RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX		CASE: PD-2017-05136 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20070201

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E7, Cannon Crewmember, medically separated for “chronic low back pain” and “chronic left shoulder pain,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION: No specific contention was made. 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 - 20061205	VARD - 20071101	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5235	10%	Low Back Pain and T-12 Traumatic Compression Fracture	5235	10%	20071210	
Chronic Left Shoulder Pain	5099-5003	0%	Bilateral Shoulder Rotator Cuff
Strain/Partial Tears	5299-5201	0%	20070913	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 20%	

ANALYSIS SUMMARY:

Low Back Pain. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s low back condition began in April 2006 after a motor vehicle roll-over accident. Spine X-rays in September 2006 revealed a stable anterior wedge fracture of T-12. The 10 October 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of persistent back pain, rated from 3-5/10, with slight radiation from the lower thoracic to the lumbar area, but not to the legs. Physical examination showed mid back tenderness, but normal posture and gait with no spasm. Thoracolumbar range of motion (ROM) measurements showed flexion of 75 degrees (normal 90) and a combined ROM of 160 degrees (normal 240) after repetition, limited by pain in all planes.

At the 10 December 2007 VA Compensation and Pension (C&P) examination, 10 months after separation, the CI reported constant thoracic pain, rated at 6/10, with no radiation. Physical

examination revealed no tenderness, with thoracolumbar flexion of 90 degrees and combined ROM of 240 degrees. There was no additional limitation after repetitive movement.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the low back condition 10%, coded 5235 (vertebral fracture or dislocation), citing pain limited ROM. The VA also rated the low back condition 10%, coded 5235, based on the C&P examination, citing thoracolumbar flexion greater than 60 degrees but not greater than 85 degrees. Panel members agreed that a 10% rating, but no higher, was justified for limitation of flexion as reported on the NARSUM examination 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 concluded there was insufficient cause to recommend a change in the PEB adjudication for the low back condition.

Left Shoulder Pain. According to the STR and MEB NARSUM, the CI’s shoulder condition began in December 2004, while carrying heavy loads during training. He also slipped and fell, and heard a "pop.” Orthopedic evaluations in January and April 2006 showed normal and full ROM, as did a physical therapy examination accomplished one month later. An MRI in March 2006 revealed a small articular surface tear of the supraspinatus tendon, mild acromioclavicular degenerative disease, and mild bursitis.

The MEB NARSUM examination noted CI complaints of weakness due to the pain, but no swelling, redness, instability, giving way, locking, fatigability, or lack of endurance. The left shoulder pain, rated at 0-4/10, lasted most of the day. Physical examination showed tenderness at the acromioclavicular joint, and after repetition, left shoulder flexion was to 104 degrees (normal
180) and abduction to 90 degrees (normal 180). At the VA C&P examination, the CI reported pain rated at 6-7/10 about 80% of the time. Left shoulder ROM, following repetitive movement, revealed flexion as well as abduction to 180 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 no significant loss of joint motion. The VA rated bilateral shoulder rotator cuff strain/partial tears 0%, analogously coded 5299-5201 (arm, limitation of motion of), based on the C&P examination, citing a non-compensable evaluation because arm motion was not limited at shoulder level. While the limitation of shoulder abduction recorded in the MEB NARSUM met the threshold for a 20% rating, the panel majority agreed that the orthopedic and physical therapy evaluations were consistent with VA ROM measurements, and thus placed greater probative value on that examination. The VA examiner did not document any limitation of shoulder motion, swelling, muscle spasm, or satisfactory evidence of painful motion or functional loss to support a 10% rating IAW VASRD §4.59, §4.40 or §4.45. There was no malunion, deformity, or recurrent dislocation of the humerus to justify a rating under code 5202 (humerus, other impairment of); and no nonunion or malunion of the clavicle or scapula to warrant any rating under code 5203 (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 low back 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 majority recommends no change in the PEB adjudication. The single voter for dissent recommends modification to 20% and did not elect to submit a minority

opinion. 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.

Dear XXXXXXXXXXXXXX:
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.

A copy of this decision has been provided to the counsel you listed on your application.

Sincerely,

Enclosure