RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-00521
BRANCH OF SERVICE:  Army		SEPARATION DATE:  20070922

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Motor Transport Operator, medically separated for “cervical degenerative disc disease (DDD)” and “lumbar DDD” rated 10% and 10%, respectively, with a combined  disability rating of 20%.

CI CONTENTION:  He was not evaluated for mental health, TBI, tinnitus, and left knee.  His 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 - 20070730	VARD - 20080429	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cervical DDD	5299-5242	10%	Chronic Cervical Sprain	5237	20%	20071206	
Lumbar DDD	5299-5242	10%	Chronic Low Back Strain	5237	10%	20071206	
Patellofemoral Pain Syndrome (PFPS) [Left]	Not Unfitting	Left Knee PFPS	5299-5261	0%	20071206	
COMBINED RATING:  20%	COMBINED RATING FOR ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:

Cervical Degenerative Disc Disease.  The CI was first seen for neck pain on 18 December 2006.  He reported that he had been dropped on his head during combative training and was “stunned.”  He also endorsed 30 minutes of PTA (post-traumatic amnesia), but drove himself to the emergency room (ER) for evaluation 30 minutes after the mishap.  He denied neurological symptoms and had a normal examination.  A computerized tomography (CT) scan of the neck was also normal.  He was seen again 2 days later reporting a stiff, painful neck.  He was treated with medications, duty restrictions, and referred to physical therapy.  A physical therapy note dated 24 January 2007 documented full, but painful range-of-motion (ROM) of the neck.  At a follow-up appointment on 20 February 2007, he again had full and painful ROM.  In primary care 2 days later, he was noted to be able to touch his chin to his chest (full flexion).  Magnetic resonance imaging (MRI) on 28 February 2007 revealed minimal disc bulging at C5-6 and mild neural canal narrowing at C6-7, but neither spinal cord nor nerve root impingement was present.  During a family practice visit on 21 March 2007, he was again noted to have normal ROM and a normal motor evaluation.  His gait was normal as well.  An orthopedics examination on 5 April 2007, his neck ROM was recorded as decreased without further detail.  The neurological examination was normal.  The formal ROM measurements were obtained by physical therapy on 14 May 2007 which documented pain with limited motion in all planes.  These are charted below.  Guarding was present, but the gait and spinal contour were normal.  On the DD Form 2808, Report for Medical Examination, dated 27 July 2007, approximately 3 months before separation, the neck was noted to be tender to palpation, but the ROM was not recorded.  At the Medical Evaluation Board (MEB) narrative summary (NARSUM) examination, dated 5 July 2007, approximately 3 months before separation, the CI reported constant pain which precluded performance of full duty.  The examiner referenced the DD Form 2808 dated 27 July 2007 and the physical therapy evaluation from 14 May 2007; a separate examination was not accomplished.

At the VA Compensation and Pension (C&P) mental health examination dated 06 December 2007, approximately 3 months after separation, the CI reported that he worked as a courier (driver and delivery) for an express delivery company and that he enjoyed playing the violin.  The general examination was the same day.  The CI reported that his head was slammed and he was thrown onto the floor.  The Board noted that this history is not entirely consistent with the ER record of the visit shortly after the incident.  He stated that his employment had not been affected by the pain and that he worked through it.  His gait and neurological examination were normal.  There was neither paraspinal tenderness nor spasm, but the “bases of the neck muscles were tender…”  The ROM was limited by pain and further limited with repetition.  X-rays were normal.  

The PEB rated the neck at 10%, coded 5299-5242 (analogous to arthritis of the spine) noting that the ROM was limited by pain.  The VA rated the neck at 20%, coded 5237 (cervical strain), for limitation in motion.  The Board considered the evidence.  The ROM recorded at the MEB and C&P examinations supports either a 20 or 30% rating.  The Board noted though that the ROM was recorded as normal in multiple examinations in the months following the injury during combative training in December 2006.  The X-rays were normal, a CT immediately after the injury was normal, and an MRI showed minimal degenerative changes.  No additional injury was recorded to account for the deterioration in movement.  The Board also noted that the CI reported playing the violin and working as a delivery driver following separation.  The Board majority opined that the level of impairment demonstrated on the ROM measurements proximate to separation is not consistent with this reported level of function.  Accordingly, the probative value of these two examinations is reduced.  The Board majority considered the totality of the evidence and concluded that a rating higher than the 10% adjudicated by the PEB was not supported.

Lumbar Degenerative Disc Disease.  The CI was first seen for low back pain (LBP) on 15 May 2006 when he reported a 3 day history of LBP after tripping over a tent wire while running in the dark.  He was treated with medications and duty restrictions.  An X-ray on 7 September 2006 was normal.  In family practice on 26 September 2006, he was noted to have full ROM and a normal motor examination.  His pain was persistent and he was referred to physical therapy.  An MRI on 28 February 2007 noted DDD at L3-4 and L4-5.  In primary care on 21 March 2007, he was again noted to have full ROM.  In orthopedics on 5 April 2007, the ROM and gait were both normal as was the neurological examination.  Formal ROM measurements were obtained in PT on 14 May 2007 and were limited by pain.  Guarding and spasm were absent; the gait and spinal contour were normal.  At the DD Form 2808, Report for Medical Examination, dated 27 July 2007, approximately 3 months before separation, the neck was noted to be tender to palpation, but the ROM was not recorded.  At the MEB NARSUM examination, the CI reported constant pain which precluded performance of full duty.  The examiner referenced the MEB 2808 dated 27 July 2007 and the PT evaluation from 14 May 2007.  The examiner recorded that the CI had an antalgic gait (abnormal) and muscle spasm; this was not recorded on either examination referenced though.

At the VA C&P general examination, the CI reported pain radiating to both lower extremities.  The gait and neurological examinations were normal.  The ROM was reduced. 

The PEB and VA both rated the back at 10%, coded 5299-5242 and 5237, respectively.  The Board noted that the NARSUM documented an abnormal gait and guarding which would support a 20% rating.  However, the examinations referenced in the NARSUM do not document this finding and the gait is otherwise recorded as normal.  This is thought to be a typographical error.  The Board found no route to a rating higher than the 10% adjudicated by both the PEB and VA.  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 lumbar degenerative disc condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that left knee patellofemoral pain syndrome 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 left knee was not profiled or implicated in the commander’s statement.  It was not judged to fail retention standards.  The left knee condition was reviewed and considered by the Board.   There was no performance based evidence from the record that it significantly interfered with satisfactory duty performance at separation.  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 left knee condition and so no additional disability rating is recommended.

BOARD FINDINGS.  In the matter of the neck condition and IAW VASRD §4.71a, the Board majority recommends no change in the PEB adjudication.  The minority member recommended modification of the rating to 20%, but did not elect to submit a minority opinion.  In the matter of the back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended left knee 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.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131223, 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, AR20160005854 (PD201400521)  

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 and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA