RECORD OF PROCEEDINGS

PHYSICAL DISABILITY BOARD OF REVIEW

NAME: BRANCH OF SERVICE: ARMY

CASE NUMBER: PD0900175 BOARD DATE: 20100311

SEPARATION DATE: 20040601

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SUMMARY OF CASE: This covered individual (CI) was an active duty SP4 (Supply) medically separated from the Army in 2004 after 2+ years of service. The medical bases for the separation were neck and shoulder conditions. She injured her neck and right shoulder on an obstacle course in Basic Training. Her shoulder required two surgeries: an arthroscopic decompression in 2002 and a rotator cuff repair in 2003. A Magnetic Resonance Imaging (MRI) of her cervical spine demonstrated some mild degenerative disc changes and congenital stenosis. She had mild disc bulging at C3/4 and C4/5 without nerve root involvement. There was no radiculopathy identified. She did not improve enough with physical therapy and conservative management for adequate Military Occupational Specialty (MOS) performance. She was placed on a permanent U3 profile for her shoulder and neck, and referred for a Medical Evaluation Board (MEB). Her cervical condition and right shoulder condition were forwarded to the Physical Evaluation Board (PEB) as separate medically unacceptable (IAW AR 40-501) conditions on the DA Form 3947. They were combined into a single unfitting condition by the Informal Physical Evaluation Board (IPEB) and it was rated 10%. There were no other significant medical conditions identified by the MEB. The IPEB’s adjudication was upheld by a formal PEB and the CI was separated with a total disability rating of 10%.

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CI CONTENTION: The CI states: ‘My diagnosis was shoulder and neck pain. I have central spondylosis with spinal stenosis. Shoulder Arthritis...I am still pending a disability rating of Post-Traumatic Stress Disorder (PTSD).’ No specific contention is elaborated otherwise.

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RATING COMPARISON:

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ANALYSIS SUMMARY:

The Board first evaluated the PEB coding approach of combining the conditions under the single analogous 5003 code. The PEB may have relied on AR 635.40 (B.24 f.) or invoked the US Army Physical Disability Agency (USAPDA) pain policy for not applying separately compensable Veterans Administration Schedule for Rating Disabilities (VASRD) codes. In either case the Board must apply separate codes and ratings in its recommendation, since compensable ratings for each condition are achieved IAW VASRD §4.71a. This is consistent as well with the VA rating decision.

Right Shoulder Condition. The goniometric range-of-motion (ROM) exam quoted in the narrative summary (NARSUM) measured 180° active shoulder abduction. Pain on motion was not documented, although a positive apprehension sign was noted. The VA examiner documented 110° abduction with pain as the end-point and painful motion in other planes. The threshold for a 20% rating under 5201 is abduction 90°, thus the VA applied the analogous 5203 code to achieve a 10% rating for painful motion. In a subsequent VA rating examination, the 90° threshold was met for a 5201 rating of 20%. This was based on an examination 22 months after separation with an effective date 18 months after separation. Since this falls well outside the 12 month window specified in DoDI 6040.44 regarding VA evaluations for Board consideration, little probative value can be assigned to the subsequent VA rating. Several informal ROM exams during the MEB and one shortly after separation were in evidence. The most restricted abduction among them was 110°. There is therefore no support for a 20% or higher rating at separation. The Board recommends a 10% rating for the right shoulder based on §4.59 (painful motion) with equivalent coding to the initial VA rating decision.

Cervical Condition. There are goniometric exams in evidence from the NARSUM and the VA rating examination. Neither of these documented all six measurements for application of combined ROM to our rating recommendation. The documented measurements did not suggest that this would have altered the §4.71a rating determination. Active flexion was measured as 35° by the MEB examiner and 45° by the VA examiner. No abnormal contour was documented on either exam. The VA examiner noted spasm, but stated ‘She seems to have no difficulty with motion.’ Both the MEB and VA examinations were consistent with a 10% rating IAW the VASRD spine formula. There were no informal ROM examinations in evidence suggesting that these goniometric exams were not reflective of a fair rating. Cervical ROM and the subsequent VA rating (10%) were unchanged at the 22 month VA evaluation noted above in reference to the shoulder condition. There was no evidence of ratable peripheral nerve impairment in this case. All evidence considered, the Board recommends a 10% rating for the cervical spine condition. The 5237 code is the closest fit with the pathology.

Other Conditions. Neither the NARSUM nor the MEB physical reflected any significant medical conditions other than those adjudicated by the PEB. The VA rating examination identified lumbar and migraine conditions. These were not service connected by the VA and not in the Disability Evaluation System (DES) packet. The PTSD condition noted by the CI in her application has not been verified or rated by the VA per submitted evidence. There is no evidence in the service treatment record of diagnosis or treatment for PTSD or any other mental health condition. 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. PTSD or any contended conditions, other than the right shoulder and neck conditions, remain eligible for Army Board of Correction for Military Records (ABCMR) consideration.

The Board, therefore, has no reasonable basis for recommending any additional unfitting conditions for separation rating.

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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, PEB reliance on the USAPDA pain policy and possibly on AR 635.40 for rating the shoulder and cervical conditions was operant in this case and the conditions were adjudicated independently of that policy and regulation by the Board. In the matter of the right shoulder condition, the Board unanimously recommends a rating of 10% coded 5299-5203 IAW VASRD §4.71a. In the matter of the cervical condition, the Board unanimously recommends a rating of 10% coded 5237 IAW VASRD §4.71a. The Board unanimously agrees that there were no other conditions eligible for review which were relevant for consideration as additionally unfitting.

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RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation.

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The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20090601, w/atchs.

Exhibit B. Service Treatment Record.

Exhibit C. Department of Veterans' Affairs Treatment Record.