RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	     CASE:  PD-2014-01218
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070716

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Financial Management Technician) medically separated for neck, back, and lower extremity pain rated at 10%, 10%, and 0%, respectively.  The MEB also identified and forwarded four other conditions (esophageal reflux, Crohn’s disease, depressive disorder not otherwise specified, and bilateral foot arch pain) for PEB adjudication which were determined to be not unfitting.  

CI CONTENTION:  Her conditions continue to worsen and negatively impact her daily activities.  Her 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 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 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 FPEB – Dated 20070319	VA* - (2 Months Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Radiating Neck Pain	5299-5237	10%	Cervical Strain	5237	20%	20070503	
Chronic Thoracolumbar Back Pain	5299-5237	10%	Thoracolumbar Degenerative Arthritis	5242	20%	20070503	
Chronic Lower Extremity Pains	5022	0%	Left Knee Patella Femoral Pain…	5024-5260	10%	20070503	
			Right Knee Patella Femoral Pain…	5024-5260	10%	20070503	
			Bilateral Tibia Stress Fractures	5024	0%	20070503	
Esophageal Reflux	Not Unfitting	Crohn’s Disease, Gastro Esophageal Reflux…	7323-7346	30%	20070503	
Crohn’s Disease	Not Unfitting					
Depressive Disorder	Not Unfitting	Mood Disorder	9435	30%	20070621	
Bilateral Foot Arch Pain	Not Unfitting	Bilateral Plantar Fasciitis	5276	0%	20070503	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 4	
Combined:  20%	Combined:  80%	
* Derived from VA Rating Decision (VARD) dated 20070830 (most proximate to date of separation [DOS]).   

ANALYSIS SUMMARY:  

Neck Pain.  The first record in evidence related to the neck pain is a neurology evaluation for a median neuropathy (carpal tunnel syndrome [CTS]) on 11 April 2006.  She reported left hand numbness and tingling upon wakening and noted that it progressed up her arm.  She denied a neck injury or neck pain at that visit and had a normal neurological examination other than diminished sensation of the left arm, worse closer to the shoulder than hand.  Provocative testing was negative as was electrodiagnostic testing (EDX).  Neck X-rays on 23 June 2006 were normal.  An evaluation in primary care on 13 September 2006 noted that her neck was supple, but tenderness and spasm were present.  The neurological examination was normal.  At the MEB examination on 31 August 2006, 10 months prior to separation, the range-of-motion (ROM) was normal.  She was tender to palpation, but spasm was absent.  She had decreased sensation thought to be consistent with CTS.  Her toe and heel walk was normal.  Four of five signs of non-organic pain were present (pain with maneuvers not expected to be painful).  The orthopedic narrative summary (NARSUM) was dated 27 September 2006, 9 months prior to separation.  The CI reported generalized neck pain which radiated into her left arm and hand in a non-dermatomal (non-radicular) pattern.  She had generalized tenderness and the ROM was full, but extension and side bending caused generalized discomfort.  The neurological examination was normal other than one sign of upper motor neuron (nerve tissue above the spinal cord) disease.  X-rays showed mild degenerative changes at C3-4 (not unexpected in a 35 year old person), but were otherwise normal.  Possible left radiculopathy was considered and an MRI ordered.  This was accomplished on 1 October 2006 and was normal.  At the VA Compensation and Pension (C&P) examination performed on 3 May 2007, 2 months before separation, the CI reported a 2-year history of neck pain aggravated by activity.  She denied incapacitation.  Her gait and posture were normal.  The neurological examination was normal.  An X-ray was normal.  The ROM was reduced, but stopped at the onset of pain for each measurement.  There was no further limitation with repetition.  In addition, four maneuvers were painful which were not expected to be painful in this condition.  She showed signs of a chronic pain syndrome and further evaluation with both a pain specialist and psychiatry was recommended.  The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Cervical ROM
(Degrees)	MEB 2808 ~10 Mo. Pre-Sep	MEB ~9 Mo. Pre-Sep	VA C&P ~2 Mo. Pre-Sep	
Flex (45 Normal)	Normal	Full ROM	25	
Combined (340)			200	
Comment	Painful motion not recorded	Discomfort with motion	Stopped on pain onset	
§4.71a Rating	0%	10%	20%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck at 10%, coded 5299-5237 (analogous to cervical strain) noting tenderness and full ROM.  The VA rated the neck at 20%, coded 5237, based on the reduced ROM on the C&P.  The Board noted that the C&P examination was the most proximate to separation.  However, the probative value of this examination is compromised by the presence of pain with multiple maneuvers not expected to be painful.  In addition, the ROM limit is the same as the onset of pain for each maneuver; typically, the ROM of motion exceeds that of pain onset if the examinee is asked to go past it.  There was no history of injury noted; multiple X-rays and an MRI were normal or showed findings of no clinical significance; the neurological examination was typically normal or showed non-anatomical findings; finally, spasm was not present on the C&P examination to account for the reduced motion.  The ROM on the two prior examinations was normal; however, painful motion was recorded on the orthopedic examination and the VA C&P examination supporting a 10% rating IAW VASRD §4.59.  The Board found no route to a higher rating.  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 neck condition.  

Back Pain.  There were no clinical records in evidence specifically addressing the thoraco-lumbar spine prior to the MEB examination on 31 August 2006.  The examiner noted that the ROM, gait, and neurological examinations were normal.  Tenderness of the upper thoracic spine was present.  Her toe and heel walk was normal.  Four of five signs of non-organic pain were present (pain with maneuvers not expected to be painful).  The CI had X-rays of her thoracic spine in conjunction with her evaluation of the neck.  An X-ray on 5 September 2006 showed degenerative changes especially at T7.  In primary care on 13 September 2006, she was noted to have point tenderness and spasm in the muscles of the upper back and left shoulder with decreased ROM (it is not clear if this refers only to the shoulder or not from the narrative).  The neurological examination was normal.  The NARSUM noted that the thoracic back pain was between the shoulder blades and aggravated by motion of the shoulders, left more than right.  The lower back pain began a year earlier and caused difficulty bending over far enough to touch her toes.  The CI reported that her left foot became numb “sometimes.”  She denied trauma.  On examination, she had some spasm of the muscles near the left shoulder blade, but none on the right or in the lumbar area.  She had global tenderness, but especially the area near the left shoulder blade.  The ROM was full.  No comment was made on gait or posture.  She was diagnosed with paraspinous muscle spasm in the thoracic spine and lumbago (back pain).  An MRI on 28 November 2006 showed anterior wedging of the T7 vertebrae, but this was not an acute finding.  At the VA C&P examination, the CI reported a 2-year history of back pain aggravated by activity and stress.  She reported incapacitation for 4 days the prior year.  Her gait and posture were normal.  Neither tenderness nor spasm was present.  The ROM was reduced and stopped at the onset of pain.  There was no further limitation with repetition.  She had pain with maneuvers not expected to be painful. The neurological examination was normal and signs of intervertebral disc syndrome were not present.  The examiner documented that signs of degenerative changes were present on X-ray of the thoracic spine.  However, the actual reports for the lumbar and thoracic spine were normal.  The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Thoracolumbar ROM
(Degrees)	MEB 2808 ~10 Mo. Pre-Sep	MEB ~9 Mo. Pre-Sep
(20060927) p.94	VA C&P ~2 Mo. Pre-Sep	
Flexion (90 Normal)	Normal	Full	50	
Combined (240)			135	
Comment	Pain free motion; tenderness	Tenderness and spasm		
§4.71a Rating	0%	10%	20%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the thoracolumbar spine at 10%, again coded 54299-5237 (analogous to degenerative arthritis of the lumbosacral spine).  The VA rated the back at 20%, relying on the VA C&P examination ROM, using the code 5242 (degenerative arthritis of the spine).  As discussed above, the probative value of the VA C&P examination is reduced and it is not used for rating purposes.  Tenderness present on both the PEB examinations supports the 10% rating adjudicated by the PEB.  The Board found no route to a higher rating.  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 chronic thoracolumbar pain condition.  

Bilateral Lower Extremity Pain.  The CI was first evaluated for bilateral knee pain on 9 September 2005, 2 weeks after accession.  She was treated with duty limitations and a bone scan ordered.  The CI was seen in primary care 10 days later and noted to be functional; the bone scan showed possible bilateral stress fractures of the tibial plateaus (base of the knees).  She continued to have pain and was referred to physical therapy (PT).  On 16 November 2005, she was trained to use crutches; X-rays from a week earlier showed healing bilateral stress fractures.  A repeat bone scan on 9 January 2006 showed continued stress related changes.  A primary care note 2 days later documented improvement and a normal gait, stance, and ROM although motion of the knees was painful.  X-rays on 4 April 2006 showed faint sclerosis (increased density) consistent with the stress fractures.  A bone scan on 12 July 2006 showed improvement with near resolution of the findings.  At the MEB examination, the CI had full ROM of the knees, ankles and feet.  She had some tenderness over shin bones bilaterally and over the right ankle.  Her toe and heel walk was normal.  The NARSUM recorded that the CI was no longer on crutches, but that she could not do high impact activities.  The 20 October 2006 general NARSUM noted constant pain which was aggravated by activity.  Painful motion was not documented.  The examination of her knees was normal.  She was diagnosed with stress reactions of the tibial plateaus and anterior shin bones.  X-rays were normal consistent with resolution of the stress fractures.  The CI was diagnosed with plantar fasciitis during the MEB evaluation process, but this was not found to fail retention standards or to be unfitting.  At the VA C&P examination, the CI reported ongoing knee and shin pain which was aggravated by activity.  She endorsed incapacitation 8 times the previous year for 8 days at a time.  The Board found no documentation in the records in evidence to support this.  On examination, her gait and posture were normal.  The ROM of the knees was reduced to 85 degrees of flexion bilaterally, which was the same as the onset of pain.  Crepitus was present bilaterally.  She reported pain to the touch of a feather.  The knees were stable and without signs of meniscal irritation or effusion.  The ROM of the ankles was normal and the examination otherwise normal as well.  Knee and foot X-rays were normal.  X-rays of the tibia and fibula (bones of the lower leg) showed healed stress fractures.  The CI was diagnosed with bilateral patello-femoral syndrome (PFS), bilateral plantar fasciitis, and chronic stress fractures.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the CI at 0% for chronic lower extremity pains with (bilateral) tibial stress reactions on bone scan, coded 5022 (periostitis).  The PEB noted that the ROM of the knees and ankles was full; neither the knees nor the ankles were found to be separately unfitting by the PEB on the DA Form 199.  However, in a response to a rebuttal by the CI, the PEB clearly stated that the unfitting condition was the bilateral tibial stress fractures without loss of motion.  Foot pain was separately considered and found to be not unfitting.  This was upheld by the PDA.  The VA rated the CI at 10% for each knee diagnosed as PFS, coded 5024-5260 (tenosynovitis-limitation in flexion), for painful motion.  The feet were rated at 0%, coded 5276 (flat feet), for plantar fasciitis.  The unfitting bilateral stress fractures were rated at 0% as the knees had been separately rated and coded 5024.  The Board considered the evidence.  The unfitting condition was determined to be the bilateral stress reactions which were shown to be healed on the VA X-rays 2 months prior to separation.  The MEB and orthopedic NARSUM examination both showed normal ROM without documentation of painful motion; rather, increased pain after activity.  The VA examination did show pain with motion.  However, it also showed pain with being touched by a feather, further reducing the probative value of this examination.  It did document a normal posture and gait which is not consistent with the limitation in flexion recorded.  The Board did not find evidence sufficient to recommend that the knees, ankles, or feet be found separately unfitting.  The VA X-rays proximate to separation indicated that the stress fractures previously present had healed.  The Board found no route to a higher rating for the unfitting “bilateral lower extremity pains” condition.  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 “bilateral lower extremity pains” condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that contended GERD, Crohn’s Disease, depressive disorder, and foot conditions were not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The plantar fasciitis condition was given a temporary profile to allow shoes of comfort, but this expired 3 months prior to separation.  The diagnosis was made while in the MEB process.  The CI was issued a P2 profile for irritable bowel syndrome, but it expired 10 months prior to separation and was not renewed.  None of the conditions were implicated in the commander’s statement and none were judged to fail retention standards.  All were reviewed by the action officer and considered by the Board.  There was no performance based evidence from the record that any of these conditions 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 any of the contended conditions and so no additional disability ratings are 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 chronic radiating neck pain, chronic thoracolumbar back pain, and chronic lower extremity pains conditions and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended GERD, Crohn’s disease, depressive disorder, and bilateral foot arch pain conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 20131227, 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 XXXXXXXXXXXXXXXXXXXXXX, AR20160003661 (PD201401218)

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