RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXXX	CASE: PD-2017-04090
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20050317

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Motor Transport Operator, medically separated for “chronic neck pain with degenerative disc disease [DDD]” and “left shoulder pain” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION: Review requested of neck and shoulder conditions, which continue to impair employment and daily activities, as well as additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB) was requested. 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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20041124	VARD - 20050406	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain With DDD	5237	10%	Cervical Spine DDD	5242	10%	20040920	
Left Shoulder Pain	5099-5003	0%	Residual of Left Shoulder Surgery	5201-5010	10%	20040920	
Cubital Tunnel Syndrome, Left	Medically Acceptable	Left Hand Paresthesias	8599-8516	10%	20040920	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 40%	
	
ANALYSIS SUMMARY:

Chronic Neck Pain and Left Shoulder Pain. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI injured his neck and shoulder when he fell from a tower in June 2002 and collided with a board on the way down, landing on his outstretched left (non-dominant) arm. He was treated conservatively, but the pain continued.  An MRI of the neck

revealed disc bulges with some neural foraminal compression at C4-C5. Neurosurgery evaluated reported left-sided weakness, but findings were essentially negative as were nerve conduction studies. The conditions were determined to be non-surgical and conservative treatment continued. During this time, an orthopedist opined that the CI had developed a shoulder condition rather than the left shoulder pain being related to the cervical disc condition. A shoulder MRI revealed a labral tear with instability, and in July 2003, he underwent an anterior acromionectomy to repair the labral detachment. Physical therapy continued for the neck and the shoulder pain without significant improvement. Radiographic studies showed a C5-6 left paracentral disc bulge with minimal impression on the ventral aspect of the thecal sac with C6-7 large disc protrusion and moderate right neural foraminal stenosis.

Chronic Neck Pain. At the 20 September 2004 VA Compensation and Pension (C&P) examination, 6 months before separation, the CI reported moderately severe neck pain 75-100% of the time, and that he was unable to carry or fire a weapon, or move with a fighting load. Physical examination showed moderate cervical spine tenderness, but normal posture, gait and spinal contour. There was decreased extension and right lateral rotation (no measurements provided). A cervical spine MRI in April 2003 revealed multilevel disc disease at C4-5, C5-6 and C6-7. The  12 October 2004 MEB NARSUM examination, 5 months before separation, noted complaints of left trapezius pain and decreased cervical range of motion (ROM). The 19 October 2004 physical therapy (PT) MEB ROM evaluation revealed cervical flexion of 35 degrees (normal 45) and combined ROM of 220 degrees (normal 340).

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the neck condition 10%, coded 5237 (cervical strain), citing passive flexion at 75-80 degrees with no focal neurological deficits. The VA also rated the neck condition 10%, but coded 5242 (degenerative arthritis of the spine), based on the C&P examination, citing forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees. Panel members agreed that a 10% rating, but no higher, was justified for limitation of flexion as reported on the PT MEB examination, or tenderness as recorded during the VA examination. 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 chronic neck condition.

Left Shoulder Pain. At the occupational therapy evaluation on 27 July 2004, 8 months prior to separation, the CI had significantly decreased grip strength with severe left shoulder pain. The examiner indicated functional status was at 40%m and left shoulder ROM tests showed flexion at 160 degrees (normal 180) with abduction at 160 degrees (normal 180).

At the C&P examination, the CI reported persistent low grade soreness, rated at 4/10, which increased with activity to a “knifelike” pain in the top and anterior aspect of the shoulder. Physical examination showed an inability to move the left shoulder above 130 degrees of flexion and 90 degrees of abduction. Tenderness was noted in the left acromioclavicular joint and there was crepitus with ROM testing Left shoulder X-rays in August 2002 revealed narrowing of the shoulder joint space with early degenerative changes.

The MEB NARSUM examination noted CI complaints of shoulder pain not improved with conservative treatment. Left shoulder flexion was to 120 degrees and abduction to 100 degrees, with considerable discomfort noted during passive abduction. The PT MEB ROM evaluation revealed left shoulder flexion of 130 degrees and abduction of 127 degrees.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the left shoulder condition 0%, analogously coded 5099-5003 (degenerative arthritis) citing passive abduction to 125 degrees with no focal neurovascular deficits. The VA rated the left shoulder condition 10%, dual coded 5201-5010 (arm, limitation of motion-arthritis, due to trauma) based on the C&P examination, citing painful or limited motion of a major joint or group of minor joints. Panel members noted that the VASRD §4.71a threshold for rating ROM impairment under code 5201 (arm limitation of motion) is “at shoulder level” (approximately 90 degrees from the side). Although the VA abduction measurement may have supported the 20% criteria, the MEB NARSUM and PT examinations had greater probative value as they were closest to separation, and documented ROM above this level. However, the panel agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion) under code 5010, or alternatively under code 5203 (clavicle or scapula, impairment of) for partial clavicle resection. There was no malunion or recurrent dislocation of the humerus to justify a rating under code 5202 (humerus, other impairment of); and no nonunion with loose movement of the clavicle to warrant the next higher 20% rating under code 5203. 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 left shoulder condition, coded 5010-5203.

Contended PEB Condition: Cubital Tunnel Syndrome (CTS) on the Left. The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting. The contended condition was profiled U3 for “left elbow painful olecranon spur,” and left hand problems and left arm weakness were implicated in the commander’s statement, but the MEB diagnosis of left CTS did not fail retention standards. The VA examination, NARSUM, and STR indicated intermittent left elbow pain and intermittent paresthesias of the left hand. Neurology considered the left upper extremity symptoms most likely cervical radiculopathy rather than CTS from the left elbow spur, and nerve conduction studies were negative. The VA examination showed a strong hand grasp, tenderness in the ulnar notch and left thumb decreased light touch. The NARSUM noted complaints “of chronic decreased sensation on the ulnar aspect of the left hand and intermittently at the thenar eminence of the left hand. These are intermittent and considered related to a mild cubital tunnel syndrome on the left, as well as radiculopathy secondary to the irritation of foraminal stenosis as noted in the MRI. There were findings of a positive Tinel's sign at the left elbow (for nerve irritation) with radiation to the forearm. This again is intermittent.” The NARSUM examiner indicated the CTS was medically acceptable. The panel considered the CI’s unfitting neck and left shoulder conditions likely overlapped with the left elbow and distal left upper extremity symptoms.

While the CI may have suffered additional pain from either the cervical or ulnar nerve involvement, any cervical nerve pain is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).” Therefore the critical decision is whether or not there was a significant neurologic impairment which would impact military occupation-specific activities. Proximate to separation, there was no evidence of hand or lower arm weakness or that other any other neurologic abnormality existed to any degree that could be described as functionally impairing. The panel therefore concluded there was insufficient evidence to find the left CTS additionally unfitting. There was no performance-based evidence from the record that the condition 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 the contended condition, so no additional disability rating is recommended.

BOARD FINDINGS: In the matter of the neck condition and IAW VASRD §4.71, the panel recommends no change in the PEB adjudication. In the matter of the left shoulder condition, the panel recommends a disability rating of 10%, coded 5010-5203 IAW VASRD §4.71a. In the matter

of the contended left cubital tunnel syndrome, the panel agrees it cannot recommend it for additional disability rating.

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Neck Pain	5237	10%	
Left Shoulder Pain	5010-5203	10%	
	COMBINED	20%	

PD-2017-04090

AR20190012034, XXXXXXXXXXXXXXXXXX 

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. 

PD-2017-04090