RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03581
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090511

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E5, Power Generator Equipment Repairer, medically separated for “lumbosacral strain” and “left shoulder pain,” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  His conditions have worsened.  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 - 20090224	VARD - 20100511	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbosacral Strain 	5237	10%	Chronic Lumbosacral Strain	5237	10%	20091015	
Left Shoulder Pain 	5099-5003	10%	Residual of Left Shoulder AC Separation with Reconstruction Surgical Repair	5201	20%	20091015	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Lumbosacral Strain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s lumbosacral strain with chronic back pain began in 1986 when he fell out of a helicopter.  He was treated with physical therapy and fully recovered by the early 1990’s.  In 2006, he twisted his back and felt pain during training.  Over the following days, the pain gradually worsened.  After several weeks of rest, he began physical therapy and was found to have a left shoulder injury.  An MRI and X-rays of the lumbar spine were normal.  No surgery was indicated.  Despite physical therapy, which increased some of the strength and range of motion (ROM) to the back, the pain continued.  

The 7 January 2009 MEB NARSUM examination, 4 months prior to separation, noted complaints of back pain that was always present and located in the lower back on the right side more than the left.  Pain intensity was reported at 6/10 and described as a dull ache.  Movement caused sharp pain.  Physical examination showed ROM of the thoracolumbar spine as flexion at 90 degrees (normal) with some increased pain with repetitions; extension was 40 degrees (normal 30) with a slight increase in pain with repetition; left lateral flexion was 35 degrees (normal 30); right lateral flexion 25 degrees (normal 30) with increased pain on repetition; left lateral rotation 30 degrees (normal 30); and right rotation 25 degrees (normal 30).  The combined range of motion was 230 degrees (normal 240).  No fatigue, weakness, lack of endurance, or incoordination was reported with repetition.  

At the 15 October 2009 VA Compensation and Pension (C&P) examination, 5 months after separation, the CI reported his low back pain increased with frequent bending, lifting weights more than 20 pounds, and prolonged sitting, standing, and walking.  Pain radiated to the left lower extremity with occasional tingling and numbness reported.  No paralysis or weakness of the lower extremities was present.  Physical examination showed minimal tenderness over the lower lumbar spine.  Alignment was normal.  No paraspinal muscle spasms were present.  ROM showed flexion at 70 degrees, extension of 15 degrees, right and left lateral flexion 20 degrees each, right and left rotation 25 degrees each.  There was no painful motion, limitation, or atrophy.  Muscle strength, sensation, and deep tendons were intact.  Gait was normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain), citing mild tenderness and spasm with flexion to 90 degrees and pain increasing with repeated use without loss of motion.  The VA also rated the back condition 10%, coded 5237, based on the C&P examination, citing spine ROM.  

The panel agreed that a 10% rating, but no higher, was justified for combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the NARSUM and VA examinations.  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 concluded there was insufficient cause to recommend a change in the PEB adjudication for the lumbosacral strain condition.  

Left Shoulder (Non-Dominant) Pain.  According to the STR and MEB NARSUM, while the CI was doing physical therapy for his back, it was discovered the left clavicle was fractured and required surgery.  In March 2007, the CI underwent acromioclavicular (AC) reconstructive surgery and rehabilitation; however, pain and numbness to the anterior shoulder remained.  

At the MEB NARSUM the CI reported persistent pain and tenderness over the left AC area.  Grip strength was 5/5 bilaterally.  Pain was rated at 5/10 at rest and aggravated by any activity that required him to lift his arm above the shoulder level, complete overhead activity, or lift greater 15 to 20 pounds.  Physical examination showed flexion of 150 degrees (normal 180) and abduction of 144 degrees (normal 180).  Measurements were taken with a goniometer.  Sensation/light touch was decreased to the anterior shoulder from mid clavicle to the top of the acromion.  Grip strength was 5/5.  

At the C&P examination the CI reported daily pain with intensity of 7/10 which occurred whenever he raised his left arm above shoulder level or handled weights more than 10 pounds.  Physical examination showed no obvious drooping, swelling, inflammation, redness, or warmness.  ROM showed limited abduction of 100 degrees and forward elevation of 120 degrees.  Muscle power was normal.  No braces or slings were required.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 10%, analogously coded 5009-5003 (arthritis, degenerative) citing painful motion.  The VA rated the left shoulder condition 20%, coded 5201 (arm, limitation of motion of), based on the C&P examination, citing minimal vague tenderness to the left shoulder with 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 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 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.  

BOARD FINDINGS:  In the matter of the lumbosacral strain condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the left shoulder condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  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.  

AR20180015293, 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.