RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01904
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20070928

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Light Wheel Vehicle Mechanic, medically separated for “bilateral leg pain,” with a disability rating of 0%, and “chronic neck pain,” which was determined to exist prior to service (EPTS) and was not permanently aggravated, therefore not compensable.  

CI CONTENTION:  “The conditions I was medically discharged for, I feel, are worse than what they were at time of discharge.”  The CI’s 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 based upon a 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 - 20070620	VARD - 20071102	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Leg Pain, due to Anterior Tibial Stress Syndrome	5099-5003	0%	Bilateral Stress Fractures	5262	NSC	20071218	
Chronic Neck Pain	5299-5237	EPTS	Cervical Spine Degenerative Disc Disease	5237-5010	10%	20071218	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Bilateral Leg Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral leg pain condition began in December 2004.  Diagnostic imaging (bone scan) studies on 17 March 2005 showed subacute Grade I stress fractures of the right mid tibia, bilateral shin splints, stress changes of the knees and ankles bilaterally.  Radiologic (X-ray) studies of bilateral legs on 15 July 2005 demonstrated no evidence of a fracture, inflammatory or neoplastic changes.  An additional bone scan on 27 July 2005 showed no evidence of stress fractures.  A repeat bone scan on 5 December 2006 showed a minimal stress-induced reaction in the left knee but was otherwise normal.  

Despite treatment, the bilateral leg pain condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “both leg pain (bilateral anterior tibial stress syndrome)” for PEB adjudication.

The MEB NARSUM examination on 29 March 2007 (6 months before separation) noted complaints of bilateral leg and knee pain.  The CI did not improve with conservative management which included activity modification, physical therapy (PT), stretching, strength training, ACE bandages, ice, and medications.  Physical examination showed a normal gait and no evidence of ligamentous laxity or meniscus pathology.  There was pain with right knee range of motion (ROM), but bilateral knee ROM was full.  Strength and deep tendon reflexes (DTRs) were normal.  The examiner recounted the findings of the X-rays and bone scans.  The diagnosis was listed as bilateral anterior tibial stress syndrome.  

At the 6 April 2007 VA Compensation and Pension (C&P) examination, performed 6 months before separation, the CI complained of bilateral lower leg pain and swelling, not related to an injury.  Pain was exacerbated by walking, running, rucking, and changes in weather and relieved by stretching.  Flare-ups to 7/10 pain were associated only with aggravating factors and lasted for hours.  Physical examination revealed a normal gait.  The bilateral knee examination revealed no evidence of ligamentous laxity or meniscus pathology.  There was no pain, tenderness, weakness, fatigue, swelling, or joint effusion (fluid collection).  Bilateral knee ROM was full and there were no limitations from pain, fatigue, weakness, or lack of endurance with repetitive ROM.  Strength, sensation, and DTRs were normal and pathologic reflexes were absent.  The bilateral foot examination was normal.  The diagnoses listed right knee patellar chondromalacia (cartilage softening or degeneration) and left knee minimal stress induced reaction.  The examiner documented there were no substantial clinical findings present to support the complaint of bilateral stress fractures to legs.

The Board directed attention to its rating recommendation based on the above evidence.  The Board must first consider whether each lower extremity condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 0% rating under an analogous 5003 code (degenerative arthritis), citing application of the U.S. Army Physical Disability Agency Pain Policy.  The VA did not service connect the bilateral lower extremity condition under the 5262 code (tibia and fibula, impairment of), based on the VA C&P examination 6 months before separation.  The VA cited a normal bone scan, no evidence of stress fractures, and no permanent, residual, or chronic disability subject to service connection was shown.  The ROM values in the proximate examinations were normal and did not support a minimum rating under the limitation of knee flexion (5260), knee extension (5261), and ankle limited motion (5271) codes.  There was no dislocated meniscus (5258), symptomatic removed meniscus (5259), knee ankylosis (5256), knee recurrent subluxation/lateral instability (5257), tibia and fibula nonunion/malunion (5262), or genu recurvatum (5263) for consideration under the respective codes.  There was no ankle ankylosis (5270), subastragalar or tarsal joint ankylosis (5272), os calcis or astragalus malunion (5273), or excision of the astragalus (5274) for consideration under the respective codes.  Members deliberated if 0% was warranted for the bilateral legs or if application of §4.40 (functional loss) or §4.59 (painful motion) justified a 10% rating.  The Board carefully considered the option of rating both legs together, noting that the PEB rated them together.  The Board concluded that the evidence did not provide sufficient grounds for recommending separate leg disability ratings in this case, and that a bilateral rating of 0% coded 5099-5003 was a good analogy to both the pathology and disability.  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 condition.  

Chronic Neck Pain.  The PEB determined the neck condition existed prior to service (EPTS) based on injuries sustained in a 26 July 2004 motor vehicle accident (MVA).  The MVA occurred 3 months prior to his 9 November 2004 entrance into the military.  In the accident, the CI experienced a hyperextension and hyperflexion cervical injury, back pain, brachial radiculitis (nerve root irritation or injury), and headaches.  The treating physician opined that the CI needed to continue therapy to the recommended release date of 11 September 2004 to avoid residual problems.  The Board found no evidence to indicate this was not correct.  The Board next considered whether or not there was evidence of service aggravation.  A presumption of service aggravation may only be overcome by a preponderance of competent medical evidence and accepted medical principles that the natural progression of a pre-existing condition was clearly unaltered by any consequence of military service.  

According to the STR and the MEB NARSUM, the CI presented for treatment on 3 December 2004 after combative training (hand-to-hand combat). The diagnosis was muscle strain.  The next appointment was not until 3 December 2005.  The CI complained of 5 days of 7/10 neck pain with associated stiffness and a “pulling sensation down into left shoulder.”  The CI denied specific trauma.  The CI denied numbness and tingling, but muscle spasms were present.  The assessment listed neck strain.  Cervical spine X-rays on 8 January 2007 showed no evidence of bony injury but loss of normal lordotic (anterior spine curvature) curvature (seen with muscle spasm or patient positioning).  Cervical spine diagnostic imaging (MRI) on 1 March 2007 showed mild C4-C5 spondylosis (spine degenerative disease), moderate C5-C6 spondylosis with mild right-sided neural foraminal (nerve root opening) narrowing, and moderate C6-C7 disc protrusion.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty. The MEB forwarded “cervicalgia” for PEB adjudication.

The MEB NARSUM examination on 29 March 2007 recounted the history of cervicalgia.  The CI complained of 2 years of neck pain with associated left trapezius and shoulder pain.  The CI did not improve with conservative management which included activity modification, chiropractic care, and medications.  Repetitive ROM measurements conducted by PT on 11 April 2007 showed a flexion of 45 degrees (normal), and a total combine ROM of 335 degrees (340 normal).  Strength and DTRs were normal.  The physical examination revealed no localized tenderness, muscle spasm, guarding, abnormal gait, or abnormal spinal contour. The diagnosis listed cervicalgia which was deemed medically unacceptable, EPTS, and was not permanently service aggravated.  

At the 6 April 2007 VA C&P examination, performed 6 months before separation, the CI complained of neck and anterior left shoulder muscle pain with no inciting injury.  There were no exacerbating factors and pain was relieved by stretching.  Flare-ups to 7/10 pain occurred 1-2 times monthly and lasted for 5 days.  Physical examination showed a normal appearance with no tenderness, a normal gait, and no muscle spasms.  Cervical spine ROM was full and there were no limitations from pain, fatigue, weakness, or lack of endurance with repetitive ROM.  Strength, sensation, and DTRs were normal and pathologic reflexes were absent.  The diagnoses listed mild to moderate advanced degenerative changes of the cervical spine.  At the 18 December 2007 VA C&P examination, performed 3 months after separation, the CI reported neck pain.  Physical examination showed tenderness, pain on motion, a normal gait, no atrophy, and no weakness.  ROM showed a flexion of 45 degrees and a combined ROM of 330 degrees.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB determined the chronic neck pain condition was not compensable, citing “there is compelling evidence to support a finding that the current condition existed prior to service (EPTS) and was not permanently aggravated beyond natural progression by such service.  Soldier’s neck pain was the result of an MVA in July 2004 and was present prior to entry into the Army.  It became symptomatic during his first week of basic training.”  The VA assigned a 0% rating under the 5237-5010 codes (cervical strain-arthritis due to trauma) based on the VA C&P examination 6 months before separation, citing a non-compensable evaluation.  However, the VA later assigned a 10% rating based on the VA C&P examination 3 months after separation, citing painful motion.  The ROM values in the PT examination for the MEB NARSUM and the C&P examination (3 months post-separation) were consistent with the 10% rating which require a combined ROM of greater than 170 degrees but not greater than 335 degrees of the cervical spine.  The Board next considered routes to a rating higher than 10%, but there was no evidence of additional functional loss from repetitive use to warrant application of VASRD §4.45, and no evidence of incapacitating episodes that would justify a minimum rating under the alternative formula for rating intervertebral disc disease.  The proximate examinations documented no evidence muscle spasm, abnormal spinal contour, or abnormal gait.  The Board agreed a 10% rating was supported based on limitation of flexion (greater than 30 degrees but not greater than 40 degrees) or combined ROM (greater than 170 degrees but not greater than 335 degrees) reported on the PT and VA examinations.  After due deliberation, considering all of the evidence the Board concluded the neck condition was permanently aggravated by service and recommends a disability rating of 10% coded 5237.

BOARD FINDINGS:  In the matter of the bilateral lower extremity condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended EPTS neck condition, the Board unanimously concluded there was permanent service aggravation and recommends a disability rating of 10%, coded 5237 IAW VASRD §4.71a.  
There were no other conditions within the Board’s scope of review for consideration.  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	PERMANENT RATING	
Bilateral Leg Pain	5099-5003	0%	
Chronic Neck Pain	5237	10%	
COMBINED 	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, 20140501, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20160010872, XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability. I have reviewed the Board's recommendation and record of proceedings (copy enclosed) and Iaccept its recommendation. This will not result in any change to your separation document or the amount of severance pay. A copy of this decision will be filed with your Physical
Evaluation Board records. I regret that the facts of the case did not provide you with the outcome you may have desired.

This decision is final. Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

A copy of this decision has also been provided to the Department of Veterans Affairs and to the counsel you listed on your application, XXXXXXXXXXXXXXXXXXX.

Sincerely,

XXXXXXXXXXXXXXXXXXX
Deputy Assistant Secretary of the Army

Enclosure