RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY 

CASE NUMBER: PD1200529 SEPARATION DATE: 20031016 

BOARD DATE: 20130207 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty SGT/E-5 (31U/Signal Support Systems Specialist), 
medically separated for chronic low back pain (LBP) and a chronic pain condition bundled as a 
right shoulder and left ankle condition. He did respond adequately to conservative treatment 
for the right shoulder, however did not respond adequately to conservative treatment for the 
low back or surgical treatment for the left ankle and was unable to meet the physical 
requirements of his Military Occupational Specialty (MOS); worldwide deployment standards or 
physical fitness standards. He was issued a permanent L3 profile for the low back and left ankle 
condition and was referred for a MEB. Degenerative joint disease (DJD) left ankle, right 
shoulder impingement and low back pain were forwarded to the Physical Evaluation Board 
(PEB) IAW AR 40-501. No other conditions appeared on the MEB’s submission. The PEB 
adjudicated the low back condition as unfitting rated 10% and the right shoulder and left ankle 
condition as unfitting, bundled them and rated, 0% with application of the Department of 
Defense Instruction (DoDI) 1332.39 US Army Physical Disability Agency (USAPDA) pain policy, 
respectively. The CI made no appeals, and was medically separated with a 10% disability rating. 

 

 

CI CONTENTION: “I was discharged from the Army on 10/16/2003 with a rating of 10%. After 
my discharge the VA scheduled an evaluation appt. sometime in early 2004 that I missed, cause 
of a mixup with my address. Once I realized I missed the appt. I immediately rescheduled and 
opened a new claim on 5/12/2004. The VA evaluation, based only on my Army medical 
records, raised my rating to 40% effective 10/17/2003 and to 50% effective 5/12/2004. The VA 
disability rating letter is attached. I respectfully request that the PDBR consider this in my 
request for a review under the Wounded warrior Act.” 

 

 

SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 
6040.44, Enclosure 3, paragraph 5.e. (2) is limited to those conditions which were determined 
by the PEB to be specifically unfitting for continued military service; or, when requested by the 
CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings 
for unfitting conditions will be reviewed in all cases. Any conditions or contention not 
requested in this application, or otherwise outside the Board’s defined scope of review, remain 
eligible for future consideration by the Army Board for Correction of Military Records. 

 

 

 

 

 

 

 

 

 


 

 

 

RATING COMPARISON: 

 

Service PEB – Dated 20030814 

VA (1 Mo. Pre-Separation) – All Effective Date 20031017 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Chronic Low Back Pain 

5299-5295 

10% 

Mechanical Low Back Pain 

5237 

10% 

20030912 

Chronic Pain Right 
Shoulder and Left Ankle 

5299-5003 

0% 

Degenerative Joint Disease 
Status Post Arthroscopy, Left 
Ankle 

5271 

10% 

20030912 

Tendonitis and Bursitis, Right 
(Dominant) Shoulder 

5304 

10% 

20030912 

.No Additional MEB/PEB Entries. 

0% X 5 

20030912 

Combined: 10% 

Combined: 30% 



 

 

 

ANALYSIS SUMMARY: The Board notes the current VA ratings listed by the CI for all of his 
service-connected conditions, but must emphasize that its recommendations are premised on 
severity at the time of separation. The VA ratings which it considers in that regard are those 
rendered most proximate to separation. The Disability Evaluation System has neither the role 
nor the authority to compensate members for anticipated future severity or potential 
complications of conditions resulting in medical separation. That role and authority is granted 
by Congress to the Department of Veterans Affairs. 

 

Low Back, Left Ankle and Right Shoulder Conditions. The CI received surgical treatment for DJD 
of the left ankle in 1999 which resulted in a P2 profile and was thus referred to reclass as a light 
wheeled mechanic (63B). While in training he reported a history of low back and right shoulder 
pain. He received physical therapy and nonsteroidal medications with some improvement in 
his right shoulder. The permanent profile reflected the low back and left ankle conditions with 
the following limitations, alternate physical training test (walk, bike and sit-ups), lift up to 30 
pounds, able to perform all functional activities. The commander’s statement corroborated 
only the back condition as functionally impairing his ability to perform duties of a 63B. The 
commander further specified this was due to the lifting profile restriction with the inability to 
move his personal effects around the battlefield as well as precluding him from performing 
critical field duties. The commander concluded the CI’s back problem did not prevent him from 
performing in his current MOS as a communications instructor and his profile did not detract 
from the company’s mission. However, he was incapable of performing the duties of a 63B. 

 

At the MEB exam, the CI reported LBP and mid right shoulder pain with over the shoulder 
motion and pushups and reported the pain was occasional and slight. After conservative care 
his shoulder was much better yet his back pain continued. The MEB physical exam 
demonstrated normal appearance of the low back, right shoulder and left ankle with no 
tenderness. The low back was absent for neurologic signs and demonstrated decreased lumbar 
lordosis with no reversal of lumbar rhythm. The left ankle had a well healed small lateral 
arthroscopy scar and no neurovascular signs. X-rays revealed a normal right shoulder, 
degenerative changes of L3 and L4 vertebral bodies, and mild DJD of the left ankle. Magnetic 
resonance imaging (MRI) a month after the MEB exam revealed a normal lumbar spine and mild 
tendinosis of the supraspinatus tendon with bursitis of the right shoulder. At the VA 
Compensation and Pension (C&P) exam prior to separation, the CI reported taking Tylenol as 
needed for his back, right shoulder and left ankle pain, reported flare-ups of no specific amount 
for the back, right shoulder and ankle that limited his lifting, the back pain was more irritating 


but he could still do things, he could no longer run and wore an ankle brace if his activity 
included prolonged standing or walking. The C&P exam demonstrated no new additional 
findings outside the ratable ROM data in the charts below. X-rays were normal of the low back 
and right shoulder and revealed bone like densities of the left ankle. There were two range-of-
motion (ROM) evaluations in evidence for the low back and left ankle, with documentation of 
additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as 
summarized in the charts below. 

 

Thoracolumbar ROM 

(Degrees) 

Narsum ~4 Mo. Pre-Sep 

VA C&P ~1 Mo. Pre-Sep 

Flexion (90 Normal) 

Within 2 inches to floor 
w/discomfort 

85 

Ext (0-30) 

20 

Full 

R Lat Flex (0-30) 

To knees 

Full 

L Lat Flex 0-30) 

To knees 

Full 

R Rotation (0-30) 

-- 

30 

L Rotation (0-30) 

-- 

30 

Combined (240°) 

-- 

235 

Comment 

No spasm 

Painful motion, no 
spasm, normal posture 

§4.71a Rating 

10%* 

10% 



*Conceding §4.59 painful motion 

 

 

Left Ankle ROM 

(Degrees) 

Narsum~4 Mo. Pre-Sep 

VA C&P ~1Mo. Pre-Sep 

Dorsiflexion (0-20) 

15 

Full 

Plantar Flexion (0-45) 

45 

Full/Painful motion 

Comment 

 

 

§4.71a Rating 

10% 

10%* 



*Conceding §4.59 painful motion 

 

The Board directs attention to its rating recommendation based on the above evidence. The 
PEB combined right shoulder and left ankle pain as a single unfitting condition coded 
analogously to 5003 and rated 0%. The PEB relied on DoDI 1332.39 and the USAPDA pain policy 
for not applying separately compensable Veterans Affairs Schedule for Rating Disabilities 
(VASRD) codes. The Board must apply separate codes and ratings in its recommendations if 
compensable ratings for each condition are achieved IAW VASRD §4.71a. If the Board judges 
that two or more separate ratings are warranted in such cases, however, it must satisfy the 
requirement that each unbundled condition was unfitting in and of itself. Not uncommonly this 
approach by the PEB reflects its judgment that the constellation of conditions was unfitting, and 
that there was no need for separate fitness adjudications, not a judgment that each condition 
was independently unfitting. Thus the Board must exercise the prerogative of separate fitness 
recommendations in this circumstance, with the caveat that its recommendations may not 
produce a lower combined rating than that of the PEB. The Board first considered if left ankle, 
having been de-coupled from the combined PEB adjudication, remained independently 
unfitting as established above. All members agreed that left ankle, as an isolated condition, 
would have rendered the CI incapable of continued service within his MOS and accordingly 
merit a separate service rating. The Board next considered whether right shoulder remains 
separately unfitting, having de-coupled it from a combined PEB adjudication. In analyzing the 
intrinsic impairment for appropriately coding and rating of the right shoulder condition, the 
Board is left with a questionable basis for arguing that right shoulder was indeed independently 


unfitting. The MEB was initiated for chronic LBP and at this time sought treatment for right 
shoulder pain, subsequently reported much improvement of the right shoulder pain with 
conservative treatment and further reported that the low back was the more irritating 
condition. Furthermore, the right shoulder condition is not profiled nor mentioned in the 
commander’s statement. After due deliberation, the Board agreed that evidence does not 
support a conclusion that right shoulder, as an isolated condition, would have rendered the CI 
incapable of continued service within his MOS and accordingly cannot recommend a separate 
service rating for it. 

 

The Board directs attention to its rating recommendation based on the above evidence for the 
low back condition. The PEB’s chosen code for the low back is analogous to 5295 from the 
2002 VASRD coding and rating standards for the spine, which were in effect at the time of 
separation. These standards were modified on 23 September 2002 to add incapacitating 
episodes (5293, Intervertebral disc syndrome), and then changed to the current §4.71a rating 
standards on 26 September 2003 which is what the VA relied upon for their chosen code 5237 
(lumbosacral strain). The 2002 standards for rating based on ROM impairment were subject to 
the rater’s opinion regarding degree of severity, whereas the current standards specify rating 
thresholds in degrees of ROM impairment. For the reader’s convenience, the 2002 rating codes 
under discussion in this case are excerpted below. The two potentially applicable codes from 
the 2002 VASRD are excerpted below: 

 

5292 Spine, limitation of motion of, lumbar: 

Severe ………………………………………………………..……….………….... 40 

Moderate …………………………………….……………….…….…………...…. 20 

Slight ………………………………………………………..…………………..….10 

 

5295 Lumbosacral strain: 

Severe; with listing of whole' spine to opposite side, positive 

Goldthwaite's sign, marked limitation of forward bending in 

 standing position, loss of lateral motion with osteo-arthritic 

 changes, or narrowing or irregularity of joint space, or some 

 of the above with abnormal mobility on forced motion …………………..…... 40 

With muscle spasm on extreme forward bending, loss of lateral spine 

 motion, unilateral, in standing' position ……………...…………..…...….….. 20 

With characteristic pain on motion ………………………………..……...…….…. 10 

With slight subjective symptoms only ……………………...………………...……. 0 

 

The PEB’s DA 199 reflected application of DoDI 1332.39 (E2.A1.1.20.2) and AR 635.40 (B-39) for 
rating, but its 10% determination was consistent with §4.71a standards. While the MEB exam 
does not have an accurate ROM measurement the descriptor revealed impairment sufficient 
for 10% rating which is also supported by the VA flexion ROM impairment. The Board 
considered the PEB’s rating under the 5295 code of the 2002 VASRD. The 20% rating for 5295 
required muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in 
standing position. The CI’s condition clearly did not meet that threshold even at the post 
separation VA examination. There is no evidence of documentation of incapacitating episodes 
which would provide for additional or higher rating. 

 

The Board next directs attention to its rating recommendation based on the above evidence for 
the left ankle condition. The PEB’s DA 199 reflected application of the USAPDA pain policy for 
rating and its 0% determination for the left ankle is inconsistent with §4.71a standards. The left 
ankle has a noncompensable loss of motion in the MEB exam and positive X-ray findings which 


warrant at least the minimum 10% rating for X-ray evidence and pain limited motion. In 
consideration of VASRD §4.7 Higher of two evaluations, the Board agreed X-ray evidence, the 
MEB ROM and VA ROM with painful motion is more consistent with the moderate criteria for 
the VA’s chosen codes for the left ankle. There is no viable approach to a higher rating for the 
left ankle which is countenanced by the VASRD. After due deliberation, considering all of the 
evidence and mindful of VASRD §4.3 (Resolution of reasonable doubt), the Board recommends 
a disability rating of 10% each for the low back and left ankle conditions and further agreed that 
the preponderance of the evidence with regard to the functional impairment of right shoulder 
does not favor its recommendation as an additionally unfitting condition 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. The Board did not 
surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD 
were exercised. As discussed above, PEB reliance on DoDI 1332.39 (E2.A1.1.20.2), AR 635.40 
(B-39) and the USAPDA pain policy for rating the low back, the single unfitting pain condition 
bundled as right shoulder and left ankle was operant in this case and the conditions were 
adjudicated independently of that policy by the Board. In the matter of the low back condition 
and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB 
adjudication. In the matter of the left ankle condition, the Board unanimously recommends a 
disability rating of 10%, coded 5271-5003 IAW VASRD §4.71a. In the matter of right shoulder 
condition, as combined in the PEB adjudication, the Board unanimously agrees that it could not 
be satisfactorily established as independently unfitting; and, therefore, is not ratable for service 
disability. There were no other conditions within the Board’s scope of review for consideration. 

 

 

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

 

UNFITTING CONDITION 

VASRD CODE 

RATING 

Chronic Low Back Pain 

5299-5295 

10% 

Chronic Pain Left Ankle 

5271-5003 

10% 

Chronic Pain Right Shoulder 

 

Not unfitting 

COMBINED 

20% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120606, w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

 xxxxxxxxxxxxxxxxxxxxxxxxxx, DAF 

 Acting Director 

 Physical Disability Board of Review 


SFMR-RB 


 

 

MEMORANDUM FOR Commander, US Army Physical Disability Agency 

(TAPD-ZB / xxxxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 

 

 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation 

for xxxxxxxxxxxxxxxxxxxxxxxxxxxxxx, AR20130006217 (PD201200529) 

 

 

1. I have reviewed the enclosed Department of Defense Physical Disability Board of 
Review (DoD PDBR) recommendation and record of proceedings pertaining to the 
subject individual. Under the authority of Title 10, United States Code, section 1554a, 
I accept the Board’s recommendation to modify the individual’s disability rating to 20% 
without recharacterization of the individual’s separation. This decision is final. 

 

2. I direct that all the Department of the Army records of the individual concerned be 
corrected accordingly no later than 120 days from the date of this memorandum. 

 

3. I request that a copy of the corrections and any related correspondence be provided 
to the individual concerned, counsel (if any), any Members of Congress who have 
shown interest, and to the Army Review Boards Agency with a copy of this 
memorandum without enclosures. 

 

 BY ORDER OF THE SECRETARY OF THE ARMY: 

 

 

 

 

Encl xxxxxxxxxxxxxxxxxxxxxxxxxxx 

 Deputy Assistant Secretary 

 (Army Review Boards)