RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXX		CASE: PD-2017-03738 BRANCH OF SERVICE: MARINE CORPS	SEPARATION DATE: 20050331

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Amphibious Assault Vehicle Repairman, medically separated for “cervical radiculopathy” and “left shoulder impingement,” rated 10% each with a combined disability rating of 20%.

CI CONTENTION: “Conditions were more serious than previously recorded, as well as existing conditions at the time that were not recorded.” 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 - 20050112	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cervical Radiculopathy	5237	10%	No VA Examination Proximate to Separation in Evidence	
Left Shoulder Impingement	5099-5003	10%		
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: NA	

ANALYSIS SUMMARY:

Cervical Radiculopathy. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s cervical radiculopathy began in July 2003 with no specific trauma or injury indicated. During the 20 August 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, the CI reported a “neck injury.” The physical examination (PE) revealed paraspinal muscle tenderness and decreased (unquantified) range of motion (ROM) of the neck.

At the 9 November 2004 MEB NARSUM examination, 5 months prior to separation, the CI’s chief complaint included “neck pain.” The CI endorsed having intermittent numbness and altered sensation extending into his left arm. An MRI of the cervical spine obtained on 1 Aug 2003 showed mild degenerative disc changes throughout the neck with narrowing of the left-sided nerve-exiting canal at the level of C3-C4. The PE revealed normal ROM of the cervical spine except for right rotation which measured to 60 degrees (normal 80). The combined ROM was 320 degrees (normal 340). There was no comment with regards to painful motion. Tenderness about the cervical spine was present. There was no VA examination proximate to separation in evidence. The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the cervical radiculopathy 10%, coded 5237 (cervical strain).

Absent any significant degree of motion limitation, panel members agreed that a maximum of a 10% impairment rating was supported by evidence of persistent tenderness about the cervical spine. There was no muscle spasm or guarding severe enough to result in an abnormal 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 that 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 cervical radiculopathy condition.

Left Shoulder Impingement. According to the STR and MEB NARSUM, the CI’s left (dominant) shoulder condition also began in July 2003 without a specific traumatic incident. The MEB NARSUM examination, noted complaints of left shoulder pain. Due to conditions of a multi- factorial nature to include the left shoulder, the provider noted the following: “[The CI] is not able to complete his daily work, group hikes, or company runs as required in his MOS. He is not able to perform any type of impact physical training, and is not able to run and pass a physical fitness test. He is not able to walk or stand without pain.” The PE revealed an impingement within the left shoulder noting ROM to 90 degrees both in flexion and abduction (normal each 180). The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the left shoulder condition 10%, analogously coded 5099-5003 (degenerative arthritis). Having no VA examination proximate to separation nor clinical STR data within one year prior to separation, the panel’s probative value was exclusively apportioned to the MEB NARSUM examination. The ROM of 90 degrees of abduction clearly supported the VASRD criteria of “at shoulder level” for the sole and maximum rating of 20%. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the left shoulder condition, coded 5201 (arm, limitation of motion).

BOARD FINDINGS: In the matter of the cervical radiculopathy and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. In the matter of the left shoulder condition, the panel recommends a disability rating of 20%, coded 5201 IAW VASRD §4.71a. 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	
Cervical Radiculopathy	5237	10%	
Left Shoulder Impingement	5201	20%	
	COMBINED	30%	

DEPARTMENT OF THE NAVY
SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309
WASHINGTON NAVY YARD, DC 20374-5023

IN REPLY REFER TO
6040
CORB:003 14 May 21

From: Director, Secretary of the Navy Council of Review Boards To:	XXXXXXXXXXXXXX

Subj:	Physical Disability Board of Review Determination Ref:	(a) 6040.44(Series)
1.	The Physical Disability Board of Review (PBDR) reviewed your case in accordance with reference
(a) and forwarded their recommendation for action.

2.	On 23 April 2021 the Assistant Secretary of the Navy (Manpower and Reserve Affairs) accepted the PDBR’s recommendation of an increase in disability rating to 30% and placement on the Permanent Disability Retired List. This decision was then sent to Navy Personnel Command for appropriate action.

3.	The PDBR determination is final and not subject to appeal or review.