IN THE CASE OF: BOARD DATE: 4 September 2012 DOCKET NUMBER: AR20120004847 THE BOARD CONSIDERED THE FOLLOWING EVIDENCE: 1. Application for correction of military records (with supporting documents provided, if any). 2. Military Personnel Records and advisory opinions (if any). THE APPLICANT'S REQUEST, STATEMENT, AND EVIDENCE: 1. This case comes before the Army Board for Correction of Military Records (ABCMR) on a remand from the United States (U.S.) Court of Federal Claims, Washington, DC for further administrative action based on the previous findings in ABCMR Board Docket AR20110010341, dated 29 November 2011. 2. The Court remanded the case to the ABCMR to consider the following issues: * whether the applicant's separation action complied with applicable laws and policies * whether the applicant had unfitting physical conditions in addition to neck pain at the time of separation * whether the applicant’s disability rating was appropriate * to take any corrective action the Board deems appropriate based on its review 3. The Court noted in its decision that this Board appeared to deny the applicant’s request for relief based at least in part upon the medical history of another service member as captured in a Board of Veteran’s Appeals (BVA) case submitted by applicant. 4. The Court stated the applicant submitted the BVA case as legal precedent in support of his case, not as substantive evidence of his own medical history. The Court directed that the ABCMR reconsider the applicant’s case in light of the purpose for which the evidence was submitted, that the BVA case served only as legal precedent and not evidence of the applicant’s personal medical history. 5. The following documents are provided in support of the application: * U.S. Court of Federal Claims Remand Order Number 10-854, dated 24 February 2012 * ABCMR Docket Number AR20110010341, dated 29 November 2011 * an Administrative Record Index comprised of Tabs A through O, consisting of 975 pages CONSIDERATION OF EVIDENCE: 1. Incorporated herein by reference are military records which were summarized in the previous consideration of the applicant's case by the ABCMR in Docket Number AR20110010341, on 29 November 2011. 2. A review of the applicant's records show he served in the U.S. Army Reserve (USAR) as an enlisted Soldier prior to his appointment as a USAR officer. He executed an oath of office on 17 May 1990 and was appointed a second lieutenant in the USAR as an Infantry officer and Signal officer. He was promoted to the rank/grade of major (MAJ)/O-4 on 1 July 2004. 3. He provided a DD Form 2808 (Report of Medical Examination) which shows he underwent a physical examination on 3 March 2004, where he was found to be physically fit for retention. The examining physician checked block 74a (Examinee/Applicant) of the form indicating the applicant was qualified for service. 4. The applicant provided a DD Form 2807-1 (Report of Medical History), dated 3 March 2004. This form shows, in part, he placed a check mark in the boxes below indicating “Yes” or “No” to the question "Have you ever had or do you have now?:" * "Yes" in block 12a (Painful shoulder, elbow or wrist) * "No" in block 12b (Arthritis, rheumatism, or bursitis) (emphasis added) * "No" in block 12c (Recurrent back pain or any back problem) * "No" in block 12d (Numbness or tingling) * "Yes" in block 12f (Foot trouble) * "No" in block 12g (Impaired use of arms, legs, hands, or feet) (emphasis added) * "No" in block 12h (Swollen or painful joint(s)) * "No" in block 12i (Knee trouble) * "No" in block 13a (Frequent indigestion or heartburn) * "Yes" in block 14a (Currently in good health) 5. In block 29 (Explanation of "Yes" Answers) he indicated block 12a was "Yes" due to "Fell on right shoulder; had surgery to remove the tip of the collarbone and two bone spurs." Block 12f was "Yes" due to a "bunion on the big toe of the right foot." 6. A review of his Official Military Personnel File (OMPF) in the Interactive Personnel Electronic Records Management System contains the following: a. A DA Form 1059 (Service School Academic Evaluation Report) shows that while attending the Signal Officer Advanced Course from 18 through 29 October 2004, he passed the Army Physical Fitness Test (APFT). b. An Officer Evaluation Report (OER) which covered 4 months of rated time from 9 September 2004 through 6 January 2005 contains an entry which shows he passed the APFT in September 2004. c. An OER for the period 7 January through 30 June 2005 shows he passed the APFT in June 2005. d. He was mobilized as a member of his USAR unit in support of Operation Enduring Freedom and he entered active duty on 6 September 2005. He was assigned to Fort Benning, GA. e. He received an OER for the period 1 July 2005 through 30 June 2006. This form contains an entry which shows he passed the APFT in June 2006. f. On 26 April 2007, he was issued a Notification of Eligibility for Retired Pay at Age 60 (Twenty Year Letter) showing he had completed the required years of service and he would be eligible for retired pay upon application at age 60. g. An OER covering the period 1 July 2006 through 30 June 2007 shows he passed the APFT in November 2006. 7. He provided the following medical documentation: a. A DA Form 2173 (Statement of Medical Examination and Duty Status), shows he injured his 4th right toe while doing unit physical training (PT) in January 2006. He also began to have bunion pain on his right foot. He was evaluated by a civilian podiatrist in Helena, AL. The date examined was 23 January 2006 and the injury was found to have been incurred in the line of duty. The DA Form 2173 is dated 25 January 2007. b. A DA Form 2173 which indicates that in April 2006 he began experiencing neck pain after performing bench presses during PT. His pain became progressively worse and he was referred to the University of Alabama for evaluation. He was examined on 22 August 2006 and his injury was found to be in the line of duty. This DA Form 2173 is dated 24 September 2007. c. A Follow-Up Evaluation, dated 22 August 2006, from The Work Place, Birmingham, AL, which is attached to the DA Form 2173, shows in part, "[The Applicant] reports onset of upper back and neck pain after a prolonged rifle shooting session. He has aching pain radiating down his shoulders into his arms and intermittent tingling in his hands and fingers. He has not noticed any hand weaknesses and had a nerve conduction test which showed no definite evidence of radiculopathy. He had polyphasic and giant motor units in the left triceps which could indicate chronic denervation-reinnervation process. The lack of findings in other muscles could not give a definitive diagnosis." d. A DA Form 2173 shows he was evaluated at Martin Army Community Hospital, Fort Benning, GA on 18 July 2007. The injury was found to have been incurred in the line of duty. This document also shows he was mobilized in September 2005 with a prior shoulder injury and he re-aggravated this injury due to carrying heavy gear. This DA Form 2173 is also dated 24 September 2007. e. Block 30 (Details of Accident-Remarks) of all three DA Forms 2173 contains the entry "Soldier injury/illness occurred while mobilized. He was not under my command on the date injury/illness occurred. He was assigned to Company B, Warrior Transition Battalion on 8 August 2007. I have no knowledge of events that occurred prior to that date." These forms are dated 24 or 25 September 2007and signed by the applicant's immediate commander. f. Two DA Forms 3349 (Physical Profile), dated 20 July 2007 and 12 September 2007, which show he was given two temporary profiles and a rating of 3 in physical capacity/stamina, upper extremities and lower extremities categories. g. A DA Form 3349, dated 11 June 2008, shows the applicant was given a permanent profile of 3 for his upper extremities and he was recommended for a medical evaluation board (MEB)/physical evaluation board (PEB). 8. On 9 June 2008, an MEB convened and diagnosed him with cervicalgia, joint pain-shoulder region, left medial meniscus derangement, hallux valgus-right, restless leg syndrome, gastroesophageal reflux disease (GERD), migraines, hypercholesterolemia, pain disorder with anxiety and depression, and inflammatory arthritis. Only the cervicalgia was rated as medically unfitting for retention and the MEB recommended he be referred to a PEB. He concurred with the findings on 18 July 2008. 9. The narrative summary of the MEB shows the board found, in part, the following: * Chronic cervicalgia - Early 2006 while exercising; no evidence of radiculopathy; experiences pain that interferes with daily function; medically unacceptable * Joint pain-right shoulder - dislocated collarbone in 2004; pain began in October 2006; tiny nondisplaced inferior labral tear; no further treatment needed; medically acceptable * Left knee pain - old injury without significant interference of duty; has P-2 running profile; medically acceptable * Hallux valgus-right - elective surgery to remove bunion in 2008; no further problems or limitations; medically acceptable * Restless leg syndrome - on Mirapex with good results; medically acceptable * GERD - on medication Acipex since June 2006, takes on an as-needed basis; medically acceptable * Migraines - December 2005, takes Imitrex as needed, taken twice this year; headaches occur about every 3 months; prompt relief with Imitrex medically acceptable * Hypercholesterolemia - June 2006, initially controlled with diet, exercise, and weight loss; medically acceptable 10. The applicant completed a DD Form 2807-1 on 10 June 2008. This form shows he checked the following boxes, indicating “yes” or “no” to the question "Have you ever had or do you have now?" * "Yes" in block 12a (Painful shoulder, elbow or wrist) * "No" in block 12b (Arthritis, rheumatism, or bursitis) (emphasis added) * "Yes" in block 12c (Recurrent back pain or any back problem * "Yes" in block 12d (Numbness or tingling) * "Yes" in block 12f (Foot trouble) * "No" in block 12g (Impaired use of arms, legs, hands, or feet) (emphasis added) * "Yes" in block 12h (Swollen or painful joint(s)) * "No in block 12i (Knee trouble) * "Yes" in block 13a (Frequent indigestion or heartburn) * "No" in block 14a (Currently in good health) As an explanation for the "No" checked in block 14a the applicant wrote "I don't consider myself in good health due to my neck issues" (emphasis added). 11. A DD Form 2808, dated 11 June 2008, shows he underwent a medical examination on that date. The examining physician checked "normal" for the physical evaluation of the applicant with the exception of block 36 (Spine, other musculoskeletal) wherein he checked "abnormal." As an explanation for block 36, the physician wrote "Pain to palpation over upper cervical spine and paraspinous muscles; pain over upper lateral trapezoid muscles to palpitation - all old." 12. On 28 July 2008, an informal PEB convened at Fort Sam Houston, TX, and confirmed his one unfitting disability. a. The PEB found the applicant's condition prevented him from performing basic Soldier functions and determined that he was physically unfit due to "spinal stenosis, cervical spine with multi-level disc protrusion, C5-6 cord flattening and mild stenosis of the canal as well as C5-6 slight spinal canal stenosis. b. No motor neurologic deficits were found. Flexion 30 degrees, combined 250 degrees. Exam shows tenderness to palpation. Pain increases with repetition as evidenced by forward flexion of 30, 20, and 25 degrees (repeated measurements)." c. He was rated under the Department of Veterans Affairs Schedule for Rating Disabilities (VASRD) code 5238 and assigned a 20 percent disability rating. The PEB recommended he be separated with severance pay and if the applicant retired, his retirement not be based on disability from injury or disability from injury or disease received in the line of duty as a direct result of armed conflict. d. On 10 August 2008, he nonconcurred with the findings and requested a formal hearing. 13. On 19 September 2008, the formal PEB reevaluated all available medical records and sworn testimony by the applicant. The board recessed and asked an MEB to obtain: a. A response to the applicant’s claim the MEB did not adequately address all of his medical conditions affecting his ability to perform his duties and responsibilities. b. An evaluation of multiple joint pain from a rheumatologist. c. A psychiatric evaluation based upon applicant’s treatment for pain disorder with anxiety and depression. d. A repeat range of motion measurements and evaluation of the cervical spine. e. An assessment of the conditions regarding medical retention standards. 14. On 17 October 2008, the approving authority approved the board's findings and recommendations. The DA Form 3947 (MEB Proceedings) shows that on 22 October 2008, the applicant signed this form and checked block 24 “I do not agree with the board findings and recommendations." 15. A formal PEB convened at Fort Sam Houston, TX on 12 December 2008. The applicant appeared before the PEB and was represented by counsel. a. The PEB confirmed one unfitting disability of "spinal stenosis, cervical spine with mulit-level disc protrusion, C5-6 cord flattening and mild stenosis of the canal as well as C5-6 slight spinal canal stenosis." He was awarded a 20 percent disability rating under VASRD code 5238. b. The PEB recommended the applicant be separated with severance pay and if retired, his retirement not be based on disability from injury or disability from injury or disease received in the line of duty as a direct result of armed conflict. c. The board also found his conditions of joint pain-shoulder region, left medial meniscus derangement, hallux valgus-right, restless leg syndrome, GERD, migraines, hypercholesterolemia panic disorder with anxiety and depression, and inflammatory arthritis were not unfitting. d. In response to the applicant's contention that he should be found unfit for arthritis and pain disorder, both conditions were specifically addressed by the MEB and were found to be medically acceptable conditions. e. The PEB noted the preponderance of evidence supported that there were no significant limitations on the applicant's ability to perform in his area of concentration, there were no restrictions or limitations in his profile, and none were listed by his commander as being conditions that hindered his performance. f. In response to his contention that new range of motion (ROM) testing of his cervical spine warranted a rating of 30 percent, the average forward flexion was greater than 15 degrees and the combined range of motion was greater than 170 degrees and according to those measurements the highest rating was 20 percent. g. In response to his contention that his cervical radiculopathy should be found unfitting, that although nerve studies confirmed the diagnosis, the physical examination showed no evidence of upper extremity weakness or atrophy. The mere presence of a condition did not constitute a physical disability nor does it result in an automatic unfit determination (emphasis added). h. The applicant had no additional limitations from pain, fatigue, weakness, lack of endurance, or lack of coordination following repetitive use. i. On 22 December 2008, the applicant nonconcurred with the PEB findings and recommendations and submitted a rebuttal. 16. On 7 January 2009, the PEB informed the applicant that after careful consideration of his rebuttal they determined it contained no new objective medical or performance evidence which would warrant a change to the original findings. The PEB found the following for each listed medical condition: a. In the ROM study for his neck, the PEB could find no requirement for the range of findings to correlate within five percent. His best active ROM was 20 degrees which merits a 20 percent rating in accordance with the VASRD. The block to document additional loss on the form used to record his original ROM findings was left blank by the provider indicating no additional loss was found. Therefore, the preponderance of evidence indicated his current level of disability was between 16 and 30 degrees forward flexion which was correctly rated at 20 percent. b. For an inflammatory arthritis and pain disorder, the PEB noted the MEB found these conditions to meet medical retention. There was no compelling evidence to show those conditions interfered with his ability to perform his military duties. The applicant's argument that an examination for rheumatoid arthritis be conducted during a flare episode and ROM studies be performed for the affected joints was immaterial because the condition was not unfitting and therefore would not be considered for a rating. c. The PEB did not find his mental health to be duty limiting at the present time. Although it may have temporarily interfered with his duty performance in the past, the preponderance of evidence showed it was being successfully treated. d. The PEB affirmed its finding that his radiculopathy did not interfere with his duty performance. The finding was not arbitrary and capricious because there was no weakness in his upper extremities. e. His contention that he was denied access to an independent medical advisor as required by the 2008 National Defense Authorization Act (NDAA) and the Department of Defense (DOD) Policy Memorandum on Implementing Disability-Related Provisions of the NDAA was a medical treatment facility issue and would not be addressed by the PEB. However, the PEB noted that his MEB was initiated on 9 June 2008 and on 18 July 2008 he indicated he agreed with the findings and was aware of and involved in the preparation of his case file for presentation to the PEB. There was no evidence the applicant was "denied" access to an independent medical advisor which could be his primary care manager. 17. On 28 January 2009, the applicant submitted his election to transfer to the Retired Reserve in lieu of receiving severance pay. 18. On 2 February 2009, the U.S. Army Physical Disability Agency (USAPDA) approved the PEB on behalf of the Secretary of the Army. 19. Orders Number 036-2215, dated 5 February 2009, issued by Headquarters, U.S. Army Infantry Center, released him from active duty (REFRAD) not by reason of physical disability. 20. He was REFRAD on 5 May 2009, by reason of completion of required active service and he was transferred to the USAR Control Group (Retired Reserve). His service was characterized as honorable. He completed 3 years and 8 months of creditable active service during this period. At the time, he had 1871 active duty points (the equivalent of 5.12 years) and approximately 1140 inactive duty and membership points (about 3.12 years). 21. In the processing of this case, two staff advisory opinions were obtained from the USAPDA, dated 23 March and 26 April 2012. The advisory official noted that: a. With respect to the BVA decision intended as legal precedent rather than evidence of the applicant’s medical history, an additional review of the applicant's case file provided no specific support for the USAPDA comments in paragraph 6 of the 8 June 2011 advisory opinion. Specifically, “The examiner noted the applicant stated that his condition had existed for the past __ years” (based upon his VA claim the condition appears to have started before 1995) and had a “gradual onset of pain in the joints.” b. The deletion of the comment referenced above does not diminish or alter the ultimate opinions provided by the USAPDA; no material errors exist in the applicant’s disability processing that would require correction. c. The original questions that the Court requested be addressed remain unchanged and the USAPDA opinion and responses to those questions remain unchanged. The USAPDA 8 June 2011 advisory opinion remains accurate and continues to reflect their findings based on the case file provided. (1) The applicant’s separation from active duty complied with applicable laws and policies as such processing errors did not result in any material errors regarding the ultimate findings of the PEB. (2) He did not have any unfitting physical conditions in addition to his neck pain at the time of separation. (3) The applicant received an appropriate disability rating. (4) The USAPDA recommended no changes to the applicant’s military records. 22. Copies of the advisory opinions were provided to the applicant for comment or rebuttal; however, counsel states he elects not to respond to either of the opinions. 23. Army Regulation 635-40 (Physical Evaluation for Retention, Retirement, or Separation) establishes the Army PDES and sets forth policies, responsibilities, and procedures that apply in determining whether a Soldier is unfit because of physical disability to reasonably perform the duties of his office, grade, rank, or rating. It states there is no legal requirement in arriving at the rated degree of incapacity to rate a physical condition which is not in itself considered disqualifying for military service when a Soldier is found unfit because of another condition that is disqualifying. Only the unfitting conditions or defects and those which contribute to unfitness will be considered in arriving at the rated degree of incapacity warranting retirement or separation for disability. 24. Army Regulation 635-40 further states the mere presence of impairment does not, of itself, justify a finding of unfitness because of physical disability. In each case, it is necessary to compare the nature and degree of physical disability present with the requirements of the duties the member reasonably may be expected to perform because of his or her office, rank, grade, or rating. The Army must find that a service member is physically unfit to reasonably perform his duties and assign an appropriate disability rating before that service member can be medically separated or retired. 25. Army Regulation 40-501(Standards of Medical Fitness) governs medical fitness standards for enlistment; induction; appointment, including officer procurement programs; retention; and separation, including retirement. Once a determination of physical unfitness is made, the PEB rates all disabilities using the VASRD. Ratings can range from 0 percent to 100 percent, rising in increments of 10 percent. 26. In most circumstances, a member is not entitled to disability retired or severance pay under the provisions of Title 10, U.S. Code (USC), section 1201, 1202, and 1203 based upon a disability incurred prior to a member becoming entitled to basic pay (e.g. a preexisting condition). Title 10, USC, section 1207a provides an exception if the Soldier has at least eight years of active service. In those situations, the preexisting condition is deemed to have been incurred while the member was entitled to basic pay and shall be so considered for purposes of determining whether the disability was incurred in the line of duty. 27. Title 10, USC, section 101(d), defines “active service” as service on active duty or full-time National Guard duty. "Active duty" means full-time duty in the active military service of the United States. Such term includes full-time training duty, annual training duty, and attendance, while in the active military service, at a school designated as a service school by law or by the Secretary of the military department concerned. Such term does not include full-time National Guard duty. 28. Title 10, USC, section 101(d), defines "inactive duty training" as: * Duty prescribed for Reserves by the Secretary concerned under Title 37, USC, section 206 (setting forth rules for participation in and payment for periods of inactive duty for training) * Special additional duties authorized for Reserves by an authority designated by the Secretary concerned and performed by them on a voluntary basis in connection with the prescribed training or maintenance activities of the units to which they are assigned 29. The DOD “Policy Memorandum on Implementing Disability-Related Provisions of the 2008 NDAA (Pub. L. 110-181)” dated 14 October 2008, which was given immediate effect and revised and replaced various sections of Department of Defense Instructions 1332.38, “Physical Disability Evaluation,” dated November 14, 1996, included the following regarding an independent medical review: a. E3.P1.2.6.1.2. Upon request of a Service member referred into the PDES, an impartial physician or other appropriate health care professional (not involved in the Service member’s MEB process) is assigned to the Service member to offer a review of the medical evidence presented by the narrative summary or MEB findings. In most cases, this impartial health professional should be the Service member’s primary care manager. The impartial health professional will have no more than 5 calendar days to advise the Service member on whether the findings of the MEB adequately reflect the complete spectrum of injuries and illness of the Service member. b. E3.P1.2.6.1.3. After a review of the findings with the assigned impartial health care professional, a Service member shall be afforded an opportunity to request a rebuttal of the results of the MEB. . . . DISCUSSION AND CONCLUSIONS: 1. The evidence of record shows the applicant's pain disorder was fully considered by the MEB and PEB and was reviewed by a psychologist and psychiatrist. a. His pain disorder was found not to be unfitting and not to require any limitations of duty. The pain and discomfort he experienced which caused him to be careful about the position he sat in so as not to cause pain or numbness was determined to be caused by his cervical condition. b. This finding was supported by the applicant when he annotated the DD Form 2807-1 to show he did not consider himself in good health "due to neck issues." Therefore, this condition was appropriately not found to be a separately compensable condition. c. When the MEB found the applicant's condition of chronic cervicalgia as unfitting, that board also reviewed his medical records which showed there was no evidence of radiculopathy. d. The PEB also found that radiculopathy was not listed on his physical profile as requiring limitation of duties, the physical findings did not support that this condition hindered his abilities to perform his assigned duties, and they appropriately did not find this condition as unfitting as the condition was considered to meet medical retention standards. Therefore, this condition was appropriately not found to be compensable. 2. The evidence shows the PEB properly rated the applicant's cervical neck pain at 20 percent. The PEB's consideration of the ROM measurements taken in June and October 2008 were both authorized and supported by the facts. a. Of the eight measurements taken only two would qualify as 30 percent. All other measurements would qualify as a 20 percent rating as found by the PEB. b. The PEB appropriately determined the totality of the evidence best supported that the overall ROM limitations of the neck were in excess of 15 degrees and thus supported the 20 percent rating. 3. The advisory opinions dated 23 March and 26 April 2012, clearly state that omission of the BVA case pertaining to the other service member does not diminish or alter the ultimate opinions provided by the USAPDA in the 8 June 2011 advisory opinion. 4. The Physical Disability Evaluation System is performance based and there is no evidence the applicant was, at any time, unable to perform his duties due to arthritis. The PEB therefore properly found his arthritis was not unfitting. 5. Additionally, the applicant does not have 8 or more years of active service for purposes of Title 10, USC, section 1207; therefore, he is not entitled to disability compensation for any pre-existing conditions. 6. With respect to the alleged denial of his request that an independent medical reviewer be assigned to his case, the policy implementing that entitlement was not in effect at the time of his MEB. Further, the applicant was notified that he would be separated rather than retired with a disability, he challenged, rebutted, and appealed at virtually all junctures. He alleged additional conditions beyond those originally considered by the MEB, he obtained additional tests, submitted additional materials, and made additional arguments at every decision point. 7. The available evidence and the independent evidence provided by the applicant and counsel failed to show he had any unfitting physical conditions other than his neck condition at the time of separation from active duty. The case is absent evidence of a compelling nature that would support a conclusion that the 20 percent rating the applicant received from the PEB was unjust or in error. His separation action complied with applicable laws, regulations, and policies. 8. In view of the foregoing, he is not entitled to the relief requested. BOARD VOTE: ________ ________ ________ GRANT FULL RELIEF ________ ________ ________ GRANT PARTIAL RELIEF ________ ________ ________ GRANT FORMAL HEARING ____x____ ____x____ ___x__ DENY APPLICATION BOARD DETERMINATION/RECOMMENDATION: The evidence presented does not demonstrate the existence of a probable error or injustice. Therefore, the Board determined that the overall merits of this case are insufficient as a basis to amend the decision of the ABCMR set forth in Docket Number AR20110010341, dated 29 November 2011. _______ _ _x_____ __ CHAIRPERSON I certify that herein is recorded the true and complete record of the proceedings of the Army Board for Correction of Military Records in this case. ABCMR Record of Proceedings (cont) AR20120004847 3 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS 1 ABCMR Record of Proceedings (cont) AR20120004847 2 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS 1