RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	     CASE:  PD-2014-00039
BRANCH OF SERVICE:  Army                                                                  SEPARATION DATE:  20091005 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E5, Motor Transport Operator, medically separated for “chronic low back pain” and “chronic neck pain,” rated 10% and 0%, respectively, with a combined disability rating of 10%.  

CI CONTENTION:  The CI has asked for consideration of all conditions.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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:  

SERVICE PEB - 20070525	VARD – 20100512	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5237	10%	Lumbosacral Strain	5237	20%	20050330	
Neck Pain	5237	0%	Neck Disc Herniation	5243	NSC	20050330	
Bilateral Knee Pain	Not Unfitting 	Chondromalacia Right Knee	5099-5010	10%	20050330	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain…without Radiculopathy.    The service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM) dated 12 April 2007 indicated X-rays of the CI’s lumbosacral spine in April 2002 demonstrated minimal degenerative change.  In March 2006, the CI was seen for a low back pain exacerbation without any history of a recent injury or strain.  Treatment consisted of Flexeril (cyclobenzaprine, a muscle relaxer), ibuprofen (a nonsteroidal anti-inflammatory drug (NSAID), and heat.  Magnetic resonance imaging (MRI) in June 2006 demonstrated a broad based central disc protrusion, which caused an indentation of the thecal sac (a membranous sac surrounding the spinal cord) at the L5-S1 level.  The NARSUM noted the CI developed low back symptoms in September 2006 when deployed.  In August 2007 a primary care attending note indicated the CI had no pain at that time.  In March 2008 the CI reported he fell on ice twice striking his coccyx (tail bone) area.  On examination there was tenderness over the lower spine.  Treatment consisted of Flexeril.  By April 2008 the CI reported his chronic low back pain was getting worse, but a joint survey was without focal findings or restriction and his gait was steady.  An MRI dated 29 May 2008 demonstrated mild multilevel degenerative changes, most prominent at L5-S1 with no central canal or neural foraminal stenosis.  There were small posterior annular tears at L3-L4, L4-L5, and L5-S1 as well as fusion of the sacroiliac joints bilaterally.  The CI was felt to be an excellent surgical candidate, but he wanted to get all of his medical conditions stabilized first. 	

At the VA Compensation and Pension (C&P) examination dated 4 November 2008, performed 11 months before separation, the CI reported his pain was localized to the lumbar area with occasional radiation down to the side of both legs.  He denied any history of spinal surgery, bowel, bladder, or sexual dysfunction.  The CI stated he missed 2 to 3 weeks of work per month, always had some degree of pain, and took gabapentin (for nerve pain), codeine/acetaminophen (a narcotic/pain reliever combination), and cyclobenzaprine to relieve the pain.  On examination his posture was functional and effective, but he was “mildly stooped 10 degree lean forward.”  Ambulation was without a limp with good propulsion.  Range-of-motion (ROM) measurements were flexion 0 to 70 degrees with pain at the end of the motion and a combined ROM of 220 degrees.  At a physical examination in December 2009, 2 months after separation, for a job as a federal police officer, the CI stated he was able to run, jump and carry the amount of weight required for the job.  At a C&P examination on 24 February 2010, 4 months after separation, ROM measurements were forward flexion 0 to 90 degrees, extension 0 to 20 degrees, left and right lateral flexion and left and right lateral rotation 0 to 30 degrees each.  There was no limitation of motion with repetition.  Bilateral lower extremity strength, sensation, and deep tendon reflexes were intact and equal without neurologic deficit.  In June 2010, the CI reported recurrent back pain, but was asymptomatic at that time.  Examination in September 2010, 11 months after separation, revealed mild tenderness over the lower lumbar spinous processes and upper sacral area, but there was no tenderness of the paravertebral muscles.  Neurologic evaluation was unremarkable.  Treatment included lidocaine ointment (a topical anesthetic), meloxicam (an NSAID) and no sit-ups.  An MRI dated 14 January 2011, 15 months after separation, demonstrated mild concentric disc bulging and degenerative disc disease at L4-5 and L5-S1 with only mild neuroforaminal (passageway of nerves through the vertebral column) impingement at L4-5 bilaterally and slight impingement at L5-S1 bilaterally.  Chronic changes of sclerosis (stiffening) and old trauma to the L5 vertebral segment were also present.  At more remote examinations with limited probative value in June 2011 and September 2012, the CI reported no lower back pain, touched his toes without a problem, and had good strength in his lower extremities bilaterally. 

The 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.
Thoracolumbar ROM
(Degrees)	
VA C&P ~11 Mo. Pre-Sep
	VA C&P ~5 Mo. Post-Sep
	
Flexion (90 Normal)	70	90	
Extension (30)	30	20	
R Lat Flexion (30)	30	30	
L Lat Flexion (30)	30	30	
R Rotation (30)	30	30	
L Rotation (30)	30	30	
Combined (240)	220	230	
Comment	Pain at the end of flexion; lumbar flattening	DeLuca negative	
§4.71a Rating	10% (VA 20%)	 10%	
The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5237 for chronic low back pain secondary to a herniated nucleus pulposus L5-S1 and degenerative disc disease L4-L5 without radiculopathy or muscle spasm and a ROM that was pain limited.  The VA assigned a 20% rating using code 5237 for lumbosacral strain retroactive to May 1995.  The PEB sought a route to a higher rating and noted an absence of military service examinations proximate to separation.  At the VA C&P examination 11 months proximate to separation a flexion of 70 degrees actually warranted a 10% rating; however, he was granted a 20% rating, but at a VA examination to appeal his VA rating 5 months after separation flexion was 90 degrees, which warrants only a 10% rating.  In the absence of ankylosis, a forward flexion of the thoracolumbar spine 30 degrees or less,  a forward flexion of the thoracolumbar spine greater than 30 degrees but no greater than 60 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, a higher rating could not be found.  While the CI reported loss of time from work, there were no episodes of incapacitation that were prescribed by a physician documented in the STR.  The Board then considered whether an additional rating could be recommended under a peripheral nerve code.  Although the pain component of the neuropathy is appropriately subsumed in the spine rating IAW VASRD §4.71, which states that “rating is performed with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease,” there was no sensory component with any significant functional implications and no motor weakness was in evidence.  Therefore, a radiculopathy could not be recommended for additional disability rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the low back pain condition.   

Neck Pain Due to Degenerative Disc Disease…no Radiculopathy.  The STR and the NARSUM indicated the CI complained of “neck pain, with periodic paresthesias into the left hand.” An X-ray series of the cervical spine in August 2003 demonstrated a straightened cervical spine, which was otherwise normal.  A note in August 2007 noted neck pain developed in September 2006 when the CI developed a popping sensation in his neck when he helped someone take cover and his left arm “went out.”  He was evaluated and was noted to have C6-C7 and “C7-T1” herniated discs.  On examination in February 2008 his neck was supple and motor and sensory examinations were normal.  Since that time he had constant neck pain with numbness in his left middle finger to fifth finger.  Physical therapy and limitation of activities did not change the symptoms.  Epidural steroid injection provided temporary relief.  Electrodiagnostic studies showed a questionable upper cervical radiculopathy on the left.  On examination he had normal muscle strength of the upper extremities bilaterally without any sensory deficit in either upper extremity or evidence of a carpal tunnel syndrome or impingement signs in his shoulders.  There was no paraspinal muscle spasm and the ROM of his neck was full and complete with some mild pain at the end of the motions.  His gait was normal as were his reflexes of the upper extremities.  Imaging studies demonstrated a degenerative disc in the upper cervical spine and foraminal stenosis bilaterally at C2-3, C3-4, and C4-5.  As a result the CI was unable to tolerate body armor and Kevlar without restrictions and was unable to deploy.   

At the VA C&P examination dated 4 November 2008, performed 11 months before separation, the CI reported that the CI developed neck and low back pain when deployed.  The pain came and went and the neck pain radiated down to his left shoulder and reached his 4th and 5th digits in the form of an “achy numbness.”  Muscles had full strength; sensation of the right upper extremity was normal.  On the left upper extremity pin prick, light touch and two point discrimination were decreased on the left upper extremity following a C-8 nerve distribution and reported as “more dull” along the 4th and 5th digits of the left hand.  The CI was mildly stooped with a “10 degree lean forward” and ambulation was without a limp.  Imaging studies of the cervical spine dated 12 September 2008 reported a mild cervical degenerative spondylosis (stiffening/arthritic changes) at C4-C5-C6-C7.  Examination of the cervical spine revealed no spasm, atrophy, guarding, pain with motion, tenderness or weakness.  ROM measurements of the cervical spine were flexion 0 to 35 degrees, extension 0 to 45 degrees, left and right lateral flexion 45 degrees each, and right and left lateral rotation 80 degrees each.  Increased numbness on the left and pain occurred after he completed the ROM for extension; and, there was pain after repetitive testing.  The diagnosis was multilevel degenerative arthritis of the cervical spine with left upper extremity radiculopathy following a C-8 myotome (group of muscles) distribution.

The 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)	MEB ~NO ROMs 	VA C&P ~11 Mo. Pre-Sep
	
Flex (45 Normal)	No ROMs	35	
Extension (45)		45	
R Lat Flexion (45)		45	
L Lat Flexion (45)		45	
R Rotation (80)		80	
L Rotation (80)		80	
Combined (340)		330	
Comment		Pain in the left arm and pain after extension; pain on repetition	
§4.71a Rating	-	10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating using code 5237 for chronic neck pain due to degenerative disc disease and cervical strain with spinal stenosis, no radiculopathy or muscle spasm, but noted the ROM was pain-limited.  The VA did not rate the chronic neck pain and determined left and right upper extremity nerve conditions associated with neck disc herniation were not service connected.  The Board sought a route to a higher rating and noted the PEB indicated the ROM was pain limited and on a VA examination proximate to separation there was pain on repetition.  Therefore, the Board considered a 10% rating using analogous code 5099-5003 since the ROMs were not compensable, but there was pain on motion IAW VASRD §4.59.  The Board then sought a route to a higher rating; however, in the absence of ankylosis, forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees,  muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, or episodes of incapacitation, was unable to do so.  The Board also considered whether an additional Service rating could be recommended under a peripheral nerve code.  Although the pain component of the neuropathy is appropriately subsumed in the spine rating IAW VASRD §4.71, which states that “rating is performed with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease,” there was no sensory component with any significant functional implications nor was there significant motor weakness in evidence.  Therefore, a radiculopathy could not be recommended for additional disability rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the neck pain due to degenerative disc disease condition.  

Contended PEB Conditions

Bilateral Knee Pain.  A note dated 5 September 2001 indicated the CI had right knee pain for 3 months status post blunt trauma/fall.  Pain continued post arthroscopy, which was performed in 2001.  X-rays dated 20 September 2002 demonstrated mild osteoarthritic changes most pronounced in the lateral compartment, and there was a bipartite superior-lateral patella (congenital kneecap made of two bones instead of one bone).  An MRI of the right knee in January 2003 demonstrated a vertical tear of the posterior horn of medial meniscus with an associated meniscocapsular separation (detachment of the meniscus from its capsular attachments) as well as a possible degenerative versus a traumatic tear of the lateral meniscus.  A note in April 2004 from a VA primary care clinic indicated the CI had two surgeries [of the right knee] while in military service.  The CI’s condition was assessed as arthralgia of both knees and braces for support were ordered.  An orthopedic evaluation in September 2005 was performed to determine whether the CI was able to join the National Guard.  ROM of the right knee was flexion to 110 degrees with no laxity.  X-rays of the knee in June 2006 showed the bipartite patella on the right without any fracture, dislocation or joint effusion.  An MRI of the knees in June 2006 revealed findings “consistent with a complex tear of the right anterior medial meniscus.” There was also a left osteochondritis dissecans (a small segment of bone degeneration or necrosis and re-calcification) of the medial side of the lateral femoral condyle and a partial tear or traumatic changes to the mid-fibers of the left PCL (posterior cruciate ligament).  A note in August 2007 indicated the CI went on deployment, exercised the knee, and “has done OK.”  Five days post-separation the CI had an orthopedics consultation on 15 October 2009 for a left knee problem.  Occasionally, he used his right knee brace on his left knee, but did not use a cane.  X-rays of the knee were within normal limits.  The ROM was 0 to 135 degrees without crepitance (a grinding sensation) or complaints of pain.  The CI’s knee was stable to anterior-posterior stress and there was slight varus-valgus instability.  The diagnostic impression was an internal derangement of the left knee with a history of a MCL (medial collateral ligament) tear.  The brace was continued.  In June 2010 the CI reported mild, but asymptomatic pain.  At an orthopedic consultation the ROM was 0 to 135 degrees without crepitance or complaints of pain, but there was slight vagus-valgus instability.  The examiner’s impression was mild degenerative joint disease of the right knee laterally and the patellofemoral joint.  In December 2010, 14 months post-separation, the CI reported his left knee had an occasional popping sound, but no pain, instability or locking.  Mild crepitus was noted and regular strengthening of the knee for prevention of long term problems was recommended.  Additional remote examinations post-separation were reviewed, which offered limited or no probative value referable to the time of separation.

The aforementioned was reviewed and considered by the Board.   There was no performance based evidence from the record that the bilateral knee pain conditions significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the bilateral knee pain contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the chronic low back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic neck pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the contended bilateral knee pain conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  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 Low Back Pain	5237	10%	
Chronic Neck Pain	5099-5003	10%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140424, 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 XXXXXXXXXXXXXXXXXX, AR20160007453 (PD201400039)

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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization 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