RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-01966
BRANCH OF SERVICE:  Army	BOARD DATE:  20150403
SEPARATION DATE:  20051206

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Health Care Specialist) medically separated for cervical and shoulder pain.  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 U3 profile and referred for a Medical Evaluation Board (MEB).  The “C6-C7 degenerative disc disease with disc protrusion,” “left shoulder pain,” and “bilateral patellofemoral pain syndrome” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded three other conditions (hypertension, hyperlipidemia, and tobacco use disorder) for PEB adjudication.  The Informal PEB adjudicated “chronic neck pain with radiating shoulder pain,” as unfitting, rated 10% with likely application of the US Army Physical Disability Agency (USAPDA) pain policy.  The bilateral patellofemoral pain syndrome was determined to be not unfitting. The remaining conditions were determined to be medically acceptable.  The CI made no appeals and was medically separated.

CI CONTENTION:  “The conditions have worsened to the point that I am at 90% service connected through the VA.  Also I was retired from the VA as an employee for my service connected disabilities.”

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 the 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 20051026	VA* - (3 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain with Radiating  Shoulder Pain	5237	10%	Degenerative Disc Disease, Cervical Spine	5242-5003	10%	20060320	
			Radiculopathy, Right Upper Extremity	8515	10%	20060320	
Bilateral Patellofemoral Pain Syndrome	Not Unfitting 
	Patellofemoral Pain Syndrome, Right Knee	5257	10%	20060601	
		Patellofemoral Pain Syndrome, Left Knee	5257	10%	20060601	
RATING:  10%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20060622 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Chronic Neck Pain with Radiating Shoulder Pain Condition.  In May 2003 the CI had a hyperextension injury to his lower neck while performing basic combat training.  The first radiologic tests documented in the service treatment record (STR) were dated May 2004 and revealed degenerative disc disease (DDD) with disc protrusion without direct spinal cord compression.  There was “loss of cervical lordosis” (straightening of the neck spine; aka…abnormal spinal contour).  A repeat magnetic resonance image (MRI) in December 2006 consistently revealed the abnormal cervical contour.  The CI was not a surgical candidate and treatment remained conservative to include medication, physical therapy (PT), and traction.  There was infrequent and inconsistent reporting of “occasional numbness” extending into his upper extremity; right greater than left.  There were no periods of incapacitation.  A permanent profile was issued in September 2005 (9 weeks prior to separation) listing DDD, and C6-C7 disc bulge.

The MEB narrative summary (NARSUM) examination performed on 10 August 2005 (4 months prior to separation), noted an endorsement of constant neck pain associated with a tingling sensation and pain shooting pain down his right arm when rotating his head to the left and or upon neck extension.  The physical exam (PE) was brief and revealed “some tingling down right arm” with cervical flexion.  PT measured cervical range-of-motion (ROM) was globally decreased coupled with painful motion.  There was no tenderness to either the shoulders or cervical spine.  Upper extremity ROM and motor findings were normal.  His diagnosis remained DDD with disc protrusion.  A repeat MRI of the cervical spine conducted on 10 October 2005 (2 months after the NARSUM and 6 months prior to Compensation and Pension [C&P] examination) revealed the same level DDD, with actual spinal cord compression.

The VA C&P examination performed on 30 March 2006 (4 months after separation), endorsed constant neck pain with numbness radiating between his shoulder blades and into his right arm.  Medication, hot baths, and or stretching his neck were noted to relieve his symptoms for a short period of time.  He additionally endorsed weekly flare-ups lasting 24 hours.  Employed as a technician in the emergency room, he denied missing work due to health reasons.  He stated an ability to perform his job and his activities of daily living.  The VA PE revealed painful and limited ROM of the cervical spine with radicular symptoms upon extension.  Motor and sensory examinations were listed as grossly intact to the extremities.  The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Cervical ROM
(Degrees)	PT (MEB) ~4 Mo. Pre-Sep
(20050906) 	VA C&P ~4 Mo. Post-Sep
(20060320) 	
Flex (45 Normal)	30	45 	
Extension (45)	40	45	
R Lat Flexion (45)	40	45	
L Lat Flexion (45)	35	45	
R Rotation (80)	50	80	
L Rotation (80)	60	80	
Combined (340)	255	340	
Comment	painful motion; tingling; 	painful motion; 
tingling right arm;	
§4.71a Rating	20%	10%-20%	

The Board directed attention to its rating recommendation based on the above evidence.  Although the service and VA titled the unfitting spine condition differently, they both utilized similar primary codes of 5237 (cervical strain) and 5242 (degenerative spinal arthritis) at 10% respectively; PEB citing original neck pain with extension and the VA citing arthritic changes.

In regards to exam probative value, Board members agreed that both the MEB and VA exams (equal distance from service separation) contained value with regards to exam depth and accuracy, but a higher degree of probative value was applied to the MEB exam secondary to its PT author and the performance of multiple measurements.  Clearly, the cervical flexion ROM is supported at the 20% impairment level.  The Board additionally considered if the symptomatic upper extremity radiculopathy symptoms warranted an additional disability rating; but, members agreed that the requisite link of the neurologic symptoms with functional impairment was not in evidence.  The pain component of a radiculopathy is subsumed under the general spine rating as specified in §4.71a.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% based upon limited motion for the cervical spine condition.

Contended PEB Condition:

Bilateral Patella-femoral Pain Syndrome (PFPS).  The Board’s main charge is to assess the fairness of the PEB’s determination that the bilateral PFPS was not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The STR noted bilateral knee pain upon running beginning in December 2003.  Initial X-rays were normal.  Orthopedic evaluation performed in December 2004 revealed full, but painful motion of both knees.  His diagnosis remained bilateral PFPS.  His permanent profile included “knee pain” as the diagnosis and the condition was not implicated in the Commanders statement.  The NARSUM did not implicate any knee complaints, but rather simply listed that he was given the PFPS diagnosis and treated with PT.  The PE revealed bilateral crepitus and patellar grind.  He maintained a normal gait and full ROM of both knees.  The VA C&P examination indicated no specific and or current knee complaints.  The PE revealed minimally decreased and painful motion; right knee flexion to 120 degrees and left knee flexion to 110 degrees (normal = 140 degrees).  There was no tenderness or instability present.

Board members could not find specific evidence in the file that documented any interference of the bilateral PFPS condition with performance of duties, nor were any physical findings documented by the MEB and or VA examiner which would logically be associated with significant disability.  After due deliberation, the Board agreed that the evidence does not support a conclusion that the bilateral knee condition, as an isolated condition or separately allocated to a single knee, would have rendered the CI incapable of continued service within his MOS; and, accordingly concluded that there was insufficient cause to recommend a change in the PEB fitness determination.

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 AR 635-40 DoDI 1332.39 for rating the neck and shoulder was operant in this case and the condition was adjudicated independently of that policy/instruction by this Board.  In the matter of the cervical spine condition, the Board unanimously recommends a disability rating of 20%, coded 5243 IAW VASRD §4.71a.  In the matter of the contended bilateral knee pain condition, the Board unanimously recommends no change from the PEB’s determination as not unfitting.  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 his prior medical separation:

CONDITION	VASRD CODE	RATING	
Chronic Neck Pain with Radiating  Shoulder Pain 	5243	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131024 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 XXXXXXXXXXXXXXX, AR20150011197 (PD201301966)

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 20% 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:

CF: 
(  ) DoD PDBR
(  ) DVA