SAF/MRBD (PDBR)
3351 Celmers Lane
JBA NAF Washington, MD 20762-6435

MEMORANDUM FOR THE DIRECTOR, AIR FORCE REVIEW BOARDS AGENCY

SUBJECT:  Physical Disability Board of Review Recommendation on 
	Case Number PD-2019-00151

	In accordance with Title 10 § 1554a and in compliance with DoDI 6040.44, the Physical Disability Board of Review (PDBR) adjudicated the disability rating accompanying the medical separation of the covered individual from the United States Air Force.  After carefully reviewing the application and medical separation case file, the PDBR recommended no re-characterization of the separation or modification of the disability rating previously assigned.  I recommend you accept this proposed decision.

The covered individual (CI) was a Reserve O3, Security Forces Officer, medically separated for “chronic low back pain…” and “right shoulder pain…” rated 10% each, with a combined disability rating of 20%.  The PEB coded the back condition 5295 (lumbosacral strain).  The VA also rated the back at 10%, but used the 5293 code (intervertebral disc syndrome) based on the Compensation and Pension (C&P) examination.  Panel members agreed no more than a 10% rating was supported for mild limitation of lumbar spine motion (5292) and there was no evidence of separately ratable limitation of dorsal spine motion (5291).  There was no evidence to support higher than a 10% rating for separately ratable mild neurologic impairment of the left lower extremity, coded 5293 (intervertebral disc syndrome).  Although the neurosurgeon and orthopedic surgeons indicated a 20% rating was supported for the CI’s tendency to back spasms due to his condition, there was no indication of frequent muscle spasms in the STR and no muscle spasm was present at the MEB narrative summary or VA examinations proximate to separation.  Although the panel acknowledges muscle spasms of the lumbar spine due to instability were an ongoing concern with the CI’s back condition, there was no objective evidence to support the 20% rating under code 5295 at the time of separation.  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.

In the matter of the right shoulder condition, the PEB coded 5304 (Muscle Group IV, intrinsic muscles of the shoulder girdle).  The VA rated the right shoulder at 0%, but coded 5010-5203 (arthritis due to trauma – impairment of clavicle or scapula), based on the C&P examination, citing “a higher evaluation is not warranted unless there is malunion or nonunion of the clavicle or scapula.”  There was no limitation of motion of the shoulder to support a rating under diagnostic code 5201 (arm, limitation of motion).  A 10% rating was supported coded 5399-5304 (analogous to Group IV muscle injury-includes muscles of shoulder involved in stabilization of the head of the humerus in the socket) for moderate muscle injury.  Although there was a note stating the CI had experienced a dislocation of the right shoulder on 19 October 2002, there was no information available in record to support a higher rating for infrequent dislocations and guarding of movement at shoulder level.  Panel members considered other shoulder and analogous codes but each was less applicable or not advantageous to rating. 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.  

In the matter of the contended history of renal calculi, 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 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 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.  	

SAF/MRB
3351 Celmers Lane
JBA NAF Washington, MD 20762-6435

Dear XXXXXXXXXXXXXXXXXXX

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2019-00151.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no rating modification or re-characterization of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that modification of your disability rating or characterization of your separation is not warranted.  Accordingly, I accept the recommendation that your application be denied.