomy	8522-5242	10%	20090304	
Hearing Loss	Not Unfitting	Bilateral Hearing Loss	6100	0%	20090304	
Chronic Joint Pain, Bilateral Hands	Not Unfitting	Residuals Status Post Right Carpal Tunnel Syndrome Release	8515-7804	10%	20090304	
Carpal Tunnel Syndrome, Right Hand	Not Unfitting					
History of Gout	Not Unfitting	Gout, Left Ankle/Foot	5017	10%	20090304	
		Gout, Right Ankle/Foot	5017	10%	20090304	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Chronic Right Shoulder Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the right hand dominant CI underwent right shoulder surgery in November 2002 for instability repair following repeated subluxations.  At an orthopedic visit on 27 August 2007 the CI reported recurrent right shoulder pain.  The surgeon indicated imaging showed acromioclavicular arthritis.  The CI underwent a second surgery on 10 September 2007 for impingement (subacromial decompression and right distal clavicle resection).  Right shoulder X-rays on 7 January 2008 showed early degenerative changes and possible acromioclavicular joint separation and clinical correlation was advised.  

During the 8 January 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, physical examination revealed “near full ROM [range of motion]” with “tightness/ache” at extremes of abduction and flexion and no instability.  At the 16 January 2008 MEB NARSUM examination, 4 months prior to separation, the CI reported complaints of right shoulder pain with difficulty sleeping and inability to do pushups or sit-ups.  Physical examination showed no pinpoint tenderness of the shoulder.  Right shoulder flexion was 160 degrees (normal 180) and abduction was 160 degrees (normal 180) after three repetitions.  Painful motion was not addressed.  

At the 4 March 2009 VA Compensation and Pension (C&P) examination, 10 months after separation, the CI reported his right shoulder pain was aggravated with heavy or repetitive lifting, especially if he attempted to raise his hands over his head.  He reported rare flare-ups occurring once every several months with duration of two days, treated with anti-inflammatory medication and rest.  Physical examination showed mild pain with tests to evaluate rotator cuff injury/impingement (empty can testing and Hawkins-Kennedy).  Right shoulder flexion was 140 degrees and abduction was 180 degrees after repetitive motion, with pain at the end ranges of motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder condition 10%, analogously coded 5003 (arthritis, degenerative), citing slight loss of full abduction and flexion.  The VA also rated the right shoulder condition 10%, dual coded 5201-5024 (arm, limitation of motion of and tenosynovitis), based on the C&P examination, citing painful and limited ROM.  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.  Although there was no limitation of motion to support a rating under the 5201 code, a 10% rating was justified coded 5099-5003 for degenerative arthritis with limited motion of a major joint.  The panel also considered rating under other VASRD shoulder codes, but all were less applicable and/or not advantageous to 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.  

Chronic Left Shoulder Pain.  According to the STR and MEB NARSUM, the CI underwent left shoulder rotator cuff repair surgery in October or November 2003.  Left shoulder X-rays on 7 January 2008 were technically flawed, as well as confused as to whether the films were of the left or right joint, but suggested it was left.  There were no abnormalities, but the study was noted to be limited.  

The MEB examination revealed “near full ROM” with “tightness/ache” at extremes of abduction/flexion and no instability.  The MEB NARSUM examination noted complaint of shoulder pain causing difficulty sleeping and inability to perform push-ups or sit-ups.  Physical examination showed left shoulder flexion was 160 degrees and abduction was 160 degrees after repetitive motion.  Painful motion was not addressed.  

At the C&P examination the CI reported his left shoulder was aggravated with heavy or repetitive lifting, especially if he attempted to raise his hands over his head.  He reported rare flare-ups occurring once every several months with duration of two days, treated with anti-inflammatory medication and rest.  Physical examination showed mild pain with tests to evaluate rotator cuff injury/impingement (empty can testing and Hawkins-Kennedy).  Left shoulder flexion was 140 degrees and abduction was 180 degrees after repetitive motion, with pain at the very end ranges of all motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 10%, analogously coded 5003, citing slight loss of full abduction and flexion.  The VA also rated the left shoulder condition 10%, dual coded 5201-5024, based on the C&P examination, citing painful and limited ROM.  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.  Although there was no limitation of motion to support a rating under the 5201 code, a 10% rating was justified coded 5099-5003 for painful, limited motion of a major joint.  Although there was no imaging evidence of degenerative changes of the left shoulder, the panel agreed it was more likely than not to be present given the history of the shoulders.  The panel also considered rating under other VASRD shoulder codes, but all were less applicable and/or not advantageous to 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 left shoulder condition.  

Chronic Low Back Pain (LBP).  According to the STR and MEB NARSUM, the CI had a history of LBP since approximately 1994 after moving artillery ammunition.  It was managed conservatively until 2004 when his back pain worsened and he started losing feeling in his left leg.  MRI showed a herniated disc at L4-5 and he underwent back surgery with L4/L5 endoscopic discectomy in March 2005.  The surgery alleviated his leg pain and somewhat improved his back pain.  An MRI performed on 7 January 2008, 4 months prior to separation, demonstrated degenerative disc disease with small midline posterior herniation of disc material that did not encroach on the neuroforamen (openings through which the spinal nerves exit the spinal canal).  

During the MEB examination the CI reported LBP, recurring for the previous three years.  Physical examination revealed limited forward flexion and extension with “no neuro deficit.”  The MEB NARSUM examination noted complaints of daily low back pain, graded 5 to 6/10.  Pain was worsened with sitting or standing for long periods of time or with any jarring.  Physical examination showed no loss of lumbar lordosis.  There was no midline tenderness or muscle spasm.  Thoracolumbar ROM (after three repetitions) was flexion of 90 degrees (normal) and combined ROM of 240 degrees (normal) and painful motion was not addressed.  

At the C&P examination the CI reported some pain in the left leg and foot.  Back pain was aggravated when shoveling snow or lifting greater than 20 pounds.  The flare-ups were achy in nature and lasted days.  He treated them with the same anti-inflammatory he used on a daily basis.  He denied any incapacitating episodes.  Physical examination showed a normal posture and gait.  There was mild tenderness at the level of L4.  There were no muscle spasms.  Back ROM was flexion of 90 degrees and combined ROM of 240 degrees, with pain at the end ranges of flexion and extension.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 0%, analogously coded 5243 (intervertebral disc syndrome), citing no tenderness to palpation of the back muscles, no spasm, deformity, or significant loss of active motion or radiculopathy.  The VA rated the low back condition 10%, dual coded 8522-5242 (incomplete paralysis of superficial peroneal nerve-degenerative arthritis of the spine), based on the C&P examination, citing mild tenderness at the level of L4 and pain at end ranges of normal motion with mild L5 sensory neuropathy.  There was no limitation of thoracolumbar spine motion or localized tenderness, muscle spasm, guarding, or painful motion noted on the MEB NARSUM examination to support a 10% rating Although the C&P examination showed “mild” tenderness localized to the L4, it was performed 10 months after separation and was judged to have less probative value for the panel’s disability rating at separation than the MEB NARSUM.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority concluded there was insufficient cause to recommend a change in the PEB adjudication for the low back condition.  

Contended PEB Conditions:  Hearing Loss; Chronic Joint Pain, Bilateral Hands; History Of Gout; Carpal Tunnel Syndrome, Right Hand.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  

Hearing Loss.  According to the STR and NARSUM, the CI had history of hearing loss with an H3 profile.  He was referred for an audiology evaluation during the MEB and determined to have high frequency hearing loss consistent with his H3 profile and he was fitted with hearing aids on 14 January 2008.  The commander noted the CI’s H3 hearing profile, however he did not implicate hearing loss as impairing the CI’s duty performance in his Recruitment and Retention battalion in the Army National Guard, where he had been assigned since 1994.  The MEB NARSUM noted the bilateral hearing loss and indicated the recent hearing aids allowed the CI to “function and to fully discriminate speech.”  The CI’s bilateral hearing loss was not judged to fail retention standards.  There was no performance-based evidence from the record that bilateral hearing loss significantly interfered with satisfactory duty performance at separation.  

Chronic Joint Pain, Bilateral Hands; History of Gout; Carpal Tunnel Syndrome, Right Hand.  Although the commander’s statement listed all of these conditions in reviewing the CI’s medical history, none of these conditions were permanently profiled or judged to fail retention standards.  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 matters of the right and left shoulder conditions and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudications.  In the matter of the low back condition and IAW VASRD §4.71a, the panel majority recommends no change in the PEB adjudication.  The single voter for dissent recommends modification to 10% and did not elect to submit a minority opinion.  In the matter of the contended hearing loss, bilateral hand joint pain, gout, and right hand carpal tunnel syndrome, the panel recommends no change from the PEB determinations as not unfitting.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

, XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.

Enclosure