RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE: PD-2017-04081 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20071217

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Helicopter Repairman, medically separated for “right shoulder pain” and “L5-S1 fusion,” with a combined disability rating of 10%.

CI CONTENTION: “I would like all of my service connected complaints to be re-evaluated.” 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 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 - 20071121	VARD - 20080328	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder Pain	5099-5003	10%	Residuals, Right Shoulder Injury	5299-5203	20%	20080124	
L5-S1 Fusion	5241	0%	Degenerative Disc Disease Lumbar Spine, L5-S1 Fusion	5242	10%	20080124	
Sleep Apnea	Not Unfit	Obstructive Sleep Apnea	6847	0%	20080124	
Left Knee Pain	Not Unfit	Residuals, Left Knee Injury	5260	0%	20080124	
Adjustment Disorder with Anxiety Features	Does Not Constitute a Disability	Adjustment Disorder with Anxiety	9440	10%	20080117	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 40%	

ANALYSIS SUMMARY:

Right Shoulder Pain. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent surgery in March of 2007 to repair a right shoulder labral tear and bone spur. At the orthopedic follow-up on 10 May 2007, 7 months prior to separation, physical examination showed full range of motion (ROM) with “minor discomfort” on extremes of motion, without instability. During the 30 October 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months before separation, the examiner documented anterior shoulder tenderness and full right shoulder ROM. At the MEB NARSUM examination the same day, the CI complained of shoulder pain, rated at 5/10, which disturbed sleep. He reported pain with extension or abduction of the arm and difficulty working at a computer or picking up his children.  Physical examination repeated findings from the MEB examination and shoulder ROM

measurements showed forward flexion to 180 degrees (normal) and abduction to 180 degrees (normal).

At the 24 January 2008 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported mild chronic right shoulder pain since surgery. Overhead and lifting activities caused flares, but he denied any swelling, locking, subluxation, dislocations, weakness, or restricted ROM. Physical examination showed mild tenderness over the right anterior shoulder, but no evidence of redness, swelling, or heat. Ligaments were tight without laxity on stress testing in any direction; impingement testing was positive. Shoulder flexion was to 180 degrees and abduction to 100 degrees, with pain at extreme ROM in all planes. Deluca factors were negative on repetitive motion testing.  Right shoulder X-rays were unremarkable.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the right shoulder condition 10%, analogously coded 5099-5003 (arthritis, degenerative), citing criteria of the US Army Physical Disability Agency pain policy. The VA rated the right shoulder condition 20%, analogously coded 5299-5003 (arthritis, degenerative) based on the C&P examination, citing abduction limited to almost shoulder level secondary to pain. Panel members noted that the VASRD §4.71a threshold for rating ROM impairment under code 5201 is “at shoulder level” (approximately 90 degrees from the side), and the preponderance of examinations in record demonstrated motion above this level. However, 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 code 5202 code (humerus, other impairment of); and no nonunion with loose movement of the clavicle to warrant the next higher 20% rating under code 5203 (clavicle or scapula, impairment of). The panel noted that the PEB’s reliance on the pain policy was not detrimental to arriving at the highest rating and no change to the PEB’s coding choice is recommended. 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.

L5-S1 Fusion. According to the STR and MEB NARSUM, the CI underwent an L5-S1 fusion in January 2007. Despite post-operative improvement, he continued to report low back pain and was unable to perform all military duties. At the MEB examination he reported ongoing low back pain for 10 years, and the examiner documented slightly decreased flexion. During the MEB NARSUM examination, the CI reported dull, aching, back pain with exacerbation from any activity. Physical examination showed normal gait and spinal curvature, and no back tenderness, spasm or guarding. Thoracolumbar forward flexion was to 65 degrees (normal 90) and combined ROM was 210 degrees (normal 240) after three repetitions, with painful motion.

At the VA C&P examination, the CI described intermittent painful flare-ups averaging 1-2 episodes a week, and exacerbated by heavy lifting activities. No additional weakness or restricted ROM was reported with flare-ups and there were no incapacitating episodes over the previous 12 months. He did not use any assistive devices and took no medication to treat the back pain. Physical examination noted a normal gait and spinal alignment with no spasm or tenderness. Back ROM revealed forward flexion to 90 degrees, with endpoint pain, and combined ROM of 220 degrees.  Deluca factors were negative upon repetitive motion testing.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the low back condition 0%, coded 5241 (spinal fusion), citing no evidence of motor neurologic deficit, forward flexion of 65 degrees limited by pain, and no tenderness, spasm, guarding, or abnormal gait. The VA rated the low back condition 10%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination, citing painful or limited motion of a major joint or group of minor joints. Panel members 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 all

examinations proximate to separation. 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 recommends a disability rating of 10% for the low back condition, coded 5241.

Contended PEB Conditions: Sleep Apnea, Left Knee Pain, Adjustment Disorder With Anxiety Features. The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting. The contended conditions were not profiled or implicated in the commander’s statement, and did not 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 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 L5-S1 fusion condition, the panel recommends a disability rating of 10%, coded 5241 IAW VASRD §4.71a. In the matter of the contended conditions, the panel majority 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 the CI’s prior determination be modified as follows, effective the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Right Shoulder Pain	5099-5003	10%	
L5-S1 Fusion	5241	10%	
	COMBINED	20%	

DEPARTMENT OF THE ARMY
ARMY REVIEW BOARDS AGENCY 251 18TH STREET SOUTH, SUITE 385
ARLINGTON, VA 22202-3531

AR20200000303, 

Dear XXXXXXXXXXXXXX
The Department of Defense Physical Disability Board of Review (DoD PDBR)
reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability. I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation. This will not result in any change to your separation document or the amount of severance pay. A copy of this decision will be filed with your Physical Evaluation Board records. I regret that the facts of the case did not provide you with the outcome you may have desired.

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.

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

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