RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03546
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070801

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E5, Bradley Systems Maintainer, medically separated for “chronic left shoulder pain… and chronic right shoulder pain,” “low back pain,” and “chronic neck pain,” rated 10%, 0%, and 0%, respectively, with a combined disability rating of 10%.  

CI CONTENTION:  He is suffering from numerous conditions, including the ones he was found unfit for as well as diabetes, knees, hips, and mental health issues.”  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 - 20071130	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Shoulder Pain and Chronic Right Shoulder Pain	5099-5003	10%	Left Shoulder Strain	5201	20%	20070123	
			Right Shoulder Strain	5201	20%		
Low Back Pain	5299-5237	0%	Degenerative Arthritis of L5-S1	5242	20%		
Chronic Neck Pain	5299-5237	0%	Degenerative Joint Disease C5-6 Spine	5242	10%		
Diabetes Mellitus	Not Unfitting	Diabetes Mellitus	7913	20%		
Adjustment Disorder		No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  100% 	

ANALYSIS SUMMARY:  

Chronic Left Shoulder Pain and Chronic Right Shoulder Pain.  The PEB combined the left and right shoulder conditions under a single disability rating, coded analogously to 5003 and rated 10%, with application of the US Army Physical Disability Agency pain policy and AR 635-40 B24.f.  This approach by the PEB not uncommonly reflected its judgment that 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 left and right shoulder conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

Chronic Left Shoulder Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI reported left shoulder pain while deployed in November 2005, 1 month prior to leaving theater; without specific injury.  An MRI in June 2006 showed a probable partial tear of the superior glenoid labrum.  Evaluation by orthopedics suggested that the CI was not a surgical candidate.   At the time of the physical therapy (PT) clinic appointment on 10 August 2006, 12 months prior to separation, the CI reported left shoulder pain, rated 0-1/10.  Physical examination showed range of motion (ROM) measurements with a flexion of 150 degrees (normal 180) and abduction of 150 degrees (normal 180).  There was a negative (O’Brien’s) test for labral tear and positive tests for impingement syndrome (Neer and Hawkins).  There was tenderness.  Shoulder strength was normal.  The examiner noted continued pain at the end of range. At the time of the PT appointment on 6 September 2006, the examiner reported ROM measurements with flexion to 150 degrees and abduction to 130 degrees.  At the 27 September 2006 PT appointment, the examiner reported ROM measurements with a flexion of 150 degrees and an abduction of 100 degrees with sharp pain at the end of all motion. 

At a medical appointment on 20 October 2006, 11 months prior to separation, physical examination showed ROM measurements with flexion of 150 degrees and abduction of 130 degrees.  There was no shoulder tenderness.  Impingement syndrome tests were positive, but testing for shoulder dislocation was negative.  There was normal strength.  The examiner noted that the CI was scheduled for left shoulder arthroscopy with subacromial decompression but the surgery was cancelled due to hypertension.  At the time of an occupational therapy clinic appointment on 8 January 2007, 8 months prior to separation, ROM measurements for the MEB showed flexion to 147 degrees and abduction to 85 degrees.  The examiner noted decreased active ROM bilateral upper extremities with pain at the end ranges.  

At the 23 January 2007 VA Compensation and Pension (C&P) examination, 6 months before separation, the CI reported constant bilateral shoulder pain.  Physical examination showed tenderness in the left shoulder.  ROM measurements showed that pain occurred with flexion to 90 degrees and abduction to 90 degrees.  The examiner noted an additional 5 degrees of limitation due to pain with repetitive motion.  X-ray studies of the left shoulder were within normal limits.

The 30 January 2007 MEB NARSUM evaluation, 6 months prior to separation, noted left shoulder pain secondary to impingement syndrome.  The examiner reported the ROM measurements from the occupational therapy as noted above.  At the time of an occupational therapy appointment on 23 April 2007, 3 months prior to separation, ROM measurements for the MEB showed flexion to 90 degrees and abduction to 80 degrees.  Pain was noted in all planes of motion.  The 1 May 2007 MEB NARSUM, 3 months prior to separation, reported chronic left shoulder pain as slight and frequent, secondary to a partial tear of the superior glenoid labrum.  Physical examination showed normal bulk and tone, and normal strength in the left upper extremity.  The examiner reported ROM measurements as reported from 23 April 2007 as noted above. 

At the 5 August 2008 C&P examination, 12 months after separation, the CI reported pain in both shoulders associated with lifting activities.  Physical examination showed ROM measurement of the left shoulder with flexion of 135 degrees with pain at the end point and abduction of 115 degrees with pain at the endpoint.  

The panel first considered if the left shoulder condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  A left shoulder condition was profiled and judged to fail retention standards. Panel members agreed the evidence reasonably justified that the functional limitations of the condition contributed to the CI’s inability to perform his military duties, and accordingly a separate disability rating is recommended. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left and right shoulder condition 10%, analogously coded 5003 (arthritis, degenerative), citing without neurologic abnormality, left and right shoulder abduction limited by pain, and pain rated as slight and frequent.  The VA rated the each shoulder condition 20%, for a combined 40%, coded 5201 (arm, limitation of motion of: at shoulder level).  Panel members agreed that the occupational therapy and VA examinations evidenced limitation of motion to shoulder level for a 20% rating under the 5201 code (arm, limitation of motion).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the left shoulder pain condition, coded 5201.  

Chronic Right Shoulder Pain.  According to the STR and the MEB NARSUM, the CI reported that he had two right shoulder surgeries and impingement syndrome.  At the time of a troop medical clinic visit on 7 December 2005, 1 week before leaving theater, the CI complained of right shoulder pain for 4 days.  Physical examination showed that the CI had full ROM, no pain with overhead reach or internal rotation, and negative impingement signs.  X-ray studies on 5 January 2006 showed moderate degree acromioclavicular joint degenerative arthritic changes.  An MRI on 17 January 2006 showed a “supraspinatus partial tear versus tendinopathy and AC joint degeneration which may predispose the patient to impingement type symptomatology.”  

At the time of the PT clinic appointment on 10 August 2006, 12 months prior to separation, the physical examination showed right shoulder ROM measurements with a flexion of 160 degrees (normal 180) and an abduction of 160 degrees (normal 180).  At the occupational therapy clinic appointment on 8 January 2007, 8 months prior to separation, ROM measurements for the MEB showed a flexion of 142 degrees and an abduction of 120 degrees.  The examiner noted decreased active ROM bilateral upper extremities with pain at the end ranges.  

At the 23 January 2007 C&P examination the CI reported constant bilateral shoulder pain.  Physical examination showed tenderness in the right shoulder.  ROM measurements showed that pain occurred with flexion and abduction at 90 degrees.  Reflexes and muscle strength were normal in the upper extremities.  X-ray studies of the right shoulder were within normal limits.  The 30 January 2007 MEB NARSUM evaluation, 6 months prior to separation, noted chronic right shoulder pain, slight, intermittent, and medically acceptable.  The examiner reported the ROM measurements from the occupational therapy as noted above, with normal muscle strength.  At the time of a follow up PT clinic appointment on 13 April 2007, the examiner noted “right shoulder: active forward flexion was not decreased.”  There were no ROM measurements recorded.  At the occupational therapy clinic appointment on 23 April 2007, 3 months prior to separation, ROM measurements for the MEB showed a flexion of 110 degrees and an abduction of 125 degrees.  Pain was noted in all planes of motion  

The 1 May 2007 MEB NARSUM, 3 months prior to separation, noted chronic right shoulder pain as slight and frequent, secondary to tendinopathy and AC joint degeneration.  Physical examination showed normal bulk and tone, and normal strength in the right upper extremity.  The examiner reported ROM measurements as reported from occupational therapy as noted above.  At the 5 August 2008 C&P examination the CI reported pain in both shoulders associated with lifting activities.  Physical examination showed ROM measurement of the right shoulder with flexion of 120 degrees with pain at the end point and abduction of 130 degrees with pain at the endpoint.  

The panel first considered if the right shoulder condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The right shoulder condition was profiled and judged to fail retention standards.  After due deliberation, members agreed that the preponderance of the evidence supports a conclusion that the functional impairment from the right shoulder condition was integral to the CI’s inability to perform his military duties, and accordingly recommend a separate rating for it.  

Although there was insufficient limitation of motion to support a rating under the 5201 code, panel members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion).  There was no malunion or recurrent dislocation of the humerus to justify a rating under the 5202 code (humerus, other impairment of); and no nonunion with loose movement of the clavicle to warrant the next higher 20% rating under the 5203 code (clavicle or scapula, impairment of).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left shoulder pain condition, coded 5299-5201.  

Low Back Pain.  According to the STR and the MEB NARSUM, the CI’s back condition began in March 2005 without any specific injury or trauma.  X-ray studies in January 2006 of the lumbar spine showed mild degree scoliosis, and X-ray of the thoracic lumbar junction showed mild degenerative disk disease.  At the time of the spine clinic appointment on 28 February 2006, 17 months prior to separation, the CI reported low back pain.  Physical examination showed thoracolumbar spine flexion as normal, and slightly decreased extension limited by pain.  There was no tenderness, no spasms, and straight leg raise testing was negative for radiculopathy.  The CI had a normal gait, stance, reflexes, and strength in the lower extremities.  At a community care center clinic appointment on 3 March 2006, the CI stated “pain intensified about 3 days ago after laying on table for PT.”  At the time of a PT clinic appointment on 26 April 2006, ROM measurements showed a normal flexion of 90 degrees.  Straight leg test was negative for radiculopathy, and lower extremity strength was normal.  

During the 17 January 2007 MEB examination the CI reported continued low back pain.  Physical examination showed a normal spine.  The examiner reported negative straight leg raise test for radiculopathy.  At the 23 January 2007 C&P examination the CI reported constant mid back pain.  Physical examination showed muscle spasm and tenderness.  Gait and posture were within normal limits.  Straight leg raise test was negative for radiculopathy.  ROM measurements showed that pain occurred at 50 degrees of flexion.  The examiner also reported a combined ROM of 170 degrees (normal 240); however, this was where pain occurred.  

At the 30 January 2007 MEB NARSUM examination the examiner reported that the low back pain was medically acceptable.  Physical examination showed no focal tenderness and normal spinal contours.  The examiner noted “he has near full range of motion of the lumbar spine with negative seated straight leg raise bilaterally.”  The CI had a normal gait and stance. There was no atrophy or fasciculation (muscle spasm).  At the time of a PT clinic appointment on 2 April 2007 for MEB ROM measurements, the CI reported 5/10 low back pain and muscle spasms with thoracolumbar rotation.  The examiner recorded flexion to 15 degrees and a combined ROM of 90 degrees (normal 240).  The examiner noted normal strength in the lower extremities.  The 1 May 2007 MEB NARSUM examination, 3 months prior to separation, included reports of low back pain secondary to mild degenerative disc disease.  The physical examination showed “near full range of motion of the lumbar spine.”  The examination noted that pain limited the ROM.  There was no fasciculation. The gait and station were within normal limits.  The examiner documented that the CI was not working in his MOS and was working as a bus driver for the medical hold company.  

At the 5 August 2008 C&P examination the CI reported chronic pain and soreness of the lower back with no radiation of pain into the lower extremities.  Physical examination showed a normal gait and no evidence of spasm or tenderness.  ROM measurements showed a flexion of 80 degrees without pain and a combined ROM of 230 degrees with pain on left and right lateral bending. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 0%, analogously coded 5237 (lumbosacral strain), citing without neurologic abnormality, thoracolumbar ROM limited by pain, without focal tenderness.  The VA rated the back condition 20%, coded 5242 (degenerative arthritis of the spine), citing criteria for rating diseases and injuries of the spine.  

The panel noted disparity between 2 ROM measurements (January 2007 VA C&P, April 2007 PT) and other ROM measurements in evidence prior to and post separation.  Although the limitation of thoracolumbar motion recorded met the threshold for a 20 and 40% rating respectively, the panel noted that limitation of motion was present during pain exacerbations with muscles spasms.  The preponderance of the evidence met criteria for a 10% rating for painful or pain limited motion.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the low back pain condition, coded 5299-5237.  

Chronic Neck Pain.  According to the STR and the MEB NARSUM, the CI’s neck condition began in conjunction with his shoulder condition.   There was no specific injury or trauma.  X-ray studies in January 2006 showed degenerative disk disease.  At the time of the internal medicine clinic appointment on 7 November 2006, 9 months prior to separation, the examiner reported “neck: appearance was normal, palpation revealed no abnormalities.”  The CI had a normal gait and stance.  At the time of a community care center clinic appointment on 9 November 2006, the examiner reported no neck symptoms.

During the 23 January 2007 C&P examination the CI reported constant neck pain.  Physical examination showed no evidence of radiating pain on movement. There was evidence of muscle spasm and tenderness.  There was no ankylosis of the cervical spine.  ROM measurements showed pain occurred with flexion at 35 degrees (normal 45).  Combined ROM was recorded as 245 degrees (normal 340).  At the 30 January 2007 MEB NARSUM examination, the examiner reported that the chronic neck pain was medically acceptable.  At the time of an occupational therapy clinic appointment on 23 April 2007, 3 months prior to separation, ROM measurements for the MEB showed a normal flexion of 45 degrees and a combined ROM of 180 degrees with pain in all planes of motion.  

At the 1 May 2007 MEB NARSUM examination the CI reported excruciating neck pain based on sleep positioning.  The physical examination showed forward flexion to 45 degrees, extension to 20 degrees (normal 45), left and right lateral flexion to 20 degrees (normal), and left and right lateral rotation to 40 degrees (normal 80).  There was pain in all planes of motion.  The 5 August 2008 C&P examination included reports of chronic low grade pain in the neck with no radiation of pain.  Physical examination showed no evidence of spasm or tenderness.  ROM measurements showed flexion of 50 degrees without pain and a combined ROM of 190 degrees with painful motion. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 0%, analogously coded 5237 (cervical spine strain), citing without neurologic abnormality, cervical ROM limited by pain, without focal tenderness.  The VA rated the neck condition 10%, coded 5242 (degenerative arthritis of the spine), citing criteria for rating diseases and injuries of the spine.

There was no limitation of cervical spine motion to support a 10% rating under the General Rating Formula for Diseases and Injuries of the Spine; however, the STR and VA examinations did note the presence of painful motion for a 10% rating.  There was no history or evidence of vertebral body fracture with loss of 50 percent or more of the height, nor was there evidence of additional functional loss that would impact functioning in the average civil occupation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the chronic neck pain condition, coded 5242.  

Contended PEB Conditions:  Adjustment Disorder and Diabetes Mellitus.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  The diabetes mellitus condition was profiled; however the condition was adjudicated by the PEB as not medically unfitting.  Neither condition was implicated in the commander’s statement.  The adjustment disorder condition is not a condition constituting a disability.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for either of the contended conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the chronic left shoulder pain condition, the panel recommends a disability rating of 20%, coded 5201 IAW VASRD §4.71a.  In the matter of the chronic right shoulder pain condition, the panel recommends a disability rating of 10%, coded 5299-5201 IAW VASRD §4.71a.  In the matter of the chronic low back pain condition, the panel recommends a disability rating of 10%, coded 5299-5237 IAW VASRD §4.71a.  In the matter of the chronic neck pain condition, the panel recommends a disability rating of 10%, coded 5242 IAW VASRD §4.71a.  In the matter of the contended adjustment disorder and diabetes mellitus conditions, 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 that 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	
Left Shoulder Pain	5201	20%	
Right Shoulder Pain	5299-5201	10%	
Low Back Pain	5299-5237	10%	
Chronic Neck Pain	5242	10%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170508, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180006238, 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 40% 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), XXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs 

Sincerely,					      
Enclosure