RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00487
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070126

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E6, Administrative Specialist, medically separated for “chronic radiating neck pain” and “chronic right (dominant) shoulder pain,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  She has had chronic injuries since leaving the service.  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 - 20061221	VARD - 20070716	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Radiating Neck Pain…	5299-5237	10%	Degenerative Changes in the Cervical Spine	5242	10%	20070423	
Chronic Right (Dominant) Shoulder Pain…	5099-5003	0%	Right Shoulder Strain	5024	10%	20070423	
Mild Heat Intolerance 	Not Unfitting	Residuals of Mild Heat Intolerance	6399-6354	NSC	20070423	
Elevated Prolactin Level	Not Unfitting	Elevated Prolactin Levels	7626	NSC	20070423	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Radiating Neck Pain.  The service treatment record (STR) indicated the CI had pain in the neck and right arm for 3 days although cervical spine X-rays dated 8 December 2002 were normal.  A note dated 9 December 2002 indicated the CI had right shoulder pain (see below), which was felt to be due to acute nerve root compression of C5/C6 and was treated with prednisone (a corticosteroid) on a tapering protocol along with physical therapy.  An electrodiagnostic examination dated 4 February 2003 was equivocal, but suggested a possible right C6-7 nerve root irritation, while an MRI [magnetic resonance imaging] dated 7 March 2003 demonstrated multi-level posterior disk osteophyte complexes (arthritic changes) causing mild right C4-C5, right C5-6, and left C6-7 neural foramina (opening in the vertebral column where nerves pass) narrowing.  There was no evidence of a disk protrusion or extrusion.  The CI received a cervical epidural steroid injection on 3 March 2005; however, in April 2005 she had neck pain with pain shooting down her right arm at times.  Treatment consisted of Tylenol (acetaminophen, a pain reliever), Percocet (a combination of oxycodone, a narcotic, and acetaminophen), and a profile.  An X-ray series of the cervical spine on 29 April 2005 demonstrated loss of the normal cervical lordosis with evidence of a mild mid to lower cervical kyphosis along with mild narrowing of the C4-C5 and C6-C7 intervertebral disc spaces and mild  spurring of the C4, C5, and C6 vertebral bodies.  An electrodiagnostic study in May 2005 revealed a radiculopathy of C7 greater than C6.  A neck collar and Mobic (meloxicam, a nonsteroidal anti-inflammatory drug (NSAID)) were added to the treatment protocol.  An orthopedic surgeon recommended physical therapy and prescribed Elavil (amitriptyline for nerve pain) in August 2003.  X-rays of the cervical spine on 30 September 2005 demonstrated degenerative disk disease of C6-7, while an MRI on 12 October 2005 showed mild degenerative disc disease with disc bulging at C4-5 and C6-7 with no evidence of spinal stenosis or nerve root impingement.  A physical therapist reported in December 2005 that cervical traction improved the CI’s neck pain 50% and she had a normal range-of motion (ROM) of her neck, but it was slow and guarded secondary to stiffness.  In February 2006, the CI received a cervical epidural steroid injection (ESI), which provided 60% improvement in her pain and she received a second ESI in March 2006.  Physical therapy ROMs performed on 16 May 2006 are in the chart below.  An MRI dated 7 June 2006 revealed no significant change from October 2005.  In July 2006, the CI had osteopathic manipulative treatment, while at a neurological examination in July 2006 the CI indicated her neck pain radiated to the middle of the back to the right shoulder with numbness/tingling down the extremity to the digits with infrequent weakness of the extremity.  A neurologist prescribed Lidoderm (lidocaine, an anesthetic) patches for neck-shoulder pain in September 2006 and suggested consideration of Neurontin (gabapentin for nerve pain) and Lyrica (pregabalin for nerve pain) depending on the clinical course.  At a rehabilitation medicine visit on 24 October 2006 the CI had fairly normal neck extension and flexion, but she did have some decrease in her right lateral flexion to approximately 30 degrees and her right rotation to approximately 65 degrees.  She was tender to palpation throughout her right posterior neck and scapular muscles.  Botox (onabotulinumtoxinA, a muscle paralyzing medication) trigger injections were offered for her posterior cervical groups and right scapular and shoulder muscles along with physical therapy for myofascial pain.

At the MEB examination dated 1 May 2006, the CI reported on DD Form 2807-1, numbness and tingling in her right arm and hand.  The MEB physical examiner also noted the CI had “chronic right shoulder (see below) and cervical spine pain...PT (physical therapy), medications, injections without substantial improvement.  No trauma history...Neck pain causes sleep disturbances...Epidural glucocorticoid injections for chronic neck and right shoulder pain.”  On a DD Form 2808 the examiner noted flattening of thoracic kyphosis and right trapezius tenderness to palpation.  The commander’s statement dated 27 April 2006 indicated the CI was physically capable of performing her duties as an administration supervisor and she was a great soldier, but her physical condition did not permit her to perform activities limited by her profile.  

The narrative summary (NARSUM) dated 14 August 2006 indicated on examination there was significant tenderness of the right paraspinal muscles of the neck, the right trapezius, the muscles medial to the upper body of the scapula and in the right shoulder.  No sensory changes were noted anywhere in her arm.  There was no sensory change detectable in her right hand, but there was weakness of all the right finger flexors, most pronounced in the index and middle finger, but also present in the 4th and 5th fingers.  A NARSUM addendum noted that an EMG (electromyogram) of the upper extremities was normal and an occupational therapy evaluation in September 2006 of both upper extremities demonstrated some weakness of right grip tests and slight shoulder and wrist weakness on the right.  A permanent U3 profile was issued on 4 October 2006 for neck and upper back pain and shoulder and arm pain (see below) with limitations of all physical fitness testing and all functional military activities except wearing a protective mask and all chemical protective equipment.  Additional restrictions included no rucking, no individual body armor or Kevlar and no forced upper body exercises.

At the VA Compensation and Pension (C&P) examination dated 23 April 2007, performed 3 months after separation, the CI reported stiffness, burning pain, and spasms of the neck.  The pain, rated 5/10 (10 being the worst pain) traveled to her shoulder and was elicited by physical activity, stress and cold.  There was no incapacitation, but the functional impairments were limited lifting, pulling, and pushing.  On examination her neck was supple.  There was no evidence of radiating pain on movement and no evidence of muscle spasm, tenderness or ankylosis.  The ROM measurements were normal.  Pain occurred at the end of each motion and the joint function was not additionally limited by repetition.

The PEB assigned a 10% rating using code 5299-5237 (cervical strain) for chronic radiating neck pain.  The VA assigned a 10% rating using code 5242 (degenerative arthritis) for degenerative changes in the cervical spine.  The Board sought a route to a higher rating but was unable to do so in the absence of a forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees or the combined ROM of the cervical spine not greater than 170 degrees, or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, ankylosis, or episodes of incapacitation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends no change to the PEB’s disability rating of 10% for the CI’s chronic radiating neck pain.

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.  Board members had a detailed discussion about whether or not motor weakness was in evidence.  The majority found functional evidence of unfitting motor weakness (wrist and finger weakness), supported by clinical evidence from the original electrodiagnostic study that demonstrated a C7 greater than C6 radiculopathy.  Board members discussed the applicability of code 8512 (Lower radicular group mild incomplete partial paralysis), which involves the flexors of the wrist and fingers, for a 20% rating.  A majority of Board members agreed that the CI’s inability to function in her MOS was impaired from the radiculopathy that manifested with weakness of wrist and grip strength as well as the occasional dropping of objects.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), a majority of the Board recommends a disability rating of 20% for the right C6/C7 radiculopathy condition, coded 8512.  

Chronic Right (Dominant) Shoulder Pain Condition.  A note in the STR indicated the CI complained of right arm/shoulder pain with tingling in the right hand on 9 December 2002.  An MRI in February 2003 demonstrated multi-level posterior disk osteophyte complexes causing right C4-C5, right C5-C6, and left C6-C7 neural foramina narrowing.  The CI was seen in May 2005 for 12 days of pain that radiated from her neck into her shoulder and arm; and she was unable to perform full ROM of her right arm.  The condition was assessed as neck strain (trapezius) and treatment consisted of OxyContin (a narcotic), Valium (diazepam, a muscle relaxer), and quarters for 24 hours.  On 17 May 2005, the CI reported neck pain with right arm/hand pain for 2-3 years; however, physical therapy, traction, electrical stimulation and medication did not provide relief.  A right radiculopathy of C7 greater than C6 was the impression and a neck collar was ordered and pain medication was continued.  In August 2005, an orthopedic evaluation revealed reduced abduction of the right shoulder and tenderness to pressure of the anterior acromioclavicular (AC) joint with positive tests for shoulder pathology. Physical therapy was instituted for the chronic neck pain and right shoulder impingement in August 2005 and was focused on increasing upper trapezius strength.  An X-ray series of the right shoulder dated 21 October 2005 demonstrated an os acromiale (a developmental unfused portion of the acromion) with a mild subacromial spur.  An MRI dated 1 November 2005 demonstrated a possible tendinosis (inflammation of a tendon) within the distal [rotator] cuff tendon, but no tear was identified.  The os acromiale was noted to be associated with chronic shoulder pain and rotator cuff tears, and there was mild hypertrophy of the AC joint.  Physical therapy did not improve the CI’s shoulder pain.  Orthopedic evaluation revealed a full ROM with pain beyond 90 degrees and positive tests for impingement.  Continued physical therapy was recommended since there was no indication for surgery.  An EMG of the upper extremities was within normal limits bilaterally on 1 September 2006.  ROM measurements of the right shoulder by an occupational therapist in September 2006 were abduction 170 degrees, extension 50 degrees, flexion 180 degrees, internal rotation 70 degrees and external rotation 90 degrees.  Measurements for the left shoulder were the same as the right shoulder.  Muscle strength of the wrist was 4+/5 and grip strength of the right hand was slightly less than the left hand.  Pamelor (nortriptyline for nerve pain) was prescribed for the shoulder pain on 22 September 2006.  A rehabilitation medicine specialist noted the CI to have tenderness of the scapular muscles and her right deltoid muscle.  Strength in the upper extremities was normal.  The examiner opined that the neck and shoulder pain was myofascial in origin and recommended Botox injections in the right scapular and shoulder muscles along with specialized physical therapy.  The ROM measurements of the right shoulder on 16 November 2006 were forward flexion 140 degrees, abduction 130 degrees, external rotation 65 degrees, and internal rotation 60 degrees with pain at the end range for all motions.  Strength was 3/5 for right shoulder flexion, abduction, external and internal rotation. 

At the MEB examination on 1 May 2006 the CI reported on DD Form 2807-1, right shoulder pain, numbness and muscle spasm, while the examiner reported the right shoulder pain radiated to the right arm and right hand and there was weakness of the right arm with paresthesias.  The examiner noted on right upper extremity motion was limited by pain in all planes of the shoulder.  The commander’s statement and the permanent U3 profile for shoulder and arm pain were discussed above.  The narrative summary (NARSUM) dated 14 August 2006 noted the CI’s shoulder pain at rest was a 3-4/10 and that with any significant activity the pain rose to an 8/10 or higher.  In cold weather the pain was constantly at 8/10 or higher and she could not open a door, comb her hair or do any significant activity of any kind with her right arm.  As a result of the pain she could not do military functional activities.  On examination the ROM of her right shoulder was slightly limited.  There was significant tenderness in the right trapezius, muscles medial to the upper body of the scapula, and in the right shoulder.  

At the VA Compensation and Pension (C&P) examination dated 23 April 2007, performed 3 months after separation, the CI reported weakness in the arm, stiffness, a burning sensation, giving way when attempting to lift objects, sometimes dropping things, and locking when reaching over or far away.  On examination the right shoulder showed signs of tenderness.  The ROM measurements were normal and are in the chart below.  On repetitive use pain had a major functional impact but joint function was not limited.  Motor function of the upper extremities was within normal limits as was sensation.   

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating using code 5099-5003 (degenerative arthritis) for chronic right (dominant) shoulder pain (rated as pain, minimal/occasional), applying the USAPDA pain policy.  The VA assigned a 10% rating using code 5024 (Tenosynovitis) for right shoulder strain.  The Board noted that the CI had noncompensable ROMs of the right shoulder, but did have painful motion, which qualifies for a 10% rating using code 5099-5003.  Board members also noted that the CI had an os acromiale which could be rated 10% using code 5203 for clavicle or scapula impairment nonunion without loose movement.  However, the use of that code would not afford any additional benefit to the CI and combining ratings for code 5099-5003 and code 5203 would evoke pyramiding IAW VASRD §4.14, which is to be avoided.  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 chronic right (dominant) shoulder pain condition.  

BOARD FINDINGS:  In the matter of the chronic neck radiating pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the right C6/C7 radiculopathy condition, the Board majority recommends a separately unfitting disability rating of 20% coded 8512 IAW VASRD §4.124a.  The minority voter did not find the radiculopathy as separately unfitting, but elected not to submit a minority opinion.  In the matter of the chronic right (dominant) shoulder pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Neck Radiating Pain	5299-5237	10%	
C6/C7 Radiculopathy	8512	20%	
Chronic Right (Dominant) Shoulder Pain	5099-5003	10%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140116, 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, AR20160005849 (PD201400487)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 40% effective the date of the individual’s original medical separation for disability with severance pay.  

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:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 40% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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:

			      
						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA