RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-05736
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20060608

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E5, Motor Transport Operator, medically separated for “chronic back pain” and “left sternoclavicular arthrosis,” rated 10% and 0%, respectively, with a combined disability rating of 10%.  

CI CONTENTION:  The CI requests the panel review the back rating, shoulder condition, gastrointestinal injuries and anxiety.  The CI requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 - 20060505	VARD - 20070306	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5299-5237	10%	L4 Spondylolysis	5010-5243	10%	20070217	
Left Sternoclavicular Arthrosis	5003	0%	Post Traumatic Arthritis Left Sternoclavicular Joint	5201	10%	20070217	
Hematemesis And Persistent Vomiting Status Post EGD	Not Unfitting	Grade II Esophagitis With Esophageal Ulcer	7399-7346	0%	20070216	
Acute Stress Disorder	Not Unfitting	Acute Stress Disorder	9499-9411	NSC	20070216	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20% 	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began in May 2004 after a motor vehicle accident while deployed.  X-rays showed L4 spondylolysis (stress fracture of the pars interarticularis) and disc space narrowing with spurring at L5-S1.  A lumbar spine MRI showed shallow disc bulges without herniation at L4-5 and L5-S1 and bilateral facet hypertrophy at L3 through S1.  The electrodiagnostic study was normal.  Neurosurgery recommended a lumbar fusion which the CI did not wish to undergo.  Additional therapy did not result in the CI’s return to unrestricted activity.  

At the 30 June 2005 orthopedics sports medicine evaluation, 11 months prior to separation, the CI complained of a constant dull, achy pain in the lower back that was worse with sitting, bending and standing.  There was no radiation of pain.  Physical examination demonstrated normal gait and full range of motion (ROM).  

During the 17 January 2006 MEB physical examination (recorded on DD Form 2808), 5 months prior to separation, the examiner recorded ROM limited in flexion, rotation and lateral bending (without reporting measurements) due to pain.  The 16 February 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of low back pain that radiated to the right buttock.  The pain was constant and made worse with activity.  Physical examination cited ROM measurements from a 9 November 2005 physical therapy evaluation which demonstrated forward flexion to 40 degrees (normal 90) with significant pain and combined ROM of 165 degrees (normal 240).  

A 16 March 2006 pain center evaluation, 3 months prior to separation, recorded complaints of a constant dull aching back pain that became worse with activity, but without radiation.  Physical examination established a normal gait and “decreased” ROM in the lumbar spine in all directions “especially with posterior extension,” again without reporting measurements.  There was “exquisite” tenderness of the paraspinal tissues of the lumbosacral region bilaterally.  

At the 17 February 2007 VA Compensation and Pension (C&P) examination, 8 months after separation, the CI reported daily low back pain without radiation.  He denied exacerbations that required bed rest.  He was unable to walk long distances due to back pain.  Physical examination showed tenderness to palpation in the L5-S1 area.  Forward flexion was to 90 degrees with pain beyond 70 degrees and combined ROM of 240 degrees.  There was no muscle spasm.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic back condition 10%, coded 5299-5237 (analogous to lumbosacral strain), citing painful limitation of motion and localized tenderness.  The VA also rated the back condition 10%, dual coded 5010-5243 (arthritis due to trauma - intervertebral disc syndrome), based on the C&P examination, citing painful motion.  

In assigning probative value to these somewhat conflicting examinations, members noted that the panel has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions nor to deduct for post-separation improvement in the condition.  The ROM values reported on the November 2005 physical therapy evaluation were more proximate to separation and significantly different from the VA examination.  

The panel agreed that a 20% rating, but no higher, was justified for limitation of flexion greater than 30 degrees but not greater than 60 degrees, as reported on the physical therapy examination.  There was no evidence of intervertebral disc syndrome resulting in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under that alternate VASRD formula.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the back condition, coded 5242 (degenerative arthritis of the spine).  

Left Sternoclavicular Arthrosis.  According to the STR and the MEB NARSUM, the CI’s left sternoclavicular joint condition began in 2004 after a vehicle accident while deployed.  A CT scan of the sternoclavicular joint in October 2005 displayed mild degenerative arthritic changes.  There was no surgical indication.  

The 16 February 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of pain, popping and crepitus in the sternoclavicular joint with movements of the left shoulder.  Physical examination cited ROM measurements from a 9 November 2005 physical therapy evaluation which showed forward flexion of the left shoulder to 158 degrees (normal 180) and abduction to 140 degrees (normal 180).  There was no mention of painful motion.  

At the 17 February 2007 VA Compensation and Pension (C&P) evaluation, 8 months after separation, the CI reported left shoulder pain with overhead motions for prolonged periods of time.  He also complained of popping and swelling about the sternoclavicular joint.  The CI stated that this pain did not significantly affect his daily life except with repetitive and overhead movements.  Physical examination demonstrated forward flexion to 150 degrees and abduction to 170 degrees.  The examiner noted popping and crepitus, accompanied by pain at the sternoclavicular joint, with motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left sternoclavicular condition 0%, coded 5003 (degenerative arthritis), citing no ratable limitation of motion.  The VA rated the left sternoclavicular condition 10%, coded 5201 (arm, limitation of motion of), based on the C&P examination, citing painful motion.  The VASRD threshold for a rating for ROM impairment (code 5201) is “at shoulder level” (90 degrees from the side), and the ROM measurements in evidence demonstrated motion above this level.  There was no malunion of the humerus; although there was a sense of subluxation there was no recurrent frank 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).  There was no demonstrable weakness of any of the rotator cuff muscles (Group IV muscles) to validate a rating using code 5304.  Finally, there was no evidence of painful motion in the examinations prior to separation to justify a minimum rating with application of VASRD §4.59 (painful motion).  After due deliberation, considering all of 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 sternoclavicular condition.  

Contended PEB Conditions:  Hematemesis, Persistent Vomiting Status Post EGD and Acute Stress Disorder.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled, implicated in the commander’s statement or judged to 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 that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the back condition, the panel recommends a disability rating of 20%, coded 5242 IAW VASRD §4.71a.  In the matter of the left sternoclavicular condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended hematemesis, persistent vomiting status post EGD and acute stress disorder, the panel 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 that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Back Pain	5242	20%	
Left Sternoclavicular Arthrosis	5003	0%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170803, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180010958, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

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.

Sincerely,					      
Enclosure