RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX		BRANCH OF SERVICE: ARMY
CASE NUMBER:  PD0900067		COMPONENT: USAR
BOARD DATE: 20090708		SEPARATION DATE: 20050526
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SUMMARY OF CASE: This covered individual (CI) was an NCO medically separated from the Army in 2005 after 15 years of combined service.  The medical basis for the separation was a neck condition.  He developed right shoulder and neck pain moving gear during mobilization in 2004.  An MRI demonstrated cervical disc disease.  There were occasional radicular symptoms, but not a clinically significant radiculopathy.  His shoulder remained symptomatic, but no internal pathology was demonstrated on MRI.   The condition was not amendable to surgery and did not respond well enough to conservative management for continued service, resulting in a medical board.  The CI was diagnosed with several other conditions during the MEB evaluation.  This included obstructive sleep apnea (OSA), requiring continuous positive air pressure (CPAP) device, and carpal tunnel syndrome (CTS).  He was referred to the PEB, found unfit for the cervical condition only and separated at 10% combined disability.  
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CI CONTENTION: The CI contends that his cervical condition was under-rated by the PEB and petitions for a review of his other conditions.
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RATING COMPARISON:

Service PEB	VA   	
PEB Condition	Code	Rating	Date	Condition	Code	Rating	Exam Date	
Chronic Cervicalgia	5237	10%	20050504	Cervical Disc C5/6	5237	20%	20050816	
OSA/CPAP	Fit	-	20050504	OSA/CPAP	6847	50%	20050816	
CTS (R)	Fit	-	20050504	CTS R wrist	5215-8515	30%	20050816	
HTN	Fit	-	20050504	>		NSC		
Chronic knee pain	Fit	-	20050504	Patel/Fem L knee	5260	10%	20050816	
Chronic sinusitis	Fit	-	20050504	>		NSC		
Hi freq. hearing loss	Fit	-	20050504	>		NSC		
Hyperlipidemia	Fit	-	20050504	>		NSC		
Erectile dysfunction	Fit	-	20050504	>		NSC		
				R Shoulder strain	5203	10%	20050816	
				Non-PEB X 2				
TOTAL Combined:    10%	TOTAL Combined (incl. non-PEB Dxs):   80 %	

ANALYSIS SUMMARY:

Cervical Rating.  Only one goniometric cervical range-of-motion (ROM) is in the service treatment record (STR), performed by Physical Therapy (PT).  This elicited Flexion 10⁰/Total 160⁰.  Pain vs. mechanical end-points was not elaborated, although the Army P.T. examiner stated ‘pain noted all throughout the motion’.  The initial VA rating exam (4 months later) yielded Flexion 30⁰/Total 240⁰, rated 20%.  This was explicit regarding pain parameters, repetition, etc.  There are six STR entries for ‘normal’ cervical ROM during the MEB period, without goniometry.  The PEB exercised pain rule application to mitigate the single goniometric ROM exam in the STR, which would have yielded a 30% rating under §4.71a.  The ROM on the P.T. exam is significantly compromised vs. any other entries in the STR or VA records.  This suggests that the P.T. exam was a ‘bad day’ or outlier on other grounds.

Peripheral Nerve or CTS Rating.  Despite radiating quality of pain, the only constant pattern was confined to the right shoulder area.  A clinically significant cervical radiculopathy was excluded by electromyeography and repeatedly normal motor-sensory physical exams.  CTS was well documented, and occasioned the use of a splint on at least some occasions.  It was deemed medically acceptable by the MEB and adjudicated as fit by the PEB.  There is no fitness input that would be unique to wrist impairment.

Right Shoulder Strain.  The CI’s initial injury manifested as a shoulder problem.  Subsequent MRI excluded an internal derangement, but soft-tissue findings and symptomatic involvement were consistent clinical indicators of ongoing R shoulder pathology.  The MEB merged the shoulder component with the overall cervical condition in the general physical exam and NARSUM, not identifying the shoulder (separately coded and rated by the VA) as a distinct condition.  The PEB, therefore, did not adjudicate the shoulder condition independently.

OSA/CPAP. This was the only other condition meriting consideration as additionally unfitting.  The MEB forwarded it the PEB as not medically acceptable IAW AR 40-501, 3-41c.  The stated rationale was that fatigue and daytime hypersomnolence precluded the CI’s ability to operate a tactical vehicle and that CPAP was prohibitive in the field and deployment environments.  The PEB adjudicated it as not unfitting.  No rationale was elaborated.  The commander’s letter did not specify any unfitting implications of the OSA
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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 PDBR to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The PEB adjudication in this case reflected application of the service-specific ‘pain rule’ to the cervical rating, which was eliminated as a factor in this board’s rating.  The Board debated whether to apply the single MEB goniometric exam, or the VA goniometric exam, as a basis for recommended rating.  As discussed above, with countervailing physical exams in the STR mitigating the single formal exam, it was agreed that the VA measurements carried the most probative value and overcame §4.3 (reasonable doubt) considerations.  With one dissenting vote for 30%, the Board agreed on a recommendation of 20%.  The dissenting voter elected not to submit a minority opinion.

The Board notes that an additional contribution to the unfitting condition of the CI was the chronic shoulder impairment related to the initial injury.  Consideration was given by the board to separate coding and rating of the shoulder as additionally unfitting.  Precedent PDBR policy, however, is that only conditions specifically noted in the DES submission (MEB physical, NARSUM and PEB documents) are within the scope of Board jurisdiction.  This criteria was not met, and no recommendation is forthcoming in this regard.

The Board considered each of the CI’s other MEB conditions adjudicated fit by the PEB.  The rationales stated by the MEB for medical unacceptability of OSA in this case are not generally accepted by any service PEB as routine grounds for rendering a member unfit.  The PEB’s fitness adjudication in this instance was unanimously judged by the board to be appropriate.  Cervical radiculopathy and CTS were also considered as candidates for additionally unfitting conditions, but neither rose to any clinical significance that would have rendered the CI unfit.  The Board was in unanimous agreement that these, or any other conditions, did not reach the threshold of affecting fitness for duty.
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RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the CI’s prior medical separation.

UNFITTING CONDITION	VASRD CODE	RATING	
CHRONIC CERVICALGIA	5237	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20090123, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans' Affairs Treatment Record.