RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2013-01576
BRANCH OF SERVICE:  Army 	BOARD DATE:  20150805
SEPARATION DATE:  20041125 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Military Police) medically separated for a cervical spine condition which could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty.  A profile allowed for an alternate aerobic event to satisfy physical fitness standards.  She was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The condition “myofascial neck pain” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded four other conditions (panic disorder, migraines, genital herpes, and acne) judged to meet retention standards.  The Informal PEB adjudicated “chronic neck pain due to myofascial pain syndrome” as unfitting, rated 0%, citing criteria of Army Regulation (AR) 635-40 (B-29, e).  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.   

CI CONTENTION:  The applicant contends she now has “shoulder radiculitis, left upper extremity” along with her cervical spine condition.  Her submission included an attachment that was reviewed by the members.  Her complete submission is at Exhibit A.

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:  

IPEB - Dated 20040916	VA* (~2 Mo. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Myofascial Neck Pain	5099-5021	0%	Cervical Spine Condition	5237	0%	20050121	
			Radiculitis, Left Upper Extremity	8515-5021	10%		
Other MEB/PEB Conditions x 4 (Not In Scope)	Other x 11	
RATING:  0%	RATING:  70%	
*Derived from VA Rating Decision (VARD) dated 20050725 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:    

Cervical Spine (with Contended Radiculitis).  The service treatment record (STR) corroborated the history in the narrative summary (NARSUM) of an onset in September 2003 (14 months prior to separation) of cervical pain radiating into the non-dominant left upper extremity (LUE).  A cervical X-ray was normal.  The pain persisted and included subjective numbness and left hand weakness; and, although improving, it did not respond adequately to a protracted trial of conservative measures (physical therapy, traction, TENS, local injections).  Various STR entries reflect psychologic contributors to the symptoms.  Magnetic resonance imaging and electrodiagnostic testing (EMG) were normal.  Earlier STR entries record some modest LUE strength deficits (4/5 shoulder abduction and hand grip), but entries more proximate to separation record grossly normal motor testing.  There are entries reflecting full cervical range-of-motion (ROM), but with painful motion.  There are no STR entries documenting more significant ROM limitation or neurologic deficits, abnormal spinal contour, or periods of incapacitation.  The NARSUM was conducted 14 June 2004 (5 months prior to separation) and documented “complaints of neck pain and [LUE] paresthesias” without elaboration of severity or limitations other than profile restrictions.  It referred to numerous consultant examinations, but did not provide an independent physical examination (no ROM or neurologic findings).  There was no formal ROM measurement by the Service in evidence.  

A VA Compensation and Pension (C&P) examination was conducted 21 January 2005 (3 months after separation) and documented that the CI “continues to complain of chronic pain ... with tingling and loss of strength in both arms ... greater on the left side ... unable to make a fist while having pain.”  Functional limitations were not elaborated.  The VA physical examination noted that the CI was “very anxious, at times emotionally tearful”; and, recorded cervical tenderness without mention of spasm or abnormal contour.  The neurologic findings for the cervical exam were “5/5 bilateral upper extremities ... bilateral dermatomes intact to fine touch;” but, confusingly, the shoulder exam (shoulder pain was a separate complaint for VA rating) recorded left shoulder and grip strength as 3/5 (right 5/5).  The VA measured ROM was 45 degrees flexion (normal) and combined ROM of 200 degrees (normal 340), annotating painful motion.

The Board directed attention to its recommendations based on the above evidence.  The PEB’s rating was under the analogous code 5021 (myositis) which defaults to criteria of 5003 (degenerative arthritis); and, conferred a 0% rating citing “motion limited by pain” and adding “no objective signs of radiculopathy.”  The VA conferred a 0% rating under 5237 (cervical strain), even though the rating decision correctly cited the C&P ROM measurments while referencing the VASRD §4.71a 10% criterion of combined ROM 170 - 335 degrees; and, either the C&P combined ROM of 200 degrees or the C&P documented painful motion meet §4.71a criteria for a 10% rating.  The VA conferred a 10% rating for the LUE radiculitis under the hyphenated code 8515-5021 (median nerve impairment rated as myositis); but, cited shoulder ROM evidence and stated that the rating was assigned “for painful or limited motion of a major joint or group of minor joints.”  Since this rationale applies to joint (not nerve) rating, the basis for the VA rating appears to be based on left shoulder joint impairment (not within the Board’s scope) rather than neurologic impairment.

With regards to the cervical spine rating, members agreed that the only ROM evidence available in this case (C&P) which is compliant with VASRD §4.46 (accurate measurement) supports a 10% rating as elaborated above.  There is no evidence of abnormal spinal contour to achieve a higher rating, and no documentation of incapacitating episodes which would provide for a higher rating under that formula.  Additionally members carefully considered whether separate rating under a peripheral nerve code for the radiculopathy in evidence could be supported.  Firm Board precedence requires a functional impairment linked to fitness to support a recommendation for addition of a peripheral nerve rating to Service disability in spine cases.  The pain component of a radiculopathy is subsumed under the general spine rating as specified in §4.71a.  The intermittently documented sensory component (subjective more than objective) has no functional implications.  The objective evidence for motor impairment, specifically diminished grip strength, was inconsistent; and, it must be considered that this was the non-dominant extremity and that there was a psychological component with probative value implications.  Members agreed there was not a preponderance of evidence for significant functional impairment from the associated radiculopathy, and the Board cannot support a recommendation for additional Service disability rating on this basis.  After due deliberation, considering all of the evidence and conceding VASRD §4.3 (reasonable doubt), the Board recommends a 10% rating for the cervical spine condition; proposing code 5237 for its clinical compatibility.

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 AR 635-40 for rating was operant in this case and it was adjudicated independently of that regulation by the Board.  In the matter of the cervical spine condition, the Board unanimously recommends a Service disability rating of 10%, coded 5237, IAW VASRD §4.71a.  With regard to the contended radiculitis associated with the unfitting spine condition, the Board unanimously agrees that it cannot recommend additional Service rating for peripheral nerve impairment.  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 her prior medical separation:    

CONDITION	VASRD CODE	RATING	
Cervical Myofascial Pain	5237	10%	
RATING	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130923, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXX, AR20150014865 (PD201301576)

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 10% 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						     

CF: 
(  ) DoD PDBR
(  ) DVA