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AF | PDBR | CY2012 | PD2012 01687
Original file (PD2012 01687.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    CASE: PD1201687
BRANCH OF SERVICE: Army  BOARD DATE: 20130418
SEPARATION DATE: 20041015

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSG/E-6 (31B30/Military Police) medically separated for chronic right shoulder and back conditions. She was told she had scoliosis in high school, but did not have any pain until June 2001 with a diagnosis of disc disease of the lumbar spine in 2002. The right shoulder pain began in April 2002 suddenly while lifting weights. She underwent an arthroscopy in September 2002 and a second in 2004. Neither condition could be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards. She was issued a permanent U3/L3 profile and referred for a Medical Evaluation Board (MEB). The back and shoulder conditions, characterized as chronic low back pain with degenerative disc disease L4/5 and post-traumatic arthritis of right shoulder status-post arthroscopic surgery, were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The PEB adjudicated the chronic pain of right shoulder status-post arthroscopic surgery condition as unfitting, rated 0% ( referencing the US Army Physical Disability Agency pain policy), and adjudicated the chronic back pain due to scoliosis condition as existed prior to service (EPTS). The CI made no appeals, and was medically separated.


CI CONTENTION: “SM after 8 years of separation is still in pain and seeking care for the conditions in which she was separated. Veteran is currently seeking a reevaluation on current VA rating as of April 2012.”


SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The ratings for the unfitting right shoulder and back conditions are addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board. 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 IPEB – Dated 20040720
 VA - (2 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Pain, Rt Shoulder 5099-5003 0% S/P Arthroscopic Surgery, Rt Shoulder 5201-5019 10% 20041209
Chronic Back Pain due to Scoliosis 5299-5237 EPTS Chronic Lumbar Strain w/Scoliosis & Lumbar Disc Disease L5-S1 5010 10% 20041209
No Additional MEB/PEB Entries
 Other x 2 20041209
Combined: 0%
 Combined: 30%
Derived from VA Rating Decision (VA RD ) dated 200 50505 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY: The Board acknowledges the CI’s information regarding the significant impairment with which her service-connected condition continues to burden her; but, must emphasize that 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 (DVA), operating under a different set of laws. The Board considers DVA evidence proximate to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12-month interval for special consideration to post-separation evidence. Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation.

Right Shoulder Pain. The goniometric range-of-motion (ROM) evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Right Shoulder ROM
(Degrees)
 MEB ~ 4 Mo. Pre-Sep VA C&P ~ 2 Mo. Post-Sep
Flexion (180 Normal)
 155 180
Extension
 50
Abduction (180)
 160 180
Adduction
 60
IR
 55 80
ER
 40 80
Comments; 2 nd Surgery 6 Mo. Pre-Sep
 No motor or sensory deficit; “with pain” on source PT eval Painful motion; same ROM during and after repetition; swelling, effusion, and mild tenderness
§4.71a Rating
 10% 10%

The CI underwent two shoulder surgeries, with the 2nd surgery including debridement of a superior labral anterior-posterior lesion, debridement of labral fraying, and decompression partial acromionectomy. The narrative summary (NARSUM) exam 30 June 2004, 4 months prior to separation, noted that pre-surgical magnetic resonance imaging (MRI) showed tendinitis and bursitis, but no significant rotator cuff tear or shoulder impingement. Physical exam revealed normal neurological exam with the ROMs noted above. The NARSUM was silent on repetition, painful motion or other DeLuca criteria; however, the ROM evaluation with the same exact ROMs as the NARSUM stated flexion of 155 degrees was with pain. Diagnosis was post-traumatic arthritis, right shoulder, status post (s/p) arthroscopic surgery. During the VA Compensation & Pension (C&P) exam 9 December 2004, the CI stated she had 2/10 pain in right shoulder for which she took Tylenol. Pain was worse with lifting more than 10 pounds or her child. Exam revealed full ROM with pain. There was swelling, effusion, and mild tenderness during the general medical exam. Right shoulder X-rays were normal. The Board carefully reviewed all evidentiary information available and directs attention to its rating recommendation based on the above evidence. PEB coded her condition as 5099-5003 and rated it as 0%. The VA coded the condition as 5201-5019 (bursitis) and rated it 10%. The CI’s right shoulder pain was essentially non-compensable based on the Veterans Affairs Schedule for Rating Disabilities (VASRD) §4.71a codes for loss of motion under specific shoulder joint codes. However; IAW VASRD §4.40 and §4.59, a 10% rating is warranted when there is satisfactory evidence of functional limitation due to painful motion of a major joint. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right shoulder condition. It is appropriately coded 5299-5019 and meets criteria for the 10% rating level.

Chronic Back Pain. The CI has had low back pain (LBP) beginning in 2001. She was told she had scoliosis in high school, but did not have any pain until June 2001 with a diagnosis of disc disease of the lumbar spine in 2002. Military Entrance Processing Station entry exam from September 1997 documented a normal spine exam. Radiographs in June 2001 documented mid thoracic scoliosis, convex right, 31 degrees. The CI was profiled P3 and MEB summaries were started, but the CI’s condition improved and profile was downgraded to P2. The back pain subsequently increased and MRI in December 2001 documented scoliosis and degenerative disease of the spine with a disc herniation at L4-5. NARSUM of 30 June 2004,
4 months prior to separation, had chief complaint including LBP. The NARSUM noted the scoliosis history and the ROMs are noted below with the source physical therapy exam indicating pain with motion. The CI had the diagnosis of “chronic low back pain with degenerative disc disease L4/5.” X-rays in March 2003 showed slight increase in the scoliosis angle from prior exams (to 34 degrees). At the C&P exam of 9 December 2004, 2 months after separation, the history indicated the CI “had referred low back pain and scoliosis since she was in high school. No injury. Pain on the scale from 1-10 is 2.” She was diagnosed with a bulging disc and there was no history of radiating pain, falls, or incapacitation. Physical exam demonstrated no loss of motion or of function, with mild pain on motion after repetition.

The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Thoracolumbar ROM
(Degrees)
 MEB ~ 4 Mo. Pre-Sep VA C&P ~2 Mo. Post-Sep
Flexion (90 Normal)
 (90) 115 90
Extension (30)
 20 30
R Lat Flexion (30)
 (30) 35 30
L Lat Flexion (30)
 30 30
R Rotation (30)
 (30) 40 30
L Rotation (30)
 30 30
Combined (240)
 230 240
Comment: VASRD Spine, Note 2 for maximum ROMs
 Some scoliosis deformity, no swelling; pain with motion No loss of motion w/ repetition, but increased pain
§4.71a Rating
 10% 10%

The Board carefully reviewed all evidentiary information available and directs attention to its rating recommendation based on the above evidence. The PEB coded the back pain as 5299-5237 and classified it as EPTS with a “---%” rating. The PEB adjudged that the chronic back pain was secondary to scoliosis which was present before the CI joined the Army, and was not aggravated beyond its natural progression. However, intake history and physical exam September 1997 did not note scoliosis, back deformity or thoracolumbar pain. The MEB considered the back pain was not EPTS, despite EPTS scoliosis. There was documented painful motion with radiographic evidence of disc bulging or herniation in the lower lumbar spine. Although pre-existing thoracic scoliosis is conceded, there is no conclusive or compelling link of normal progression to lumbar disc pathology, although there is an increased incidence with individuals with other underlying spine pathology. The Board therefore adjudged that there was sufficient doubt and evidence to consider the LBP as permanently service aggravated and compensable. The CI’s LBP was ratable at 10% from the MEB exam for combined ROM of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees, and either the Service or VA exams met the provision of VASRD §4.40 and §4.59, for a 10% rating. There was not sufficient evidence to justify a rating higher than 10%. Given the normal entry exam, there was no deductible prior to service rating (it was either 0% or undetermined). After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the low back condition. It is appropriately coded 5010 and meets criteria for the 10% rating level.

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. In the matter of the right shoulder condition, the Board unanimously recommends a disability rating of 10%, coded 5299-5019 IAW VASRD §4.71a. In the matter of the low back condition, the Board unanimously recommends a disability rating of 10%, coded 5010 IAW VASRD §4.71a. 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 her prior medical separation:

UNFITTING CONDITION
 VASRD CODE RATING
Chronic Pain, Right Shoulder 5299-5019 10%
Chronic Low Back Pain 5010 10%
COMBINED
 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120501, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




         Physical Disability Board of Review


 SFMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(TAPD-ZB),


SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for AR20130010308 (PD201201687)
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                                                 
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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