RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2020-00176
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070517

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E4, Health Care Specialist, medically separated for “low back pain,” “bilateral shoulder pain,” and “bilateral knee pain” rated 10%, 0% and 0%, respectively, with a combined disability rating of 10%.  

CI CONTENTION:  “PTSD Rating Increase. Linx device for GERD…”  The CI also requested review of an additional condition (CPAP machine) not identified by the Medical Evaluation Board (MEB) and/or 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 – 20070406	VARD - 20080416	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5237	10%	Spinal Stenosis L5-S1	5238	10%	STR
	
Bilateral Shoulder Pain	5099-5003	0%	Right Shoulder Pain (Major)	5201	NSC		
			Left Shoulder	5299-5203	NSC		
Bilateral Knee Pain	5099-5003	0%	Chondromalacia, Left Knee	5257	NSC		
			Chondromalacia, Right Knee	5260	NSC		
GERD	Not Unfitting	GERD	7399-7346	NSC		
Adjustment Disorder with Anxiety	Not Unfitting	Adjustment Disorder with Anxiety	9440	NSC		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:    

Low Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began in June 2005 while deployed.  A lumbar MRI on 22 March 2007 revealed a broad-based protrusion at L5-S1 with no significant canal stenosis and only mild neural foraminal stenosis on the left.  The exiting nerve root did not make contact and remaining levels were normal.  

During the February 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the examiner noted low back pain and tenderness with reported tingling down the left leg to the knee; range of motion (ROM) was limited due to pain.  The 2 March 2007 MEB physical therapy (PT) ROM test showed thoracolumbar flexion to 80 degrees (normal 90) and a combined ROM of 205 degrees (normal 240) after three repetitions.  

The 5 March 20007 MEB NARSUM examination, 2 months before separation, noted CI complaints of throbbing, shooting type pain that radiated into both legs just past the knees.  He rated resting pain at 3/10, but this increased with prolonged sitting or standing.  Physical examination showed a normal gait and spine appearance with no paraspinal muscle spasm, but there was diffuse tenderness to palpation in the L4-5 region.  The examiner referenced the MEB PT measurements and noted that while ROM was full, pain was elicited throughout testing.  There was no VA in evidence.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5237 (lumbar spine strain), citing full but painful ROM without radiculopathy or muscle spasms.  The VA also rated the back condition 10%, coded 5238 (spinal stenosis), based on STR.  The panel agreed a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the  MEB PT ROM 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, and there was no associated radiculopathy for separate peripheral nerve rating.  While the CI may have experienced radiating pain from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There was no objective evidence of a radiculopathy with functional impairment (such as weakness) that directly impacted fitness for duty.  The panel therefore concluded that an additional disability rating was not justified on this basis.  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 back condition.  

Bilateral Shoulder Pain.  According to the STR and MEB NARSUM, the CI experienced bilateral shoulder pain in June 2005 while deployed.  The pain occurred with increased activity and when wearing individual body armor as well as extra gear.  Although he had a left shoulder surgical decompression on 14 April 2006, followed by PT and activity modifications, the pain remained.  

The MEB examiner noted complaints of bilateral shoulder pain and decreased ROM, but did not document any measurements.  Bilateral shoulder X-rays on 2 March 2007 revealed findings suspicious but not conclusive for rotator cuff injury, with changes more pronounced on the left.  The MEB PT ROM test revealed left shoulder flexion to 176 degrees (normal 180) and abduction to 104 degrees (normal 180), after repetition and with painful motion. Right shoulder flexion and abduction were to 180 degrees after repetition and without objective evidence of painful motion.  

The MEB NARSUM examination documented complaints of stabbing shoulder pain, greater on the left than right, and worsened by overhead activity.  Physical examination showed normal appearance of both shoulders with full active ROM.  Pain was elicited during right shoulder Neer and Hawkins impingement tests and during left shoulder Neer testing.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB combined the right and left shoulders under a single disability rating, coded 5099-5003 (arthritis, degenerative), citing degenerative arthritis without loss of joint motion.  The VA did not service connect the right shoulder and continued to deny a connection until the decision became final on 21 April 2009.  The panel first considered whether each shoulder, having been de-coupled from the combined PEB adjudication, remained separately unfitting.  Both shoulders were profiled and failed retention standards, and the commander indicated the CI could not perform a number of military specialty tasks because of the conditions.  The panel concluded there was not a preponderance of evidence in the service records that overcame the presumption that the bundled shoulders were reasonably considered separately unfitting.  

The panel then considered its rating recommendation for each unfitting shoulder.  Although documented ROM did not meet the VASRD §4.71a threshold for impairment “at shoulder level” (approximately 90 degrees from the side) under code 5201 (arm limitation of motion), panel members agreed a 10% rating for the left shoulder was justified with application of VASRD §4.59 for limitation of motion due to pain noted at the PT examination.   However, a 10% was not justified for the right shoulder since there was full ROM and no objective evidence of painful motion.  The panel considered other VASRD shoulder and analogous codes, but all were less applicable and not advantageous for rating.  After due deliberation, considering all the evidence, the panel recommends a disability rating of 10% for the left shoulder condition and a 0% disability rating for the right shoulder condition, both coded 5003.  

Bilateral Knee Pain.  According to the STR and MEB NARSUM, the CI experienced bilateral knee pain while deployed in 2005.  The pain occurred with increased activity and when wearing individual body armor and extra gear.  

During the MEB examination, the CI reported knee pain and locking, and the provider noted complaints of pain with knee flexion.  Radiographic studies of both knees on 2 March 2007 were normal and showed no arthritis or structural abnormalities.  Rheumatology examination on 2 March noted full ROM and a normal gait.  

The MEB NARSUM recorded complaints of daily burning knee pain, which increased with stairs, squatting, running and prolonged sitting.  Physical examination showed a normal gait and muscle strength, with no edema or erythema, and no complaints of locking or giving way.  Pain was not elicited with motion, and McMurray’s testing was negative.  The examiner referred to the March 2007 PT ROM examination which showed left knee flexion to 132 degrees (normal 140) and extension to 0 degrees (normal); and right knee flexion to 130 degrees and extension to 0 degrees; there was no limitation due to pain.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB combined the right and left knees under a single disability rating, coded 5099-5003,  citing normal X-rays, full ROM, and rating analogous to degenerative arthritis without loss of joint motion.  The VA did not service connect the right shoulder and continued to deny a connection until the decision became final on 21 April 2009.  Both knees were profiled and failed retention standards, and the commander indicated the CI could not perform a number of military specialty tasks because of the conditions.  Panel members concluded there was not a preponderance of evidence in the service records which overcame the  presumption that the bundled knees were reasonably considered separately unfitting.  

The panel then considered its rating recommendation for each unfitting knee.  There was no objective evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) for either knee.  The panel considered other VASRD knee and analogous codes, but all were less applicable and not advantageous for rating.  No additional functional limitation was evidenced by the examinations.  Therefore, the panel concluded there was not sufficient evidence to support a rating higher than the 0% adjudicated by the PEB.  After due deliberation, considering all the evidence, the panel recommends a disability rating of 0% each for the right and left knee conditions, both coded 5099-5003.  

Contended PEB Conditions:  GERD and Adjustment Disorder with Anxiety (claimed as PTSD).  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement, and did not fail retention standards.  The psychiatry examination in March 2007 noted the CI met retention standards and was fit for duty for adjustment disorder with anxiety.  Additionally, at the time of separation, adjustment disorder was a condition not constituting a physical disability, IAW DoDI 1332.38.  Therefore, the panel has no basis for recommending it as unfitting.  

There was no performance-based evidence from the record that GERD 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 any of the contended conditions, so no additional disability ratings are recommended.  

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 bilateral shoulder condition, the panel recommends an unfitting left shoulder, rated 10% and an unfitting right shoulder, rated 0%, both coded 5003 IAW VASRD §4.71 .  In the matter of the bilateral knee condition, the panel recommends unfitting left and right knee conditions, each separately rated 0%, and both coded 5099-5003, IAW VASRD §4.71a.  In the matter of the contended GERD and adjustment disorder, the panel recommends no change from the PEB determination.  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	
Low Back Pain	5237	10%	
Right Shoulder Pain	5003	0%	
Left Shoulder Pain	5003	10%	
Right Knee Pain	5099-5003	0%	
Left Knee Pain	5099-5003	0%	
COMBINED	20%	

AR20210006356, XXXXXXXXXXXXXXX

Dear XXXXXXXXXX

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.