RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00051
BRANCH OF SERVICE:  Army  	SEPARATION DATE:  20070924

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Unit Supply Specialist) medically separated for neck pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  The profile allows for an alternate aerobic event to satisfy physical fitness standards.   He was issued a permanent P3U3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic neck pain due degenerative disc disease” and “chronic upper back/shoulder pain secondary to #1,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded one other condition (chronic headaches) for PEB adjudication.  The Informal PEB adjudicated the chronic neck pain condition as unfitting rated 10%, with likely application Army Regulation (AR) 635-40.  The remaining condition was determined to be not unfitting.  The CI made no appeals and was medically separated.  

CI CONTENTION:  The applicant has asked for consideration of all his conditions.  His 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 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 20070823	VA* - (~12 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain…	5299-5237	10%	Cervical Spine Degenerative Disc Disease with Bulging Disc…	5243	10%	20080926	
			Thoracic Spine Arthritis	5242	0%	20080926	
			Left Upper Extremity Radiculopathy (claimed as Left Shoulder Injury/Pain) associated with Cervical Spine Degenerative Disc Disease with Bulging Disc	8512	0%	20080926	
			Right Upper Extremity Radiculopathy (claimed as Right Shoulder Injury/Pain) associated with Cervical Spine Degenerative Disc Disease with Bulging Disc…	8512	0%	20080926	
Chronic Headaches	Not Unfitting	No VA Placement	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 8 (equals SC, NSC & deferred)	
RATING:  10%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20081114 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Chronic Neck Pain Condition.  The narrative summary (NARSUM) notes the CI had a history of neck pain since 2005 which was aggravated by a motor vehicle accident (MVA) in February 2006.  Cervical X-rays 13 February 2006 were negative for fracture or subluxation.  The CI was subsequently involved in a second MVA in March 2006.  Notes in the service treatment record indicated the CI was experiencing some left upper extremity (UE) symptoms that were possibly nerve related.  Cervical MRI noted degenerative disc disease (DDD) at C5-7, but no significant central canal stenosis or neuroforaminal (bony canal through which the spinal nerves exit) narrowing.  According to the NARSUM the CI was evaluated by neurology and referred to physical therapy.  Chiropractic visits from 10–30 January 2007 all noted neck pain without UE symptoms.  On the exams there was tenderness of the neck and upper back with muscle spasm present and there was no evidence of cervical nerve root compression on testing.  The CI’s neck range-of-motion (ROM) improved, but the pain continued and he was referred to a pain specialist.  At the pain evaluation on 7 March 2007, the CI reported localized neck pain, without radiation or UE symptoms.  The exam noted neck tenderness and painful motion with a normal neurological exam and the CI was treated with bilateral neck muscle trigger point injections.  According to the NARSUM the CI then received three epidural steroid injections by physical medicine, which provided only temporary relief.  The commander’s statement dated 16 May 2007 noted that the CI had recurrent periods of 24-48 hours quarters following the second MVA and before he was reassigned to a position with less physical demands in June 2006.

At the MEB exam on 21 June 2007, 3 months before separation, the CI reported neck, upper back, and shoulder pain and numbness and tingling (paresthesia) behind both ears.  The MEB physical exam noted tenderness of the entire neck and of the trapezius muscles bilaterally (trapezius muscles extends from the neck to the mid back and both posterior shoulder regions in a diamond shape) and painful, limited neck motion.  Physical therapy ROM for the MEB on 22 June 2007 was flexion of 20 degrees (normal 45) with combined ROM of 215 degrees (normal 340) after three repetitions.  The MEB examiner indicated that the shoulder and upper back pain were both milder than the neck pain. 

At the VA Compensation and Pension (C&P) exam on 26 September 2008, 12 months after separation, the CI reported shoulder pain that started at the same time as his neck.  He reported he was advised it was due to his neck pain.  He denied UE weakness and was able to do push-ups, but reported paresthesia into the upper back on both sides.  The CI also reported constant neck pain graded 1-2/10, with frequent right side muscle spasms and flares every couple of months for a few days.  The examiner indicated there had been no incapacitating episodes requiring bed rest and treatment by a physician in the last 12 months.  The CI reported no symptoms of the thoracolumbar (TL) spine, and exam of the TL-spine was normal.  The exam of the right and left shoulders was normal, with full ROM and normal strength, sensation and reflexes of the upper extremities.  On exam of the neck, head position and posture were normal and there was no tenderness, guarding, muscle spasm, or weakness.  Neck ROM was flexion 45 degrees and combined ROM of 285 degrees with painful motion, and there was no additional loss of ROM with repetition.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition, 10%, coded 5299-5237 (analogous to cervical strain).  The VA rated the neck condition 10%, coded 5243 (intervertebral disc disease).  The Board noted that the MEB forwarded two conditions to the PEB; neck pain and upper back/shoulder pain, and the PEB adjudicated the two conditions as a single unfitting condition.  The Board first considered if these conditions should be unbundled for individual fitness determinations and ratings.  There was no evidence in record of a diagnosis of a condition of either shoulder or the upper back, other than pain.  The CI was advised that his neck condition accounted for his pain and Members agreed that there were not separate neck, upper back and shoulder conditions which could be reasonably justified as separately unfitting; nor would separate ratings be achievable without violation of VASRD §4.14 (avoidance of pyramiding).  Therefore, the Board deliberated the rating of the neck condition.  Members agreed that at the time of separation the evidence supports a 20% rating according to the VASRD General Rating Formula for the spine in effect on the date of separation based on the finding at the MEB exam of cervical spine flexion of “greater than 15 degrees, but not greater than 30 degrees”.  The Board noted that at the post-separation C&P exam neck flexion was normal; however, it was 12 months after separation.  The MEB exam was more proximate to the date of separation in this case and was judged by the Board to have greater probative value for its rating recommendation for the disability due to the condition at the time of separation.  The Board reviewed to see if the next higher rating of 30% was supported, but there was no evidence in record of cervical spine flexion “15 degrees or less”.  The Board considered if rating the neck condition using the VASRD formula based on incapacitating episodes due to intervertebral disc syndrome resulted in a higher rating.  The criteria are based on the number of incapacitating episodes in the prior 12 months requiring bed rest prescribed by a physician.  There was one episode of quarters documented in the STR in May 2006 and the commander’s statement referenced recurrent periods of quarters prior to June 2006, but there were no quarters documented within the 12 months before separation.  In any case the Board notes that quarters are not necessarily equivalent to physician prescribed bed rest and no periods of physician-directed bed rest were documented in the STR and the C&P examiner specifically noted there had not been any in the year after separation.  Thus, the Board determined that the evidence supports a 20% a rating and no higher and recommends coding as 5243 for DDD.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the neck condition.  

The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  While the CI reported radiating pain to the shoulders from the neck condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  The CI also reported paresthesias of the upper back and behind the ears.  However, there was no objective motor or sensory deficit or functional impairment with an impact on fitness due to the described sensory disturbances noted in the record.  The Board therefore concluded that additional disability rating was not justified on this basis.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the headache condition 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.  

Headache Condition.  The NARSUM noted that during a parachute jump in July 2005, the CI hit the back of his head on the ground and developed headaches, but was deployed in the second half of 2005.  After return from deployment, the CI was involved in two MVAs in February and March 2006 (as noted above).  Notes in record indicated treatment for the neck with reported neck, shoulder and upper back pain, but no notes mention headaches.   A request for neurology consultation dated 31 May 2006 noted chronic headaches since an MVA, 3 months earlier.  The headaches were aggravated by stress and wearing a helmet and were not associated with visual changes, vertigo, nausea, or vomiting.  An undated neurology clinic sheet indicated the CI was given neck exercises and medications for the headaches.  A computed tomography (CT) scan of the head 5 October 2006 was normal.  There were a few visits for HAs documented in the record from 10 April 2006 to 5 May 2006 and again on 22 September 2006.  Six chiropractic evaluations in January 2007 made no mention of headaches.  The DD Form 2808, Report of Examination, noted “chronic headaches” that were non-disqualifying.  The CI did not report headaches on the DD Form 2807, Report of Medical History or DD Form 2697 Report of Medical Assessment and he did not report that headaches were a current issue at the MEB exam.

The headaches condition was not permanently profiled or implicated in the commander’s statement and was not judged to fail retention standards.  There was no performance based evidence from the record that the headaches condition 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 headaches condition and so no additional disability rating is recommended.

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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the neck condition, the Board unanimously recommends a disability rating of 20%, coded 5243 IAW VASRD §4.71a.  In the matter of the contended headaches condition, the Board unanimously recommends no change from the PEB 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 Condition	5243	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131222, 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, AR20160000326 (PD201400051)

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