RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX XXX	CASE:  PD-2017-05829
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060712

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Signals Analyst, medically separated for “chronic thoracolumbar pain” and “left shoulder pain,” rated 10% and 0%, respectively, with a combined disability rating of 10%.  

CI CONTENTION:  Review requested 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 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 - 20060328	VARD - 20070425	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Thoracolumbar Pain	5237	10%	Thoracolumbar Strain	5010-5237	0%	20060907	
Left Shoulder Pain	5099-5003	0%	S/P Repair of Left Shoulder AC Joint	5299-5203	10%	20060907	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Low Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s condition began in 2003 after awakening with back pain with no specific injury.  MRI of the thoracic spine on 30 August 2005 revealed minimal degenerative Schmorl’s nodes at multiple levels.  The 17 January 2006 MEB NARSUM examination, 6 months prior to separation, noted complaints of low back pain.  Physical examination showed a large amount of parathoracic and lumbar spasm was present.  Strength was 5/5.  Thoracolumbar range of motion (ROM) measurements performed by physical therapy (PT) on 23 January 2006, 6 months prior to separation, showed flexion of 85 degrees (normal 90) and combined ROM of 195 degrees (normal 240) after repetition.  Painful motion was noted.  

At the 7 September 2006 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported intermittent back pain with remissions.  Physical examination showed a normal gait.  Thoracolumbar ROM showed flexion of 90 degrees and combined ROM of 240 degrees.  Deep tendon reflexes were 2+ (normal).  Imaging revealed a normal thoracic and lumbar spine.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5237 (lumbosacral strain), citing tenderness, ROM limited by pain alone, and non-deformity muscle spasm noted on examination.  The VA rated the low back condition 0%, dual coded 5010-5237 (arthritis due to trauma-lumbosacral strain), based on the C&P examination, citing no abnormality of the back noted upon physical examination.  

The panel 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 the MEB PT ROM examination.  Painful motion and spasm (without abnormal gait or contour) alternatively supported the 10% rating.  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 right-handed CI underwent left shoulder surgery in January 2005 (capsular shift and distal clavicle resection) for instability and arthritis.  At the time of the PT clinic appointment on 26 August 2005, 11 months prior to separation, the CI reported his left shoulder was “much improved.”  Left shoulder ROM after repetition showed flexion of 185 degrees (normal 180) and abduction of 168 degrees (normal 180).  Painful motion was noted.  Strength was 3/5.  The 17 January 2006 MEB NARSUM examination, 6 months prior to separation, noted complaints of left shoulder pain.  Physical examination revealed full ROM and normal strength, but with obvious discomfort.  Left shoulder ROM measurements performed by PT on 23 January 2006 (6 months prior to separation) showed flexion of 169 degrees and abduction of 125 degrees after repetition.  Painful motion was noted.  

At the 7 September 2006 C&P examination, 2 months after separation, the CI reported intermittent left shoulder pain with remissions.  Physical examination showed left shoulder muscle weakness.  There was no muscle spasm, tenderness or joint swelling.  Left shoulder ROM showed flexion of 180 degrees and abduction of 180 degrees.  Painful motion was noted with internal and external rotation.  Imaging showed the left shoulder with widening of the AC joint as a result of probable amputation of the distal end of the clavicle but the space between the acromion and the humeral head was maintained with a final impression of “within normal limits.”  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 0%, analogously coded 5003 (degenerative arthritis), citing “residual pain without significant loss of joint motion but with painful motion… rated as analogous to degenerative arthritis without significant loss of joint motion” with likely application of AR 635-40, B-29 (in effect at the time), which indicated “ratings for loss of joint motion can only be awarded where a mechanical basis for limited motion is found,” and not joint pain resulting in loss of motion.  The VA rated the left shoulder condition 10%, analogously coded 5203 (clavicle or scapula, impairment), based on the C&P examination, citing objective evidence of painful motion.  

The VASRD §4.71a threshold for rating for ROM impairment (code 5201, arm limitation of motion) is “at shoulder level” (approximately 90 degrees from the side), and the examinations in evidence demonstrated motion above this level.  However, panel members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion).  There was no malunion or recurrent dislocation of the humerus and no dislocation or nonunion of the clavicle or scapula with loose movement to justify a higher rating under the 5202 (humerus, other impairment) or 5203 (clavicle or scapula, impairment) codes.  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 5099-5003.  

BOARD FINDINGS:  In the matter of the chronic thoracolumbar pain 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 10%, coded 5099-5003 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, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Thoracolumbar Pain	5237	10%	
Left Shoulder Pain	5099-5003	10%	
COMBINED	20%	

AR20200004553,

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.