VA (7 Mos. Prior to TDRL Placement) - Effective 20031216 | ||||||||
Code | Rating | Condition | Code | Rating | Exam | |||
TDRL | Sep. | |||||||
Low Back Pain | 5299-5237 | 10% | 10% | Low Back Strain | 5237 | 10% | 20030530 | |
Left Shoulder Pain | 5201 → 5099-5003 |
20% | 0% | Left Rotator Cuff | 5299-5203 | 10% | 20030530 | |
Neck Pain | 5099-5003 → 5099-5021 |
0% | 0% | Cervical Strain | 5237 | 20% | 20030530 | |
Other x 2 | ||||||||
Rating: 40% | ||||||||
Thoracolumbar ROM (Degrees) |
VA C&P ~7 Mos. Pre-TDRL* |
PT ~5 Mos. Pre-TDRL |
MEB ~3 Mos. Pre-TDRL |
MEB ~ 3 Mos. Pre-TDRL Removal |
Flexion (90 Normal) | 50 | 80 | 80 | 90 (110) |
Extension (30) | 20 | 10 | 10 | 20 |
R Lat Flexion (30) | 20 | 20 | - | - |
L Lat Flexion (30) | 20 | 20 | - | - |
R Rotation (30) | 20 | - | - | 30 |
L Rotation (30) | 20 | - | - | 30 |
Combined (240) | 150 | N/A | N/A | > 170 and < 230 |
Comment | No spasm | |||
§4.71a Rating | 20% (VA 10%) | 10% | 10% | 10% |
Left Shoulder ROM (Degrees) |
VA C&P ~ 7 Mos. Pre-TDRL* | OT ~ 5 Mos. Pre-TDRL | MEB ~3 Mos. Pre-TDRL | MEB ~ 3 Mos. Pre-TDRL Removal |
Flexion (180 Normal) | 120 | 90 | 90 | 170** |
Abduction (180) | 120 | 75 | 75 | 160** |
Comments | +Painful motion | |||
§4.71a Rating | 10% | 20% | 20% | N/A** |
Cervical ROM (Degrees) |
VA C&P ~ 7 Mos. Pre-TDRL* | OT ~ 5 Mos. Pre-TDRL | MEB ~ 3 Mos. Pre-TDRL | MEB ~ 3 Mos. Pre-TDRL Removal |
Flex (45 Normal) | 30 | 40 | 40 | “Full” ROM |
Extension (45) | 20 | 15 | 15 | |
R Lat Flexion (45) | - | 30 | - | |
L Lat Flexion (45) | - | 20 | - | |
R Rotation (80) | 20 | 65 | - | |
L Rotation (80) | 20 | 50 | - | |
Combined (340) | NA | 220 | NA | |
Comment | No spasm | +painful motion | ||
§4.71a Rating | 20% | 10% | 10% | 0% or 10% (PEB 0%) |
UNFITTING CONDITION | VASRD CODE | RATING | |
TDRL | PERMANENT | ||
Chronic Low Back Pain | 5299-5237 | 10% | 10% |
Chronic Left Shoulder Pain | 5201 | 20% | 20% |
Chronic Neck Pain | 5099-5021 | 10% | 0% |
COMBINED | 40% | 30% |
AF | PDBR | CY2014 | PD-2014-00630
Left Shoulder Condition . At the VA C&P examination, performed 16 months prior to separation, the CI reported a cervical spine injury in 1998 with continual pain accompanied by a left upper extremity radiculopathy. Based on the ROMs in the record the Board was unable to find a route to a higher rating.The MEB referred cervical spondylosis with C7-8 radiculopathy; however, the PEB noted cervical spondylosis “without significant neurologic abnormality.” The Board considered whether an...
AF | PDBR | CY2013 | PD 2013 00095
Despite the CI’s remarks of pain during portions of flexion of both knees, the VA C&P noted that examination of his knee on 10 June 2003 “ was grossly unremarkable” the examiner of on to state that the knee examination revealed “ no soft tissue swelling, no point tenderness, or joint effusion and there was no ligamentous instability appreciated.” After due deliberation in consideration of the preponderance of the evidence, the Board concluded there was insufficient cause to recommend a...
AF | PDBR | CY2009 | PD2009-00071
ROMs were pain limited to Cervical: 30˚/190˚, and Thoracolumbar 30˚/140˚. Although Physical Evaluation Board findings showed that your chronic cervical and thoracic pain was secondary to myofascial pain syndrome, VA finding showed instability of the cervical spine with limited range of motion, and chronic sprain, with scoliosis thoracolumbar spine, with limited range of motion which warrant the higher evaluation. The Cervical spine condition rating of 5021-5237 at 20% for forward flexion...
AF | PDBR | CY2010 | PD2010-00019
The MEB listed “chronic low back pain secondary to intervertebral disc disease,” “chronic neck pain” and “chronic shoulder pain” forwarded to the Physical Evaluation Board (PEB) as medically unacceptable IAW AR 40-501. The Board considered that the MEB and PT exams were closer to the date of separation, comprehensive, more indicative of the CI’s level of disability described in the service records, and therefore had a higher probative value. Minority Opinion : The Action Officer (AO)...
AF | PDBR | CY2012 | PD-2012-00310
He was treated with injections and physical therapy (PT), but did not significantly improve so an Condition Neck pain Left shoulder pain Code 5237 5099‐5003 Rating 10% 10% ↓No Addi(cid:415)onal MEB/PEB Entries↓ Combined: 20% Condition Code 5243 Cervical spine condition (C6‐C7) Left shoulder, anterior labral tear Left arm radiculopathy Paralumbar muscle spasms Tinnitus Right shoulder tendonitis 8515 5237 6260 5024 0% x 2 / Not Service‐Connected x 3 5299‐5203 Combined:...
AF | PDBR | CY2013 | PD-2013-02740
No other conditionwas submitted by the MEB.The Informal PEB adjudicated “chronic bilateral shoulder pain” and “chronic neck pain, without neurologic abnormality”as unfitting, rated 10% and 10%, citing application of the US Army Physical Disability Agency (USAPDA) pain policyfor the shoulder condition and with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) for the neck condition. However, the option of not recommending separate disability ratings, but...
AF | PDBR | CY2012 | PD2012-00473
The PEB adjudicated the chronic bilateral neck and shoulder pain as unfitting, rated 10% with application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD). Neck pain. RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation: VASRD CODE RATING 5241 COMBINED 20% 20% Chronic Bilateral Neck and Shoulder Pain UNFITTING CONDITION The following documentary evidence was...
AF | PDBR | CY2010 | PD2010-01293
In the matter of the neck pain condition, the Board unanimously recommends a disability rating of 10%, IAW VASRD §4.71a. RECOMMENDATION : The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation: Right Shoulder Pain, due to Myofascial Pain Syndrome5099-502110%Right Neck Pain, due to Myofascial Pain Syndrome5290-502110% COMBINED20% The following documentary evidence was considered:
AF | PDBR | CY2014 | PD2014 01910
The MEB also identified and forwarded two other conditions (high frequency hearing loss and anxiety disorder) for PEB adjudication.The Informal PEBadjudicated left shoulder pain, neck pain and LBPas unfitting, rated 10%, 0% and 0% respectively, with likely application of the VA Schedule for Rating Disabilities (VASRD) for the neck and back condition and citing the US Army Physical Disability Agency (USAPDA) pain policy for the shoulder condition. The PEB rated the condition of chronic neck...
AF | PDBR | CY2013 | PD-2013-02800
Almost 2 months prior to TDRL removal, the CI underwent an orthopedic evaluation for her upper back pain as noted in the neck pain section above. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient evidence to recommend that an unfitting MH condition was present at the time of TDRL placement and so no additional disability rating is recommended. RECOMMENDATION : The Board, therefore, recommends that there be no...