RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-01688
BRANCH OF SERVICE:  Army	BOARD DATE:  20150113
SEPARATION DATE:  20061113

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6 (Network Switching Systems Operator/Maintainer) medically separated for a neck condition.  The neck condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The MEB initially forwarded “chronic cervical and thoracic pain” for Physical Evaluation Board (PEB) adjudication IAW AR 40-501.  However, after a PEB request to determine whether separate diagnoses were warranted, the MEB forwarded “chronic cervical pain” and “chronic thoracic pain” for adjudication.  The MEB also identified and forwarded two other conditions, various musculoskeletal pains and hemorrhoids, both medically acceptable.  The Informal PEB adjudicated “chronic neck pain and stiffness” as unfitting, rated 0%, with likely application of AR 635-40; there was no evidence of a separate adjudication for the thoracic pain condition.  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions.”

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 20060831	VA* - (~2 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain and Stiffness	5299-5237	0%	Cervical Spine Degenerative Disc Disease 	5243	10%	20060824	
			Right Upper Extremity Radiculopathy 	8599-8516	0%	20060824	
Chronic Thoracic Pain	PEB Adjudication Unascertained	Lumbosacral Strain and Degenerative Changes of Thoracic Spine	5237	20%	20060824	
Various Musculoskeletal  Pains	Not Unfitting	Left Shoulder Impingement… 	5201-5024	10%	20060824	
		Bilat. Temporomandibular Joint… 	9999-9905	0%	20060824	
		Left Knee Pain	5299-5260	Deferred	
		Left Ankle Sprain	5019-5271	10%	20060824	
Hemorrhoids	Not Unfitting	No VA Placement	
Other x 0 (Not In Scope)	Other x 3 	
RATING:  0%	COMBINED RATING:  50%	
*Derived from VA Rating Decision (VARD) dated 20070109 (most proximate to date of separation (DOS)).

ANALYSIS SUMMARY:

Chronic Neck Pain and Stiffness.  The CI had chronic neck pain progressing in severity over several years.  X-rays of the cervical spine in 2003 and 2005, demonstrated degenerative changes predominantly at the C3-4 level with narrowing of the neuroforamina (bony space through which the spinal nerve roots course).  Magnetic resonance imaging (MRI) of the cervical spine on 24 October 2005 demonstrated degenerative changes with bulging discs at multiple levels (C3-4, C4-5, C5-6 and C6-7) with narrowing of the neuroforamen of the right C3-4 level, and mild symmetric neuroforaminal narrowing at C5-6.  Neurosurgery evaluation on 8 November 2005, recorded a history of chronic neck pain with some numbness of the right arm.  On examination, strength and reflexes were normal in the arms and legs and the gait was normal.  Electrodiagnostic testing (electromyogram) performed on 23 November 2005, demonstrated evidence of injury to the right C5 and C6 cervical nerve roots.  At the follow-up evaluation with neurosurgery on 6 December 2005, the CI reported some intermittent paresthesias of right ring and middle finger but no radicular pain.  The neurosurgeon noted the recent MRI did not show any spinal cord or nerve root compression and advised non-surgical treatment at that time.  Physical therapy (PT) examination on 17 March 2006, recorded active flexion of 30 degrees (normal 45), extension of 27 degrees (normal 45), right lateral bending of 27 degrees (normal 45), left lateral bending of 32 degrees, right rotation of 26 degrees (normal 80) and left rotation of 32 degrees (all values from the third repetition).  Range-of-motion (ROM) was limited by pain and apprehension.  Passive ROM included flexion to 47 degrees.  At a clinic appointment on 21 April 2006, the CI reported chronic neck pain.  At that time he denied any numbness, tingling or radiation.  The CI underwent cervical spine injections by a pain clinic in May and June 2006.  At the time of the VA Compensation and Pension (C&P) examination on 24 August 2006, 3 months prior to separation, the cervical spine ROM was flexion 40 degrees, extension 35 degrees, right lateral bending of 25 degrees, left lateral bending of 35 degrees, right rotation of 60 degrees and left rotation of 55 degrees (combined 250 degrees).  Neurologic examination showed the upper extremity motor and sensory functions were normal.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the chronic neck pain and stiffness at 0% coded 5299-5237 (cervical strain) citing normal passive flexion of 47 degrees.  The VA rated the cervical spine degenerative disc disease (DDD) at 10% coded 5243 (intervertebral disc syndrome) citing the ROM examination from the prior to separation VA C&P examination.  The VA also granted a 0% service-connected rating for right radiculopathy associated with the cervical spine disease, citing the normal neurologic examination at the time of the pre-separation VA C&P examination.  The Board noted the VA C&P examination was more proximate to separation and was performed after treatment with injections by the pain clinic.  Therefore the Board placed greater weight to the VA C&P cervical spine examination.  The limitation of motion at the VA C&P examination supports a 10% rating.  The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The CI had DDD with narrowing of neuroforamen with intermittent right upper extremity numbness symptoms and an electromyogram demonstrating evidence of injury to the cervical spine nerve roots C5 and C6 on the right.  However, examinations indicated normal strength, reflexes, and gait.  The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting.  While the CI may have experienced some numbness from the nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  Therefore the critical decision is whether or not there was a significant motor weakness which would impact military occupation specific activities.  There is no evidence in this case that motor weakness existed to any degree that could be described as functionally impairing.  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), the Board recommends a disability rating of 10% for the chronic neck pain and stiffness (DDD) condition.

Chronic Thoracic Pain.  The Board noted the MEB initially referred chronic thoracic pain combined with the chronic neck pain but subsequently revised the MEB referral form listing chronic thoracic pain as a separate diagnosis.  The available PEB documents do not show if the PEB adjudicated the chronic thoracic pain separate from the neck pain.  Therefore, the Board concluded the condition should be addressed separately.  In view of the absence of documentation of a separate PEB fitness determination, the Board considered the chronic thoracic pain condition to be reasonably considered unfit unless a preponderance of evidence showed the condition was not unfit.  The CI had chronic recurrent thoracic pain since approximately 1997 with significant exacerbations of thoracic pain in 2001 and 2003.  X-rays of the thoracic spine demonstrated mild degenerative changes.  The CI experienced a recurrent episode from September to October 2005, which was similar to prior episodes.  MRI of the thoracic spine on 24 October 2005, noted the presence of small Schmorl’s nodes (small defects at the vertebral body end plates usually associated with developmental changes) and no other abnormalities (no disc herniation, no spinal nerve root compression etc.).  The commander’s statement dated 1 January 2006 indicated that the CI could no longer perform his duties due to chronic back pain.  At the time of evaluation for the MEB, the CI reported chronic thoracic pain for 10 years.  The MEB narrative summary noted severe neck and upper back pain and the MEB referred the thoracic back pain as not meeting retention standards.  The MEB PT thoracolumbar ROM examination on 2 August 2006, recorded active ROM with three repetitions: active flexion 75 degrees (normal 90), extension 15 degrees (normal 30), right lateral bending 20 degrees (normal 30), left lateral bending  25 degrees, right rotation 25 degrees (normal 30), and left rotation 20 degrees (combined 180).  There was pain with motion.  At the VA C&P examination on 24 August 2006, thoracolumbar flexion was 90 degrees with pain and cramping noted at 60 degrees.  Extension was 35 degrees, right lateral bending 30 degrees, left lateral bending 35 degrees, right rotation 55 degrees, and left rotation 55 degrees (combined 300).

The Board directed its attention to its rating recommendation based on the above evidence.  All Board members agreed that the chronic thoracic pain condition was reasonably considered unfit based on a preponderance of evidence.  The VA rated lumbosacral strain (claimed as pain in mid to upper back T5-T11 and pain in lower back) at 20% coded 5237 (thoracolumbar strain) citing flexion of 60 degrees from the pre-separation VA C&P examination.  The Board noted that the MEB physical therapy ROM examination supported a 10% rating and that the VA C&P examination recorded flexion of 90 degrees with pain at 60 degrees.  All members agreed that both examinations more nearly approximated the 10% rating under the General Rating Formula for Diseases and Injuries of the Spine which accounts for painful motion.  
The Board did not conclude the report of pain at 60 degrees at the C&P examination overcame the evidence of the MEB physical therapy examination.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a separately unfit determination with a disability rating of 10% for the chronic thoracic pain condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the various musculoskeletal pains and hemorrhoids were 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.

Various Musculoskeletal Pains.  At the time of the MEB history and physical examination, the CI reported a history of left shoulder bursitis and left knee pain.  The CI was treated for left shoulder pain of 4 years duration in the fall of 2004.  The pain interfered with push-ups.  MRI on 17 November 2004 demonstrated a cyst in the humeral head (the end of the upper arm bone at the shoulder) and evidence of tendonitis of the supraspinatus tendon.  The MRI was otherwise normal.  The CI passed the Army Physical Fitness Test in May 2005.  No further care for shoulder pain is evident in the file.  The CI sought care for left knee pain after running sprints in November 1996.  The physical examination was normal.  He again sought care in November 1999 for left knee pain after being struck on the knee while playing sports.  No further care for knee pain is present in the service treatment records (STRs).  STRs also reflect ankle sprains in 1995 and 2002, and shin splints in 2001.  None of these conditions were active medical problems in the time leading into the MEB, and none were profiled.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  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 various musculoskeletal pain conditions and so no additional disability ratings are recommended.

Hemorrhoids.  The CI listed a history of hemorrhoids during the MEB history and physical examination.  There are no STRs documenting the condition required the attention of medical staff, and the condition was never profiled.  There was no performance based evidence from the record that this condition significantly interfered with satisfactory duty performance.  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 hemorrhoids condition 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.  In the matter of the chronic neck pain and stiffness condition, the Board unanimously recommends a disability rating of 10%, coded 5242 IAW VASRD §4.71a.  In the matter of the chronic thoracic pain condition, the Board unanimously recommends a separately unfitting determination with a disability rating of 10%, coded 5237 IAW VASRD §4.71a.  In the matter of the contended various musculoskeletal pains and hemorrhoid 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 recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

CONDITION	VASRD CODE	RATING	
Chronic Neck Pain and Stiffness 	5242	10%	
Chronic Thoracic Pain	5237	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140417, 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, AR20150009539 (PD201401688)

1.  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 to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl		     XXXXXXXXXXXXXXX
			     Deputy Assistant Secretary of the Army
			         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA