RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00965
BRANCH OF SERVICE:  Air force	SEPARATION DATE:  20090424

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Forward Air Controller, medically separated for “chronic cervicalgia due to degenerative disk disease C4-5 with radiculopathy to trapezius and arms,” with a disability rating of 10%.

CI CONTENTION:  “Conditions worsened.  Further conditions were added separate from the one which rendered me unfit.”

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 - 20081229	VARD - 20090619	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Cervicalgia	5243	10%	DDD and Spondylosis of the
Cervical Spine…	5242	10%	20090209	
COMBINED RATING:  10%	COMBINED RATING FOR ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:

Chronic Cervicalgia.  The service treatment record (STR) and narrative summary (NARSUM) documented neck and shoulder pain that first came to medical attention in January 2008 (15 months pre-separation).  Radiographic imaging in January 2008 documented C4-C5 degenerative disc disease (DDD) with bone spurs (osteophytes).  Further imaging in February 2008 (14 months prior to separation) documented DDD with no bony slippage (subluxation).  Magnetic resonance imaging in March 2008 (13 months prior to separation) documented bilateral narrowing (stenosis) of the nerve canals.  At a primary care visit in March 2008, the examiner documented tenderness of the C4-C6 spinous processes and bilateral paracervical musculature, with pain elicited by bilateral motion.  At an orthopedic visit in April 2008 (12 months prior to separation), the CI reported pain and tightness in the neck with pain that radiated into his arms “at times.”  The examiner documented normal sensation, strength and reflexes.  At a physical therapy visit for range of motion (ROM) testing in April 2008, the examiner documented flexion to 45 degrees (normal); extension to 25 degrees (normal 45); left and right lateral bending to 20 and 30 degrees respectively (normal 45); and left and right rotation to 55 and 50 degrees respectively (normal 80); all with pain.  (Combined ROM was 225 degrees; normal 340.)  There was no STR documentation of more significant limitations of flexion or extension of the cervical spine and no episodes of physician prescribed bed rest for episodes of incapacitation.

The MEB NARSUM exam was performed on 21 May 2008 (11 months prior to separation).  The CI reported 5/10 pain in the neck and both shoulders; numbness into his fingertips, left greater than right.  The examiner documented muscle spasm and tenderness, painful motion of the neck, and “some” decreased ROM.  There was normal sensation and strength.  A NARSUM addendum, written on 2 October 2008 (6 months prior to separation), reaffirmed “no appreciable change” since May 2008.

At the VA Compensation and Pension (C&P) exam performed on 9 February 2009 (2 months prior to separation), the CI reported daily, constant, severe cervical pain, associated with numbness and pain in both upper extremities and extending to the fingers.  He reported an inability to rotate the head while driving without incurring pain.  The CI denied episodes of physician prescribed bed rest for incapacitating episodes in the previous 12 months.  The examiner documented tenderness to palpation of the cervical spine, and pain with all movements.  Forward flexion and extension were to 35 degrees each, right and left lateral flexion was to 35 degrees each, and bilateral rotation was to 60 degrees each (combined ROM was 260 degrees; normal 340).  There was no change in ROM after repetition.

The Board directed attention to the rating recommendation based on the above evidence.  The PEB adjudicated the “DDD and C4-C5 cervicalgia with radiculopathy” condition as unfitting and rated 10%, coded 5243 (intervertebral disc syndrome).  The VA rated the “DDD of the cervical spine with bilateral upper extremity radiculopathy” condition at 10%, coded 5242 (degenerative arthritis of the spine).

The Board considered the evidence for a higher than 10% rating.  There was no evidence of flexion greater than 15 degrees but not greater than 30 degrees; and no evidence of a combined ROM not greater than 170 degrees in support of a higher rating.  There was no evidence of spasm or guarding severe enough to result in an abnormal spinal contour in support of a higher rating.  There was, however, documentation of recurrent painful motion, and decrements in ROM in support of a 10% rating coded 5242 (degenerative arthritis of the spine).  There was no associated radiculopathy for separate peripheral nerve rating.  While the CI may have experienced radiating pain from the neck condition, there was no evidence in this case that there was a radiculopathy with a direct impact on fitness.  Pain is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  The Board therefore concluded that additional disability rating was not justified on this basis.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), §4.59 (painful motion) and §4.45 (the joints), members agreed that a disability rating of 10% for the cervical spine condition was appropriately recommended in this case.

BOARD FINDINGS:  In the matter of the cervical spine condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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 20140224, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-00965.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings