RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-00577
BRANCH OF SERVICE:  ARMY	BOARD DATE:  20150303
SEPARATION DATE:  20050521

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E-4 (Combat Engineer) medically separated for chronic cervical pain and chronic back pain.  The conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty; however, per his profile, he was authorized an alternate physical training test.  He was issued a permanent U3/L3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic cervical pain/spasm C3 and 4 posterior disc osteophyte complex C6-7 small central disc protrusion” and “focal degenerative changes L1-2, L5 spondylolysis” were the only conditions forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The Informal PEB (IPEB) adjudicated the cervical pain as unfitting, rated 10%, adjudicating the chronic back pain as unfitting, but did not rate it as the condition was determined to have existed prior to service (EPTS).  The CI made no appeals and was medically separated.

CI CONTENTION:  “The rating for permanent nerve damage and disc damages was to low.  My 
back and neck injuries have along w/PTSD dis-abled me.  The board low balled my rateings [sic] 
and disreguarded [sic] my back injuries.  When I re-enlisted after 9-11 after over a 15 year break 
in service I was in good shape, skilled and could max the army P.T. test.  Heck I finally had 
surgery on my service connected knee last Feb. 7 2013.”

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 20050501	VA* - (~5 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic cervical pain…	5237	10%	Degenerative Disc and Joint Disease, Cervical Spine	5243-5242	10%	20051011	
Chronic back pain…
EPTS without permanent service aggravation
	5237	---%	Degenerative Disc and Joint Disease,Thoracolumbar Spine	5243-5242	10%	20051011	
Other x 0 (Not In Scope)	Other x 6 	
RATING:  10%	RATING:  50%	
*Derived from VA Rating Decision (VARD) dated 20060712 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Chronic Cervical Pain Condition.  Review of the service treatment record indicated that the CI was working as a construction carpenter in the Persian Gulf area and presented to clinic in November 2004 with complaints of numbness and tingling in the right hand over 2-3 weeks without any history of injury to the hand, arm, or neck.  The initial examiner diagnosed possible ulnar neuropathy at the elbow.  Subsequent complaint of neck discomfort with examination maneuvers raised a concern for cervical spine disease causing the right hand symptoms.  X-rays of the cervical spine performed on 18 November 2004, demonstrated degenerative disc disease (DDD) with narrowing of the neuroforamina at the C3-4 level.  At a family practice clinic appointment on 20 December 2004, the CI complained of numbness in the 4th and 5th fingers, loss of strength of the right hand, and difficulty grasping and pinching things.  The examiner noted the CI’s report that problems with the neck had been going on for approximately 2 years.  On examination there was decreased neck motion.  Magnetic resonance imaging (MRI) of the cervical spine on 6 January 2005, demonstrated a protruding disc with associated osteophyte (bone spur) formation at the C3-4 level causing mild neuroforaminal narrowing on the right and moderate on the left (opening through which the left C4 nerve root exits the spine).  Electrodiagnostic studies (electromyogram and nerve conduction velocity testing) demonstrated a right ulnar nerve neuropathy (at the elbow) but no evidence of any cervical spinal nerve root radiculopathy.  At the MEB examination on 21 March 2005, 2 months prior to separation, the CI complained of right hand tingling and numbness that had improved with rest.  On examination there was limited motion of the neck.  Neurological exam of the upper extremities was indicated as normal; specifically, there was no weakness including the hand muscles controlled by the ulnar nerve, and no loss of sensation.  Right neck rotation elicited right hand symptoms (“ulnar neuropathy”).  Physical therapy assessment a week later recorded active and passive cervical forward flexion 25 degrees (normal 45) and combined range-of-motion (ROM) 200 degrees (normal 340) noting voluntary limitation of motion without indicating presence of pain.  At the neurology consult on 7 April 2005, the CI complained of right arm symptoms and exhibited diffuse (proximal and distal) right arm weakness (4 to 4+/5) affecting numerous muscles innervated by multiple spinal nerve roots and multiple peripheral nerves.

At the VA Compensation and Pension (C&P) exam on 11 October 2005, 5 five months after separation, the CI reported sharp pain in the right shoulder that radiated down the arm, which caused numbness in his fingertips.  He had flares with turning his neck too fast.  He worked full-time as a carpenter and had not missed time from work related to the neck condition; however, “He may take a day of rest from work, but he tries to go to work as soon as possible and can do all things, just not quickly, he has to move slowly.”  He described himself as physically active, and had not been seen for this issue since he left the military.  On examination, he had cervical flexion to 40 degrees (normal 45), extension to 40 degrees (normal 45), and combined ROM of 215 degrees (normal 340).  With repetitive motion he complained of pain throughout the entire ROM with radiation to the right trapezium and right shoulder area.  His ROMs were flexion to 40 degrees, extension to 30 degrees, and combined range of motion of 200 degrees.  He had 4/5 strength and normal sensation of the right upper extremity.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic cervical pain with VASRD code 5237 (Cervical strain) at 10%, noting that pain limited the ROMs.  The VA rated the condition with code 5243-5242 (Intervertebral disc syndrome - Degenerative arthritis of the spine) at 10%, citing the limitation of motion at the VA C&P examination.  The Board noted that the evidence was clear the CI had DDD of the cervical spine that existed prior to entry on active duty.  There was no neck injury and the radiographic changes that were present took several years to develop.  The predominant symptoms reported by the CI were of the right arm and hand.  Although the MEB examination demonstrated more severe limitation of motion than at the proximate VA C&P examination, there was no evidence of injury or acute worsening to explain the limitation.  The underlying DDD clearly EPTS and by the time of the VA C&P examination proximate to separation, the ROM had improved indicating the MEB examination represented transient rather than permanent worsening.  The Board therefore concluded the VA C&P examination more nearly approximated the permanent level of impairment and further noted the CI had been working full-time as a carpenter at the time of that examination.  There were no incapacitating episodes of intervertebral disc syndrome requiring bed rest prescribed by a physician for consideration of a minimum rating under the alternate formula for intervertebral disc syndrome.  The Board also considered if additional disability rating was justified for peripheral nerve impairment due to cervical radiculopathy associated with cervical spine intervertebral disc syndrome.  The CI complained of right upper extremity symptoms; however, an MRI demonstrated only mild neuroforaminal narrowing of the left C4-5 level without evidence of spinal nerve root impingement.  The moderate neuroforaminal narrowing on the left (C4-5) was not associated with symptoms.  Electrodiagnostic studies also did not show evidence of cervical radiculopathy.  The variable diffuse right arm weakness reported on some examinations did not have any objective evidence for an underlying medical cause.  There was no evidence of a cervical radiculopathy associated with the cervical spine DDD for consideration of separate rating as a residual of the cervical spine condition.  The Board noted that the CI was diagnosed with right ulnar neuropathy at the elbow confirmed by electrodiagnostic studies.  This condition was not related to the cervical spine condition and was likely caused by repetitive stress associated with intense construction duties while deployed.  By the time of the MEB examination (2 months prior to separation), the CI stated that the tingling and numbness in his right hand had improved due to rest and limited use, and neurological examination was normal (no weakness including specifically of the hand muscles controlled by the ulnar nerve as well as no loss of sensation).  The subsequent neurology examination and proximate after separation VA C&P examination recorded a pattern of diffuse right upper extremity weakness that had no objective medical cause and did not correlate to the ulnar neuropathy.  Although the ulnar neuropathy condition was not specifically forwarded by the MEB, the Board concluded there was insufficient evidence to conclude the ulnar neuropathy was unfitting at the time of separation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic cervical pain condition.

Chronic Back Pain Condition.  The back pain condition was found to be unfitting by the IPEB, but characterized as EPTS without permanent service aggravation.  Service treatment records (STRs) recorded a history of mid and low back pain that preceded entry on to active duty and X-rays demonstrated the presence of degenerative changes which take several years to develop.  Following entry on active duty in January 2003, prior to his current deployment, the CI sought care for transient episodes of back pain in June 2003 (occurred after jogging and lifting) and February 2004 (after heavy lifting).  These episodes were followed by recovery and return to unrestricted duties.  The CI was activated from January 2003 to June 2004 for Operation Noble Eagle and then re-activated in August 2004.  The CI sought care for mid back pain in August 2004 characterized as a pulled muscle of the mid-lower back while reaching up to secure a ruck sack on top of a locker.  A three year history of chronic back pain was noted without a history of trauma.  The CI was treated with physical therapy and subsequently deployed in October 2004.  He was seen in-theater on 11 November 2004 for the right hand symptoms at which time it was noted that he had “chronic back problems,” had been in therapy for this prior to deployment, and that he “did feel better after therapy.”  There was no indication the back had been injured, worsened or impeded performance of his deployed duties.  Subsequent STRs noted the history of chronic intermittent back pain but there was no reference to injury or exacerbation of back pain while deployed and no treatment for worsening or injury to the back after return from deployment.  The chronic back pain condition was noted at the time of MEB.  At the MEB exam on 11 March 2005, 2 months prior to separation, the CI reported constant mid and lower back pain that limited power and motion.  Also, “Spine and neck pain is constant due to bulging disc’s and other back problems.  Less use less pain.  …  Use of back brace to ease pain and stability.”  On examination there was muscle spasm, pain with motion, no muscle wasting, and normal lower extremity strength and sensation.

At the time of the VA C&P examination, 5 months after separation, the CI complained of chronic back pain but was working fulltime as a carpenter.  Although the CI reported chronic duty limiting back pain at the time of the MEB examination, the STRs documented three episodes of back pain associated with jogging, lifting, or reaching with recovery and return to full duties.  Therefore the Board concluded that the chronic back pain condition was not permanently aggravated by service.  After consideration of the totality of the evidence and due deliberation, the Board majority determined that the preponderance of evidence supported a conclusion that the chronic back pain condition was not permanently aggravated by military service, and 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.  In the matter of the chronic cervical pain and IAW VASRD §4.71a, the Board by a majority vote recommends no change in the PEB adjudication.  The single voter for dissent chose not to submit a minority opinion.  In the matter of the chronic back pain condition, the Board by a majority vote recommends no change from the PEB determination as EPTS with no evidence of permanent service aggravation.  The single voter for dissent chose not to submit a minority opinion.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  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 20140122, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

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, AR20150013212 (PD201400577)

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:

Encl						     XXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA