RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02625
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20091112

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Water Treatment Specialist, medically separated for “cervical impingement with radiculopathy C5-6” and “lumbar degenerative disc disease (DDD) with left leg paresthesias,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The applicant contended that not all of his medical problems were taken into consideration for his rating.  He specifically named his mood disorder, but later implicated “all [his] medical problems” that occurred during service.  The CI’s complete submission is 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 - 20090818	VARD - 20100324	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cervical Impingement with Radiculopathy C5-6	5237	10%	C5-C6 DDD	5242	10%	20090908	
Lumbar DDD with Left Leg Paresthesia	5237	10%	L4-L5 DDD with Residual	5242	0%	20090908	
			Left Leg Numbness & Tingling	8520	NSC	20090908	
Right Knee Pain	Not Unfitting	Residual, S/P Right Knee Strain	5299-5260	10%	20090908	
Bilateral Wrist Pain	Not Unfitting	Left Wrist Strain	5299-5215	0%	20090908	
		Right Wrist Strain	5299-5215	0%	20090908	
Adjustment Disorder with Depressed Mood	Not Unfitting	Depressive Disorder, Not Otherwise Specified	9499-9434	30%	20100127	
Pseudofolliculitis Barbae	Not Unfitting	Pseudofolliculitis Barbae	7813-7806	0%	20090908	
Mild Hearing Loss	Not Unfitting	Hearing Loss	6100	NSC	20090908	
Hyperlipidemia	Not Unfitting	No VA Placement	
Impaired Fasting Glucose	Not Unfitting	No VA Placement	
Elevated Creatine Kinase	Not Unfitting	No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	
ANALYSIS SUMMARY:  

Cervical Impingement with Radiculopathy C5-6.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI injured his neck on two separate occasions during military training; October 2007 and again in April 2008.  Diagnostic studies performed in May 2008 revealed multi-level cervical DDD with a C3-4 herniated disc.  Although absent source documentation, the STR referenced electro-diagnostic studies performed in June 2008 that indicated a left upper extremity radiculopathy was present.  Surgical intervention was not recommended.  Despite conservative treatment, his cervical spine condition could not be adequately rehabilitated to meet the physical requirements of his military specialty and therefore, he was referred for an MEB.  The MEB forwarded “cervical impingement with radiculopathy C5-6” for PEB adjudication.

At the MEB NARSUM examination performed on 29 December 2008, 11 months before separation, the CI reported neck pain intermittently extending into his left shoulder and associated with ‘heaviness’ in the upper left arm and ‘tingling’ into 2 fingers of his left hand.  Additionally, he endorsed flare-ups that included left hand weakness bad enough to drop lightweight objects; however, the examiner specifically noted, “He [the CI] is able to perform all activities of daily living during a flare.”  The MEB physical examination (PE) revealed painful, but minimal loss of cervical range of motion (ROM).  There was no guarding, tenderness, or abnormal sensation about the cervical spine.  Upper extremity strength was normal.  Both the NARSUM and examination noted ‘absent’ deep tendon reflexes of the upper and lower extremities, bilaterally.  There was no abnormal cervical spine contour.  At an orthopedic follow-up appointment on 10 February 2009, 9 months before separation, the CI complained of neck pain and burning symptoms to the left shoulder.  The examination revealed full active ROM of the cervical spine.  His upper extremity strength, sensation, and deep tendon reflexes were normal.  Provocative maneuvers for signs of radiculopathy were negative.  At the VA Compensation and Pension (C&P) evaluation (8 September 2009), performed 2 months before separation, the detailed spinal examination was normal.  There was no objective evidence of pain or additional limitation of motion after repetitive use.

The Board directed attention to its rating recommendation based on the above evidence.  Although utilizing different, but similar VASRD codes, both the PEB and VA rated the cervical spine condition at 10% citing ROM parameters and combined cervical movements, respectively.  The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion greater than 30 degrees but not greater than 40 degrees and/or combined ROM greater than 170 degrees but not greater than 335 degrees.  The next higher 20% rating was not supported in the absence of either muscle spasms and or guarding severe enough to result in an abnormal spinal contour.  Additionally, there was no evidence of intervertebral disc syndrome (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of an additional rating under the alternate VASRD formula for IVDS. 

Lastly, the Board also considered if additional disability rating was justified for a peripheral nerve impairment due to radiculopathy.  The CI reported radiating pain and intermittent altered sensation to his left arm and hand.  X-rays and electro-diagnostic studies supported some level of radicular nerve irritation or involvement, but PE’s proximate to separation revealed no objective findings of a radiculopathy that would impact duty performance.  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 suffered additional pain from a nerve involvement, such pain 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 neurologic impairment which would impact military occupation-specific activities.  There was no evidence in this case that a neurologic abnormality 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, and 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 cervical spine condition.

Lumbar Degenerative Disc Disease.  According to STR and the MEB NARSUM, the CI’s low back condition began in March 2008 after jumping 10 feet landing on a concrete floor.  Diagnostic studies revealed DDD of the lumbar spine.  Despite non-surgical treatment, the back 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 “lumbar DDD with left leg paresthesias” for PEB adjudication.

At the MEB NARSUM examination, the CI reported back pain with numbness in his left thigh and foot.  His PE revealed a normal gait.  Thoracolumbar ROM was normal excepting a 10 degree loss in extension (20 vs 30 degrees as normal) due to painful motion.  All other PE parameters were either normal or intact.  At the orthopedic follow-up appointment the CI complained of back pain and tingling in his left leg.  The PE showed full active ROM of the thoracolumbar spine.  All other PE parameters were normal.  Provocative maneuvers for signs of radiculopathy or radiating pain due to lower spinal nerve root involvement were negative.  At the VA C&P examination, the PE revealed full and painless ROM of the thoracolumbar spine.  There was no objective evidence of pain or additional limitation of motion after repetitive use.  All other objective PE parameters were normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10% coded 5237 (lumbosacral strain), citing combined ROM parameters.  The VA rated the back condition 0% coded 5242 (degenerative arthritis), based on the VA C&P examination 2 months before separation, citing “x-ray evidence of degenerative arthritis without objective evidence of painful or limited motion of the lumbar spine.”

The Board agreed that a 10% rating, but no higher, was justified for painful motion as reported on the NARSUM examination.  The next higher 20% rating was not supported in the absence of either muscle spasms and or guarding severe enough to result in an abnormal gait or abnormal spinal contour.  Additionally, there was no evidence of intervertebral disc syndrome (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of an additional rating under the alternate VASRD formula for IVDS.  The Board also considered if additional disability rating was justified for peripheral nerve impairment due to a low level spinal radiculopathy.  Members concluded that in the absence of any motor deficits within the lower extremities, there was no evidence that existed to any degree that could be described as functionally impairing.  The Board therefore concluded that an additional disability rating was not justified on this basis.  After due deliberation, and 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’s adjudication for the low back condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that right knee pain, bilateral wrist pain, adjustment disorder with depressed mood, pseudo folliculitis barbae, mild hearing loss, hyperlipidemia, impaired fasting glucose, and elevated creatine kinase 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.  The right knee, bilateral wrist, adjustment disorder, pseudo folliculitis, and hearing loss conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  There was no performance-based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance near the time of separation.  The conditions of hyperlipidemia, impaired fasting glucose, and elevated creatine kinase, were symptoms and or laboratory findings and not actually disabling conditions.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB’s fitness determination for any of the contended conditions listed above and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the neck condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the low back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended right knee, bilateral wrist, adjustment disorder, pseudo folliculitis, hearing loss, hyperlipidemia, impaired fasting glucose, and elevated creatine kinase conditions and symptoms, the Board unanimously recommends no change from the PEB’s determinations as not unfitting.  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 20140530, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 AR2016001 0953 (PD201402625)

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