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AF | PDBR | CY2013 | PD-2013-02577
Original file (PD-2013-02577.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX         CASE: PD-2013-02577
BRANCH OF SERVICE: ARMY  BOARD DATE: 20141015
SEPARATION DATE: 20070307


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard SGT/E-5 (11B/Infantry) medically separated for chronic right shoulder and hip and back conditions. The conditions 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 U3L3H2 profile and referred for a Medical Evaluation Board (MEB). The right shoulder, hip and back conditions, characterized as “right shoulder arthopathy status post (s/p) injury,” “right hip arthopathy status post injury” and “chronic lumbar pain status post injury” by the MEB were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB adjudicated “chronic pain right shoulder and right hip” and “chronic back pain without neurologic abnormality” as unfitting and rated at 10% and 10% respectively citing application of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals and was medically separated.


CI CONTENTION : “ During my initial MEB I was issued a 20% disability rating from the Army and was medically discharged and given severance pay. This rating did not include my diagnoses of TBI or PTSD. I received a Purple Heart for the TBI injury. ”


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, right hip and low back conditions are addressed below; and, no additional conditions (to include the contended traumatic brain injury and posttraumatic stress disorder 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 Board for Correction of Military Records.


 RATING COMPARISON :

Service IPEB – Dated 20070119
 VA - (15 Mos. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Pain Right Shoulder and Right Hip 5099-5003 10% Degenerative Arthritis Right Hip 5010 10% 20051214
Right Shoulder Dislocation 5201 Not Service Connected
Chronic Back Pain 5299-5237 10% Chronic Lumbosacral Strain 5237 10% 20051214
Others x 0 (Not in Scope)
 Other x 7 20051214
Combined: 20%
 Combined: 60%
Derived from VA Rating Decision (VA RD ) dated 200 60112 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY: The PEB combined the right shoulder and right hip conditions and rated as a single entity. The Board’s initial charge in this case was, therefore, directed at determining if the PEB’s approach of single rating as a single entity was justified in lieu of separate ratings. The Board must apply separate codes and ratings in its recommendations if compensable ratings for each condition are achieved IAW applicable VA Schedule for Rating Disabilities (VASRD) sections. If the Board judges that separate ratings are warranted in such cases, however, it must satisfy the reasonable requirement that each ‘unbundled’ condition was unfitting in and of itself or at least an indispensable element of a combined effect rating.

Chronic Back Condition. This right hand dominant CI was involved in a HUMVEE accident during preparation to deploy to Iraq in February 2004. At the initial emergency room evaluation the CI reported back and abdominal pain. On examination slight tenderness of the right hip point, tip of the right shoulder joint (acromio-clavicular joint) and lower abdomen were noted. X-rays of the shoulders, hips and abdominal CT scan were normal and the CI was discharged to quarters. Discharge diagnoses were multiple contusions, C-spine strain and mild right shoulder separation. The CI recovered and was deployed to Iraq in October 2004. While in Iraq the back pain increased. The CI was seen in theater (Ibn-Sina Hospital, Baghdad, physical therapy [PT] department) performed on 2 February 2005 with increased back pain. At that time range-of-motion (ROM) of the lumbar spine was “full” with normal motor and neurological exams. The examiner opined that CT scan was not indicated and CI could be administratively evacuated if unable to perform his MOS. The CI was returned CONUS in March 2005 for the back pain condition and placed in a medical-hold company.

At the VA Compensation and Pension (C&P) general exam, performed on 14 December 2005, 15 months prior to separation, the CI reported being able to walk 2 to 3 miles without back pain, using no back braces and taking only nonprescription medication for pain. On examination, gait was normal. On ROM analysis, forward flexion (FF) was 70 degrees (normal: 90 degrees) with pain on motion, but no tenderness or muscle spasm. Motor, sensory and reflex exams were normal. On physical exam for the narrative summary (NARSUM) (DD Form 2808) performed on 6 July 2006, ROM of the spine was reported as “full” with normal upper and lower extremity motor strength. At the MEB/NARSUM evaluation performed on 27 July 2006, 8 months prior to separation, the CI reported continued low back pain. The MEB physical exam noted the CI to be in no acute distress. Pain in the low back was reported with bending. Para vertebral muscle spasms were present. On PT evaluation of the back for the MEB performed on 28 July 2006, ROM of the back was 65 degrees FF with pain. On orthopedic consultation for the MEB performed on 7 November 2006, ROM of the spine was “decreased” with pain. Motor strength and reflexes were normal. The examiner referenced a magnetic resonance imaging (MRI) of the lower spine, obtained September 2006, showing multiple small disc herniation’s without nerve compression.

The Board directs attention to its rating recommendation based on the above evidence. Both the PEB and the VA rated the back condition 10%, coded 5237 (lumbo-sacral strain) IAW §4.71a, citing reduced FF of the back of 65 and 70 degrees respectively. Under this code, a rating of 10% requires FF of the lumbar spine greater than 60 degrees, but not greater than 85 degrees. The next higher rating, 20%, requires flexion of the lumbar spine greater than 30 degrees, but not greater than 60 degrees. The Board unanimously agreed that the preponderance of evidence in record supported a 10% rating, but no higher, for the lower back for reduced ROM from pain. The Board considered a rating under code 5243, (incapacitating episodes/intervertebral disc syndrome). An incapacitating episode is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed and treated by a physician. A 10% rating under this code requires “incapacitation episodes having a total duration of at least one week but less than two weeks during the past 12 months.” The record documents one episode of incapacitation under this definition for a total of 24 hours in the 12-month period prior to the MEB examination. The Board agreed that no rating could be recommended under this code. The Board considered a rating IAW §4.123 (neuritis, peripheral nerve). The Board agreed there was no evidence for ratable peripheral nerve impairment in this case, since no motor weakness was present, sensory symptoms had no functional implication and radiation of pain was subsumed under the back rating IAW §4.71a. The Board found no other appropriate codes for consideration. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the back condition.

Chronic Right Shoulder Condition. The CI sustained a probable mild separation of the acromioclavicular joint of the shoulder in the Humvee accident of February 2004 as referenced above. This was a clinical diagnosis as X-rays were normal. The condition was treated with a sling. On proximate follow-up evaluations, the record makes no mention of this condition. On evaluation performed on 4 April 2004, the right shoulder had full ROM without pain and full arm strength. On exam for the back performed on 28 January 2005, the CI noted being able to do all his missions with only back pain. On evaluation performed on 2 February 2005, at the Ibn-Sina Hospital, no mention was made of any shoulder difficulties.

At the VA C&P general exam performed on 14 December 2005, 15 months prior to separation, the CI reported “popping” of the shoulder with movement. He noted being unable to do any activities that required raising the arms. On examination of the right shoulder “popping without dislocation” was recorded. No tenderness or swelling was present on palpation. ROM of the right shoulder FF was 100 degrees and abduction (AbD) of 110 degrees (Normal for both: 180 degrees) both with pain on motion. No DeLuca findings were present. On physical exam for the NARSUM performed on 6 July 2006, ROM of the right shoulder was reported as “full” with normal upper and lower extremity motor strength. No instability was reported. At the MEB/NARSUM evaluation on 27 July 2006, 8 months prior to separation, the CI reported being unable to work overhead for any extended period of time due to shoulder pain. The MEB physical exam noted “decreased ROM of the shoulder” with crepitus on AbD. No instability was reported. On the PT evaluation for the MEB on 28 July 2006, ROM of the shoulder was FF of 120 degrees and AbD of 145 degrees, both with painful motion. On the orthopedic consultation for the MEB performed on 7 November 2006, examination of the right shoulder revealed no tenderness to palpation, obvious swelling, and ROM to be apparently “full” without pain. No instability was reported. The examiner referenced a recent MRI of the shoulder, not in record for review, read as “normal” by the radiologist, with which he disagreed, stating that “significant arthritis” of the shoulder was present in his opinion.

The Board directs its attention to fitting and rating recommendations based on the above evidence. The PEB, as noted before, combined the shoulder and hip conditions, and rated 10% using the Army Pain Policy. The VA adjured the right shoulder condition, claimed as ‘right shoulder dislocation’ as not service connected (NSC) citing the lack of confirmation in the record of any actual shoulder dislocation. The Board first agreed that the record reasonably supported the right shoulder condition to be unfitting as it is present in the permanent profile. The Board next undertook to rate the condition. The Board unanimously agreed that the preponderance of evidence did not support a rating for the shoulder condition for decreased ROM, codes 5201, 5202 (instability or recurrent dislocation). The Board agreed that use of code 5293 (impairment of the clavicle), as not indicated in the absence of a confirmed diagnosis of clavicle injury and/or pathology. The Board unanimously agreed that the record in evidence, supports a rating of 10% for painful motion with crepitus IAW §4.40 and §4.59. The Board found no other appropriate codes for rating consideration. 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.

Chronic Right Hip Condition. The CI suffered a hip contusion in the Humvee accident of February 2004 as reported above. X-rays at that time were negative. On examination 15 May 2004, gait was described as “normal.” On an exam for the back dated 28 January 2005, the CI noted being able to do all his missions with only back pain. On evaluation, dated 2 February 2005, at the Ibn Sina Hospital, no mention was made of any hip or lower extremity difficulties.

At the VA C&P general exam performed on 14 December 2005, 15 months prior to separation, the CI reported “popping” of the hip without dislocation with movement, pain described as “tightness” and difficulty with “squatting.” He noted that this did not adversely affect his occupation. On examination gait was normal. Tenderness to palpation was present on the front and side of the right hip. ROM of the right hip was FF was 70 degrees (Normal: 125 degrees). Other ROM of the hip (adduction, internal/external rotation) were normal. Pain on motion without popping was recorded. The CI was able to “squat.” No DeLuca findings were present. On physical exam for the NARSUM dated 6 July 2006, ROM of the hip was reported as “full” with normal lower extremity motor strength. At the MEB/NARSUM evaluation on 27 July 2006, 8 months prior to separation, “full” “ROM of the hip was recorded with pain on ‘extension greater than 60 degrees and internal rotation’.” The NARSUM examiner in his statement of the present medical condition did not mention the hip condition noting that: “SGT P--’s condition is stable. He has chronic lumbar pain which affects all activities of daily living. He cannot bend over and is unable to participate in many sporting and athletic events secondary to lumbar pain. He cannot work overhead for any length of time secondary to shoulder pain. He continues to maintain core muscle to prevent another exacerbation of lumbar pain.” On the PT evaluation for the MEB dated 28 July 2006, ROM of the hip was FF of 85 degrees and AbD of 40 degrees, both with painful motion. On the orthopedic consultation for the MEB on 12 September 2006 there is no mention of a hip condition or examination thereof. The examiner opined the CI to have only low back and shoulder pain syndromes. On repeat orthopedic evaluation on 7 November 2006, there is again no mention of a hip condition. A recent MRI of the hip was quoted as being “normal.”

The Board directs its attention to fitting and rating recommendations based on the above evidence. The Board noted the commander’s statement to specifically address only the back condition. The Board also noted the permanent profile of 26 July 2006 to be the only profile in record to contain the hip condition and to note “R hip pain status post surgery” - not supported by the preponderance of evidence in record. The Board also noted the absence of pathology on normal X-rays and MRI of the hip condition and documentation of normal gait throughout the record. The Board reviewed the decreased flexion of the hip caused by pain on motion on two examinations but concluded that, with reasonable medical certainty, this was a de facto expression of the back pain condition. After discussion, the Board unanimously concluded that the record did not reasonably support the hip condition to be unfitting per se and, thus, could not recommend a rating. The Board recommends no change in the PEB adjudication for the back condition. Upon unbundling the shoulder and hip conditions, the Board recommends a rating of 10%rating for the shoulder condition, coded 5299-5003 IAW §4.71a and §4.59 and assignment of the hip condition as not-unfitting and not subject to rating. This would result in a recommended combined rating of 20%. As this provides no rating benefit to the CI, the Board recommends no change in the PEB’s 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, PEB reliance on the USAPDA pain policy for rating the shoulder and hip conditions was operant in this case and these conditions were adjudicated independently of that policy by the Board. In the matter of the back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the unbundled shoulder condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a and §4.59. In the matter of the unbundled right hip condition, the Board unanimously agrees that it cannot recommend a finding of unfit for additional rating at separation. There were no other conditions within the Board’s scope of review for consideration.


RECOMMENDATION: The Board recommends that there be no re-characterization of the CI’s disability and separation determination.


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131104, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record








                 
XXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557


 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXX AR20150006485 (PD201302577)

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 and hereby deny the individual’s application.
This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

BY ORDER OF THE SECRETARY OF THE ARMY:




Encl                                                  XXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)
                                                     
CF:
( ) DoD PDBR
( ) DVA

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