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AF | PDBR | CY2012 | PD2012 01788
Original file (PD2012 01788.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    BRANCH OF SERVICE: Army
CASE NUMBER: PD1201788   SEPARATION DATE: 20031202
BOARD DATE: 20130423


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSG/E-6 (63H30 /Light Wheeled Vehicle Repairman), medically separated for low back pain (LBP) without specific history of trauma or injury and bilateral shoulder pain with a history of an injury occurred during the line of duty (LOD) with subsequent surgeries to both shoulders. His bilateral shoulder problems began in 1995 when he had a forceful abduction placed on his right shoulder with an internal rotation on his left by a runaway steering wheel. After continued pain and ineffective treatment he underwent a right shoulder acromial fixation with two screws in 1999 and a similar open reduction and internal fixation (ORIF) of his left acromion in 2000 with subsequent arthroscopic lysis of capsule adhesions in 2001. Despite physical therapy, injections and the surgeries he did not improve adequately with treatment. His LBBP began in 2002 without significant trauma or injury and was diagnosed as degenerative disc disease (DDD). The CI could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent U3/L3/H2 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded the Physical Evaluation Board (PEB) left shoulder pain, right shoulder pain, and low back and right lower extremity pain as medically unacceptable IAW AR 40-501. Right knee instability, right foot pain, neck pain, hypothyroidism and H-2 hearing loss conditions, identified in the rating chart below, were also identified and forwarded by the MEB. The PEB adjudicated the low back and bilateral shoulder conditions as unfitting, rated 10% and 0% respectively, with application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD) and US Army Physical Disability Agency (USAPDA) pain policy. The remaining conditions were determined to be not disqualifying. The CI made no appeals, and was medically separated with a 10% disability rating.
CI CONTENTION: “1. Right and left shoulder loss of range of motion 2. Back DDD”


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 of bilateral shoulder and low back conditions as requested for consideration meet the criteria prescribed in DoDI 6040.44 for Board purview; and, are addressed below. 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 20031021
 VA (1 Mos. Pre -Separation) – All Effective Date 20031203
Condition
 Code Rating Condition Code Rating Exam
Low Back Pain w/out Trauma or Injury 5299-5237 10% Degenerative Disc Disease Lumbar Spine 5243 20% 20031118
Bilateral Shoulder Pain w/ Hx Injury & Subsequent Surgeries 5099-5003 0% S/P Open Coracoplasty; Open OS Acromiale Fixation; Arthroscopic Debridement Anterior Labral Tear with Glenohumeral Arthroscopy, Lt Shoulder w/ Residuals 5299-5024 10% 20031118
S/P Open Reduction Internal Fixation w/ Bone Graft Due to OS Acromiale & Coracoid Impingement, Rt Shoulder w/ Residuals 5299-5024 10% 20031118
Rt Knee Instability Not Disqualifying NO CORRESPONDING VA ENTRY
Rt Foot Pain Not Disqualifying Bilateral Foot Condition 5276 NSC 20031118
Neck Pain Not Disqualifying Cervical Spine Strain 5237 10% 20031118
Hypothyroidism Not Disqualifying Grave’s Disease 7900 10% 20031118
H-2 Hearing Not Disqualifying Bilateral Hearing Loss 6100 0% 20031118
↓No Additional MEB/PEB Entries↓
 Asthma 6602 30% 20031118
Osteoarthritis Rt Hip 5003 10% 20031118
Recurrent Bilateral Tinnitus 6260 10% 20031118
Hypertension 7101 10% 20031118
Diabetes Mellitus Type II 7913 10% 20031118
0% X 4 / Not Service-Connected x 9 20031118
Combined: 10%
 Combined: 80%
* Sleep apnea was added as an additional condition in a 20040929 VARD rated 50% effective 20031203 changing the combined rating to 90%.

ANALYSIS SUMMARY: The PEB combined the right and left shoulder pain conditions as a single unfitting condition rated as 5099-5003 (analogous to arthritis) at 0%. The PEB relied on AR 635.40 (B.24 f.) and/or the USAPDA pain policy for not applying separately compensable VASRD codes. The Board must apply separate codes and ratings in its recommendations if compensable ratings for each condition are achieved IAW VASRD rating guidelines. 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. 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 the PEB.

Low Back Condition. The narrative summary (NARSUM) notes the CI had a history of LBP that radiated to the right leg without a history of trauma since September 2002. A magnetic resonance imaging (MRI) exam performed on 28 January 2003 showed DDD without evidence of disc herniation, or stenosis. He had physical therapy (PT) with some improvement and was discharged from PT due to maximal medical improvement. At the MEB exam, 9 August 2003, approximately 4 months prior to separation, the CI reported sharp right LBP with radiation to the right leg, rated 5/10, but 10/10 at worst, and improved by over the counter medications. He reported difficulty with sitting, standing, walking for long periods and difficulty sleeping. He denied any neurological symptoms. The MEB exam showed tenderness to palpation (TTP) over the right sacroiliac joint (SI) and the left lumbar muscles. Lumbar range-of-motion (ROM) was flexion of 80 degrees (normal 90 degrees) and extension of 10 degrees (normal 30 degrees). Straight leg raise (SLR) was negative bilaterally with no signs of nerve impingment. Strength and reflexes were normal. Sensation was not mentioned in the exam, but in the prognosis section the examiner referred to lack of objective findings of radicular symptoms. At the VA Compensation and Pension (C&P) exam 18 November 2003, approximately 2 weeks prior to separation, the CI reported LBP that radiated to both legs. The pain was sharp and he rated it 10/10. He reported difficulty with running and bending at the waist. The VA exam showed normal posture and gait. Lumbar ROM was decreased with flexion of 50 degrees, limited by pain, and the examiner noted that CI did not allow movement beyond that point. There were no DeLuca criteria. There was no radiation of pain with movement or muscle spasm. There was TTP of the lumbar musculature. Muscle strength, sensation, and reflexes were normal. Lumbar spine X-rays showed mild arthritis. The Board directs attention to its rating recommendation based on the above evidence. The PEB rated LBP as 5099-5237 (analogous to lumbar strain) at 10%. The VA rated lumbar spine DDD as 5243 at 20%. The Board considered rating the LBP condition as 5243 or 5237. There was no documentation in the record of incapacitating episodes and therefore both 5243 and 5237 are coded equivalently according to the VASRD General Rating Formula for Diseases and Injuries of the Spine. The coding choice in this case does not influence the rating. The CI’s lumbar flexion was noted by the MEB examiner to be 80 degrees limited by pain, 4 months prior to separation, the MEB/PT ROM evaluation indicated flexion of 90 degrees limited by pain 3 months prior to separation, and the VA exam indicated flexion of 50 degrees limited by pain. The VA examiner emphasized that each ROM was stopped at the point of pain, and that the CI did not allow movement beyond that point. The VA exam also noted normal gait and posture without muscle spasm. Therefore, the Board gave greater probative value to the MEB and MEB/PT ROM evaluations and agreed that the CI’s LBP disability most nearly met the 10% rating IAW §4.71a coded either as 5243 or 5237. The Board also considered if additional disability rating was justified for peripheral nerve impairment due to right lower extremity radiculopathy. Board precedent is that a functional impairment tied to fitness is required to support a recommendation for addition of a peripheral nerve rating at separation. The CI’s right leg pain is subsumed under the general spine rating as specified in §4.71a. The CI had normal muscle strength, sensation and reflexes of the lower extremities. Since there is no evidence of functional impairment in this case, the Board cannot support a recommendation for additional rating based on peripheral nerve impairment. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the LBP condition.

Bilateral Shoulder Condition. The CI was noted to be right hand dominant. The NARSUM notes the CI injured both shoulders in an incident in 1995, trying to control a runaway steering wheel. He was treated with conservative measures with some relief. In 1999 MRI studies of both shoulders resulted in open reduction and internal fixation of the right shoulder which did improve his ROM. He had a similar surgery of the left shoulder in 2000, but developed a frozen shoulder post-operatively. He had a second arthroscopic surgery of the left shoulder in 2001 for lysis of adhesions with joint manipulation to improve ROM.

Left Shoulder Condition At the MEB exam the CI reported decreased and painful ROM, especially internal rotation. He denied instability and felt his symptoms were stable but reported difficulty sleeping due to pain and over the counter medications were helpful. The MEB exam showed shoulder ROM to be decreased with flexion of 120 degrees (normal 180 degrees); abduction of 120 degrees (normal 180 degrees); external rotation(ER) 10 degrees (normal 90 degrees); internal rotation (IR) to the same side “hip pocket” (normal 90 degrees). There was TTP of the shoulder joint, biceps tendon, and acromion. All ROM was reported as “with symptoms”. The joint was without effusion, stable, and positive for impingement signs. Strength and sensation was normal. MEB/PT ROM evaluation17 September 2003 appears to document reduced left shoulder abduction of possibly 15 degrees but is illegible; the NARSUM noted the PT consultation as abduction 110 degrees. At the C&P exam the CI reported pain, decreased ROM, and difficulty with overhead motion. The left shoulder ROM was described as moderately severe loss of ROM with forward flexion of 120 degrees; abduction of 100 degrees; ER of 50 degrees; IR of 60 degrees. There were no DeLuca criteria. Left shoulder X-rays showed post-surgical changes but were otherwise normal.

Right Shoulder Condition At the MEB exam the CI reported decreased and painful ROM, but not as severe as on the left. He felt his symptoms were stable but reported difficulty sleeping due to pain. The MEB exam showed shoulder ROM to be decreased with forward flexion of 95 degrees; abduction of 120 degrees; external rotation(ER) 10 degrees; internal rotation (IR) to the same side “hip pocket”. There was no TTP. All ROM was reported as “with symptoms”. The joint was without effusion, stable, and with positive impingement signs. Strength and sensation was normal. At the C&P exam the CI reported pain, decreased ROM, and difficulty with overhead motion. The right shoulder ROM was described as moderately severe loss of ROM with forward flexion of 120 degrees; abduction of 100 degrees; ER of 80 degrees; IR of 50 degrees. There were no DeLuca criteria. Right shoulder X-rays showed post-surgical changes but were otherwise normal.

The Board directs attention to its rating recommendation based on the above evidence. The PEB bundled the right and left shoulder conditions as one unfitting condition and rated as 5099-5003 (analogous to degenerative arthritis) at 0%. The Board undertook to unbundle the right and left shoulder conditions. The CI’s right and left shoulders were each injured and required surgical treatment and post-operative care with residuals of pain and decreased ROM in both. The permanent profile lists bilateral shoulder pain, restricted motion. The commander’s statement notes injury to both shoulders with consequent difficulty lifting and working overhead as impairments to duty performance. The Board agreed that the right and left shoulders were separately unfitting. The VA rated the right and left shoulders separately as 5299-5024 (analogous to tenosynovitis) at 10% for painful motion. The Board opined that coding as 5201 for limited arm motion was most consistent with the CI’s left and right shoulder conditions of stable joints with decreased ROM. The VASRD §4.71a threshold for compensable ROM impairment is ROM less than “shoulder level” (i.e. 90 degrees abduction). All three ROM evaluations at the MEB, MEB/PT and VA examinations demonstrated this ROM to be exceeded for the left and right shoulders precluding a compensable rating under ROM. Service treatment records (STRs) indicate that following his shoulder surgeries the CI had decreased ROM of both shoulders but pain was a greater issue in the left shoulder than the right. The Board agreed that the CI’s left shoulder met the 10% rating of 5201 IAW §4.59 (painful motion), but that the evidence in the record did not support the 10% rating for the right shoulder. Therefore, 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 left shoulder condition and 0% for the right shoulder condition.
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 for rating the bilateral shoulder pain was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the LBP condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the bilateral shoulder condition, the Board unanimously recommends a disability rating as follows: an unfitting left shoulder condition of 10%, and an unfitting right shoulder condition of 0%, coded 5201 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 his prior medical separation:

UNFITTING CONDITION
 VASRD CODE RATING
Low Back Pain w/out Trauma or Injury 5299-5237 10%
Left Shoulder Pain 5201 10%
Right Shoulder Pain 5201 0%
COMBINED
20%

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120907, 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 AR20130009089 (PD201201788)
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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