RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01487
BRANCH OF SERVICE:  Army 	separation DATE:  20060812

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Signal Support Systems Specialist, medically separated for “chronic neck pain, status post C6-7 fusion, without neurologic abnormality,” “chronic low back pain, due to lumbar degenerative disc disease without neurologic abnormality,” and “chronic bilateral wrist pain,” rated 10%, 10%, and 0% respectively, with a combined disability rating of 20%.  

CI CONTENTION:  His wrist condition continues to worsen and negatively impacts his daily activities.  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 - 20060621	VARD - 20070213	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain…	5241	10%	DDD Cervical Spine…	5242	10%	20061030	
Chronic LBP due to DDD …	5299-5242	10%	Lumbar Strain with DDD	5242	10%		
Chronic Bilateral Wrist Pain	5099-5003	0%	Left Wrist Sprain	5215-5024	0%		
			Right Wrist Sprain	5215-5024	0%		
COMBINED RATING:  20%	COMBINED RATING FOR ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:   

Chronic Neck Pain, Status Post C6-7 Fusion, without Neurologic Abnormality.  The first record in evidence for the neck pain is an MRI dated 7 September 2005 which showed a herniated disc at C6-7.  Conservative therapy including medications and chiropractic manipulation did not resolve pain and the CI underwent cervical fusion at C6-7 on 13 February 2006.  Despite rehabilitation, the CI could not return to full duty and was entered into the MEB process.  Formal range-of-motion (ROM) measurements in physical therapy were accomplished on 11 May 2006.  These were limited by pain and were 3 months after surgery.  At the MEB examination, the CI reported that he injured his neck while in a Bradley vehicle (elsewhere it was documented that it was hit by an explosion).  The MEB physical examination noted limited and painful motion, but a normal neurological examination.  A physical medicine and rehabilitation (PMR) evaluation on 9 June 2006 documented decreased sensation of the thumb, index, and middle fingers, but a normal motor and reflex examination.  Stance and gait were normal.  The narrative summary (NARSUM) was dated 12 June 2006, 2 months prior to separation, and accomplished by an orthopedic surgeon.  The examiner noted spasm of the neck muscles, but a normal neurological examination.  The gait was not recorded.  At the VA Compensation and Pension (C&P) examination performed on 30 October 2006, less than 3 months after separation and 8 months after surgery, the CI reported continued pain.  He also reported 35 days of incapacitation, but this appears to be secondary to the post-surgical recovery period.  The ROM was near normal and recorded below; it was limited by pain.  Spasm was not present.  The gait and neurological examinations were normal.  No assistive device was in use.  X-rays were normal other than expected post-surgical changes.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck at 10%, coded 5241 (spinal fusion).  The VA also rated the neck at 10%, but coded it 5242 (degenerative arthritis of the spine).  The rating criteria for these codes are the same and that neither affords a rating advantage over the other.  The Board considered the evidence and observed that while both the MEB physical therapy ROM measurements and the PMR ROM measurements support a higher rating, both are more proximate to the date of surgery and, therefore, less reflective of the permanent disability.  In addition, an improving trend is evident when looking at all three sets of values.  The Board therefore assigned a highest probative value to the VA C&P examination.  It supports a 10% rating due to the limitation in motion.  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 neck pain condition.  

Chronic Low Back Pain, Due to Lumbar Degenerative Disc Disease.  Without Neurologic Abnormality.  The CI was evaluated for low back pain (LBP) on 30 December 2004.  He reported a long standing problem recently aggravated moving equipment in his shop.  Over the course of the next year, he was treated conservatively with medications and chiropractic manipulation without resolution of his pain.  An MRI noted a disc protrusion at L5-S1 on 10 May 2005, but the back condition was not thought to be amendable to surgery.  Formal range-of-motion (ROM) measurements in physical therapy were accomplished on 11 May 2006 and are charted below.  These were limited by pain, but near normal.  The MEB physical examination noted limited and painful motion, but a normal neurological examination and gait.  A PMR examination documented a normal stance and gait.  The NARSUM examiner noted that the CI rose “stiffly” from his chair.  Spasm of the back muscles, but the neurological examination was normal.  The gait was not recorded.  At the VA C&P examination, the CI reported continued pain.  He also reported 5 days of incapacitation.  The ROM was normal, but painful.  Spasm was not present.  The gait and neurological examinations were normal.  No assistive device was in use.  There was no loss of motion with repetition and signs of intervertebral disc syndrome were absent.  X-rays were normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA both rated the back at 10%, coded 5242 (although the PEB did so analogously).  The Board noted that the VA increased the back rating on subsequent VA ratings.  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 low back pain condition.  

Chronic Bilateral Wrist Pain.  The first record in evidence for the bilateral wrist pain condition was an occupational therapy note dated 14 October 2005, 10 months prior to separation.  The CI reported a 5 year history of pain.  X-rays were normal and he began occupational therapy.  His pain persisted and he was referred to a hand surgeon.  On 14 December 2005, he was noted to have bilateral pain with a mid-carpal shift test (a test for instability) and an audible clunk.  Circumduction (circular rotation) of the wrists was painful.  X-rays and CTs of both wrists were normal.  An MRI on 12 January 2006 showed degenerative changes of two of the wrist (carpal) bones.  The MEB physical examiner noted that the wrist ROM (not quantified) was limited by pain.  Grip strength was reduced at 3/5 and the CI reported a “popping sensation” with ROM maneuvers.  The narrative summary (NARSUM) noted a 3-year history of atraumatic bilateral wrist pain without specific trauma, but aggravated by lifting, typing, and grasping.  His pain persisted despite occupational therapy, medications, and braces.  Other than the above abnormalities on testing, the wrists were normal to examination.  Surgical correction was not considered to be an option for this condition.  Sensation and strength were normal.  At the VA C&P examination, the CI reported that he could function with medications, but that his pain was aggravated by push-ups, lifting, and gripping.  There was tenderness over each wrist near the base of the little, ring, and middle fingers (lunate bone).  The ROM was full and pain free.  Motor function and X-rays were normal.  He had no pain or limitation with repetition.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral wrist condition at 0%, coded 5099-5003, citing the USAPDA Pain Policy.  The VA also rated the wrists at 0% each, coded 5215-5024 (limitation of motion of the wrist and tenosynovitis).  The Board noted that the VA retained these ratings on subsequent VA ratings.  The Board observed that the MEB examiner documented that the CI had painful and limited motion as well as significantly reduced strength at 3/5.  This is not consistent with the NARSUM examination, accomplished by an orthopedic surgeon a month later, or the VA C&P examination with quantified the ROM values and also accomplished repetitive motion.  The C&P examination is therefore assigned a higher probative value for rating purposes (note: later VA examinations also show normal strength without atrophy and, generally, normal and pain free ROM).  The Board majority found no route to a rating higher than the 0% for each wrist assigned by 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 chronic bilateral wrist pain condition.  

BOARD FINDINGS:  In the matter of the neck condition and IAW VASRD §4.71a, the Board by a majority, recommends no change in the PEB adjudication. 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 bilateral wrist conditions and IAW VASRD §4.71a, the Board by a majority vote, recommends no change in the PEB adjudication.  The minority voter on the neck and bilateral wrist conditions submitted the appended minority opinion.  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 20140324, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

Minority Opinion:  As the minority voter, I recommend that the highest probative value for rating at separation be placed on the Service exams.  Prior to separation, there is clear and incontrovertible evidence that the cervical spine condition warranted a disability percentage of 20% based on ROM limitation and the VASRD spine formula (absent the USAPDA pain policy).  The ROM improvement by the time of the first VA exam should be adjudged as post-separation improvement (while there is also later documentation of post-separation worsening later after separation).  Coupled with the CI’s overall disability picture proximate to separation (IAW VASRD §4.7, higher of two evaluations) and in consideration of VASRD § 4.3 (reasonable doubt), the CI’s unfitting neck condition at the time of separation should be rated at 20% (coded 5241).  

It is my recommendation that the CI be awarded a 20% disability for his unfitting cervical spine condition, coded 5241.  

Regarding the bilateral wrist condition, the PEB found the bilateral wrist condition unfit at 0% applying the pain policy.  There was clear evidence in the record at 2 months before separation (including at the NARSUM exam) that there was pain and a clunk with midcarpal shift and functional loss of the wrists.  The CI had abnormal imaging of both wrists (bone scan), and MRI evidence of right-sided degenerative changes of two of the wrist (carpal) bones.  

The post-separation VA exam documented crepitation on motion, no painful or limited motion, and normal X-rays.  The VA exam did not comment on midcarpal stability and did not provide advanced imaging of the carpal bones (wrists) which are difficult to completely visualize on plain X-rays.  

The CI clearly had abnormal imaging “evidence of involvement of 2 or more major joints or 2 or more minor joint groups,” based on advanced imaging which the post-separation VA’s plain X-rays cannot overcome.  The CI’s bilateral midcarpal instability clearly warrants a 10% rating IAW VASRD §4.71a coded analogously to 5024 (tenosynovitis) using the rating criteria of code 5003.  There was insufficient evidence to unbundle and separately rate the wrists to provide any rating other than the combined 10%.  

Given the above, it is my recommendation 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 prior to medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Neck Pain, S/P C6-7 Fusion, …	5241	20%	
Chronic LBP, Due to Lumbar DDD …	5299-5242	10%	
Chronic Bilateral Wrist Pain	5099-5024	10%	
COMBINED	40%	

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 XXXXXXXXXXXXXXXXXXXXXXX AR20160006748 (PD201401487)

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