RECORD OF PROCEEDINGS
                     PHYSICAL DISABILITY BOARD OF REVIEW

NAME:                  BRANCH OF SERVICE: ARMY
CASE  NUMBER:    PD0900160                        SEPARATION   DATE:
20021106
BOARD DATE: 20110310
____________________________________________________________________________
__

SUMMARY OF CASE:  Data extracted  from  the  available  evidence  of  record
reflects that this covered individual (CI) was  an  active  duty  SSG  (95B,
Military Police) medically separated from the Army in  November  2002.   The
medical basis for  separation  was  low  back  pain,  neck  pain,  and  left
shoulder pain.  At his Medical Evaluation Board (MEB), the  low  back  pain,
cervical pain (with bilateral radicular symptoms)  and  left  shoulder  pain
were determined to be medically unacceptable IAW  AR  40-501.   Three  other
conditions (palpitations, atrial fibrillation,  and  left  foot  pain)  were
forwarded as medically acceptable conditions.  The CI was  referred  to  the
Physical Evaluation Board (PEB) and was found unfit for  continued  military
service due to low back pain, neck pain and shoulder  pain.   The  low  back
pain and neck pain were rated 10% each   and  the  left  shoulder  pain  was
rated 0%.  The CI accepted the  PEB  findings,  and  was  separated  at  20%
combined disability using the Veterans Administration  Schedule  for  Rating
Disabilities (VASRD) and applicable Army and DoD regulations.
____________________________________________________________________________
_________

CI’s CONTENTION:  The CI states, “I have  4  disqualifying  conditions  that
should be rated, as these conditions made me unfit for duty  as  established
by law: 1) L5-SI disc herniations and discectomy; 2) C5-C6  herniation  pain
with bilateral  radicular  symptoms;  3)  Impingement,  post-operative  left
shoulder pain; and 4) Left foot sesamoid bone fracture,  post-sesamoidectomy
(chronic left foot pain).”
____________________________________________________________________________
__

RATING COMPARISON:

|Army PEB – dated 20020716        |VA ( 1 mo. Pre-Separation) – All       |
|                                 |Effective 20021107                     |
|Condition                        |Code          |Rating                 |
|TOTAL Combined:  20%             |TOTAL Combined: 70%                    |


____________________________________________________________________________
__


ANALYSIS SUMMARY:

Low Back Pain.  The CI injured his back while moving furniture in  September
1995.  Magnetic resonance  imaging  (MRI)  in  October  1995  revealed  left
paracentral disc herniation at L5-S1, displacing the  left  S1  nerve  root.
Despite treatment,  the  CI  continued  to  experience  low  back  pain  and
subsequently  underwent  three   more   MRIs   and   numerous   evaluations.
Conservative management for his back included  activity  modification,  non-
steroidal anti-inflammatory drugs, physical therapy (PT), and  strengthening
exercises.  He was evaluated by neurosurgery in March 2001, but the  planned
surgery was cancelled due to the surgeon transferring to another  base.   In
January 2002, he was having increased back pain and was  sent  to  a  German
neurosurgeon, where he had a L5-S1 discectomy.  After the  surgery,  the  CI
reported a 75% decrease in pain, but he still experienced some pain  in  the
left buttock and small toe.  He could not lift objects heavier than 25  lbs.
without having pain.  He had trouble stretching and bending  over.   He  was
able to run and ruck, but as  soon  as  he  did  he  experienced  pain  that
prevented him from performing other activities for the rest of the day.   He
had difficulty firing in the prone position, and  after  shooting  had  pain
for the rest  of  the  day.   He  was  able  to  continue  in  his  military
occupational specialty after the surgery, but he had pain whenever he  would
sit or stand for periods longer than two hours.

The 1 July 2002 VASRD was in effect at the time of the CI’s separation  from
service.  In 2002, lumbar spine range of motion (ROM) impairment was  judged
to be slight (10%), moderate (20%), or severe (40%), based upon the  rater’s
opinion regarding degree of severity.  In  this  case,  the  CI  had  a  MEB
examination on 3 June 2002 which demonstrated full thoracolumbar  ROM,  with
no limitation of motion.  Four and a half months later on 18  October  2002,
he had a VA compensation  and  pension  (C&P)  goniometric  ROM  evaluation,
which was just three weeks prior to separation.  The Board felt that the  VA
exam had greater probative value because it was much closer  to  separation.
The results of his back exams are summarized in this table:

|Thoracolumbar        |Separation Date:  20021106            |
|Goniometric ROM      |MEB – 20020603    |VA C&P – 20021018  |
|Flexion (90⁰ normal) |90⁰               |46⁰                |
|Combined (240⁰       |240⁰              |229⁰               |
|normal)              |                  |                   |
|Comments             |5 mos.            |3 wks.             |
|                     |Pre-separation    |Pre-separation     |

The Board evaluated the CI’s limitation of motion, with application  of  the
2002 VASRD coding and rating criteria, not the  current  coding  and  rating
criteria.  The Board unanimously agrees that the  5292  code  would  be  the
most appropriate code for  the  CI’s  limitation  of  lumbar  spine  motion.
After careful review of all available  evidentiary  information,  the  Board
unanimously recommends a disability rating of 20%  for  low  back  pain  IAW
VASRD 4.71a.  It is appropriately coded 5292, and  meets  criteria  for  the
20% (moderate) rating.

Neck Pain.  The CI injured his  neck  performing  weight  training  in  July
1998.  He was doing 25 pound lifts when he felt a sharp pain  in  his  neck.
Within three weeks, he was experiencing radicular symptoms going  down  both
arms into the thumb, index and middle fingers.  An  MRI  was  done  in  July
1999 and revealed loss of disc height  at  C5-C6.   The  CI  was  offered  a
fusion of the C5-C6 vertebrae,  by  neurosurgery  at  Madigan  Army  Medical
Center.  However, the CI was transferred to another base before the  surgery
could be performed.  By January 2000, the CI had worsening of the neck  pain
when wearing kevlar and load bearing equipment (LBE).  An MRI at  that  time
revealed a C5-C6 herniated disc, and he had  no  improvement  with  cervical
steroid injection.  In March 2000, he completed a course  of  PT,  involving
cervical traction.  In August 2001, a third cervical MRI was  performed  and
he was re-evaluated by neurosurgery.  Neck surgery was offered  to  the  CI,
but not performed as the surgeon was transferred.  Since then,  the  CI  has
not felt confident that surgery would help him,  and  he  has  declined  any
further surgical management.  The CI has still experienced  pain,  numbness,
and tingling going down both arms.  The pain is most noticeable in the  left
arm around the elbow region.  He reported being awakened at night with  pain
and difficulty feeling his fingers in the morning.

As mentioned above, the 1 July 2002 VASRD was in effect at the time  of  the
CI’s separation from service.  The MEB orthopedic neck exam on 3  June  2002
revealed excellent forward flexion, but some limitation of  neck  motion  in
other planes of movement.   The  pre-separation  VA  examination  documented
pain with motion as well as  some  tenderness  to  palpation  of  the  lower
cervical spine.  No radicular signs were noted  and  strength  was  5/5  for
both upper extremities.  The CI’s two goniometric ROM neck  evaluations  are
summarized in this table:

|Cervical Spine         |Separation Date:  20021106          |
|Goniometric ROM        |MEB – 20020603  |VA C&P – 20021018  |
|Flexion (45⁰ normal)   |90⁰             |44⁰                |
|Combined (340⁰ normal) |195⁰            |288⁰               |
|Comments               |No mention of   |Pain with motion   |
|                       |pain            |                   |

The Board evaluated the CI’s limitation of motion, with application  of  the
2002 VASRD coding and rating criteria, not the  current  coding  and  rating
criteria.  The Board unanimously agrees that the  5290  code  would  be  the
most appropriate code for the CI’s cervical spine condition.  After  careful
review of all  available  evidentiary  information,  the  Board  unanimously
recommends a disability rating of 10% for the painful  neck  condition.   It
is appropriately coded 5290 IAW VASRD 4.71a and meets criteria for  the  10%
(slight) rating.  The Board then directed its  attention  to  the  issue  of
cervical radiculopathy.  The CI clearly had a history  of  subjective  upper
extremity complaints (pain, numbness, and tingling).   However,  his  muscle
strength was normal, and there was no motor impairment.  Furthermore,  there
was no clearly documented evidence that his radicular  symptoms  caused  any
significant interference with the performance of required  military  duties.
All evidence considered,  the  Board  cannot  find  sufficient  evidence  to
support recommending  cervical  radiculopathy  as  an  additional  unfitting
condition.

Left Shoulder Pain.  The CI had left shoulder pain in  1985  which  he  felt
was due to wearing LBE and  a  pistol  belt.   He  had  increasing  pain  in
February 1994.  His X-rays of the left shoulder were unremarkable.   The  CI
reported that the pain in the shoulder also radiated down the left  arm.  In
February 1997, MRI revealed no pathology  in  the  glenohumeral  joint,  but
possible  shoulder  impingement  syndrome  and  possible  pathology  in  the
acromioclavicular  (A-C)  joint.   He  had  several  injections   into   the
shoulder, with no improvement.   In  May  1997,  he  underwent  left  distal
clavicle resection.  He had  some  improvement  post-operatively,  but  over
time the pain returned.  In June 1999, he  was  re-operated  on  and  had  a
spike of bone removed from  the  A-C  joint.   He  continued  to  have  left
shoulder pain which  was  worse  when  he  wore  his  LBE,  pistol  belt  or
rucksack.  He could not perform pushups and had difficulty firing  a  rifle.
His goniometric shoulder ROM evaluations are summarized below:

|Left Shoulder           |Separation Date 20021106                  |
|Goniometric ROM         |MEB – 20020603    |VA C&P – 20021018     |
|Fwd Flexion (180⁰       |160⁰              |140°                  |
|normal)                 |                  |                      |
|Abduction (180⁰ normal) |Not measured      |125⁰                  |
|Comments                |Pain not clearly  |Pain with motion      |
|                        |stated            |                      |

The Board examined all of the evidentiary information available.   Based  on
ROM alone, the left  shoulder  is  essentially  non-compensable,  using  the
VASRD §4.71a shoulder and arm codes (5200  to  5203).   However,  the  VASRD
makes it clear that painful motion of a major joint  warrants  a  rating  of
10% IAW §4.40 and §4.59.  After due deliberation,  considering  all  of  the
evidence  and  mindful  of  VASRD  §4.3  (reasonable   doubt),   the   Board
unanimously recommends a separation rating of 10% for  left  shoulder  pain.
It is appropriately coded 5099-5019, and meets criteria for the 10%  rating.


Left Foot Condition.  The CI had a tibial sesmoidectomy in August  of  1999,
with good results.   The  MEB  foot  exam  was  normal.   The  VA  C&P  exam
documented  a  full  weightbearing,  non-antalgic  gate.   The   left   foot
condition was not  profiled  and  was  not  implicated  in  the  commander’s
statement.  The left foot condition was reviewed in  detail  by  the  action
officer, and was considered by the Board.  There was no indication from  the
treatment record that  this  condition  significantly  interfered  with  the
performance of CI’s military duties.  All evidence considered, there is  not
reasonable doubt in the CI’s favor supporting reversal of  the  PEB  fitness
adjudication for the left foot condition.

Other PEB Conditions.  Atrial fibrillation and palpitations were  judged  to
be within AR 40-501 standards, were not profiled, and  were  not  identified
as disabling in the commander’s statement.  All  evidence  considered  there
is not reasonable doubt in the CI’s favor supporting  reversal  of  the  PEB
fitness adjudication for these two cardiac conditions.

Remaining Conditions.  Nasal  deformity,  numbness  in  hands,  and  several
additional conditions were documented in the  Disability  Evaluation  System
(DES) file.  None of these conditions  were  clinically  significant  during
the MEB/PEB period, carried permanent duty limiting  restrictions,  or  were
implicated in the commander’s statement.  These other  conditions  were  all
reviewed by the  action  officer  and  considered  by  the  Board.   It  was
determined that none could be argued as unfitting and subject to  separation
rating.  Additionally, several other conditions were  service  connected  by
the VA, but were not documented in the DES file.  The Board  does  not  have
the  authority  under   DoDI   6040.44   to   render   fitness   or   rating
recommendations for any conditions not considered by  the  DES.   Therefore,
there is no reasonable  basis  for  recommending  any  additional  unfitting
conditions for separation rating.
____________________________________________________________________________
_

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military  Department
regulations or guidelines relied upon by the PEB will not be  considered  by
the Board to the extent they were inconsistent with the VASRD in  effect  at
the time of the adjudication.  As discussed above, Army PEB reliance on  the
USAPDA pain policy  may  have  been  operant  in  this  case  and  the  CI’s
conditions were adjudicated independently of that policy by the  Board.   In
the matter of the low back pain IAW  VASRD  §4.71a,  the  Board  unanimously
recommends a disability rating of 20%, coded 5292.  In  the  matter  of  the
neck  condition  IAW  VASRD  §4.71a,  the  Board  unanimously  recommends  a
disability rating of 10%, coded 5290.  In the matter of  the  left  shoulder
pain IAW VASRD §4.71a, §4.40, and §4.59, the Board unanimously recommends  a
disability rating of 10%, coded 5099-5019.  In the matter of the  left  foot
pain, atrial fibrillation, palpitations, or any  other  conditions  eligible
for Board  consideration,  the  Board  unanimously  agrees  that  it  cannot
recommend any findings of unfit for additional rating at separation.
____________________________________________________________________________
_

RECOMMENDATION:  The Board recommends that the CI’s prior  determination  be
modified as follows, and that  the  discharge  with  severance  pay  be  re-
characterized to reflect permanent disability retirement,  effective  as  of
the date of his prior medical separation.

|UNFITTING CONDITION                               |VASRD CODE  |RATING  |
|Low Back Pain                                     |5292        |20%     |
|Neck Condition (Pain and Subjective Radicular     |5290        |10%     |
|Symptoms)                                         |            |        |
|Left Shoulder Pain                                |5099-5019   |10%     |
|COMBINED    |40%     |


The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20090201, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans' Affairs Treatment Record.





[pic]