RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-02686
BRANCH OF SERVICE:  Army	Date of seperation:  20030720

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5, Infantryman, medically separated for “chronic upper back and lower neck myofascial pain” and “thoracic (mid-back pain) myofascial pain with mild degenerative joint and disc disease, without radiculopathy or spasm,” rated 10% and 10%, respectfully, with a combined disability rating of 20%.

CI CONTENTION: “Please consider all conditions.”  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 - 20030416	VARD - 20110303	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Upper Back and Lower Neck Myofascial Pain	5299-5295	10%	Degenerative Disc Disease Cervical Spine with Spinal Stenosis Resulting in Left Upper Extremity Paresthesia’s and Mild Loss in Strength	5237	20%	20030528	
Thoracic (Mid-Back Pain) Myofascial Pain…	5299-5295	10%	Thoracolumbar Strain	5292	20%	20030528	
Chronic Right Knee Pain	Not Unfitting	Right Knee Meniscus Tear Treated Arthroscopically	5259	10%	20030528	
Chronic Mild Impingement Syndrome, Left Shoulder	Not Unfitting	Impingement Syndrome Left Shoulder Status Post Dislocation	5299-5202	20%	20030528	
COMBINED RATING:  20%	COMBINED RATING FOR ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Neck (Upper Back and Lower Neck).  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI injured his neck when he fell off a ladder while trimming a bush approximately 7 months prior to referral for MEB.  Cervical radiographic imaging (X-ray) showed early degenerative changes in the mid cervical spine and mild left neuroforaminal (nerve root opening) narrowing at C4-5.  Cervical spine diagnostic imaging (MRI) showed diffuse degenerative changes, multilevel bone spurs with central canal stenosis (severe at C3-4 and C4-5), and multilevel neuroforaminal narrowing (severe at left C4-5).  At a physical medicine evaluation, 6 months before separation, the CI complained of constant 4/10 neck pain which radiated to the mid back.  Physical therapy and cervical traction provided no relief.  The physical examination tenderness to upper back and neck muscle regions.  The neck examination revealed full range of motion (ROM) with painful motion.  The Spurling’s (assesses cervical nerve root compression) and Lhermitte's (assesses cervical spinal cord compression) signs were negative.  Upper extremity strength and deep tendon reflexes were normal.  Sensation was subjectively reduced throughout the left arm and hand in an inconsistent and non-anatomic pattern.  Electromyogram showed no evidence of a left cervical radiculopathy (nerve root irritation or injury).

In the 24 February 2003 NARSUM by neurosurgery, 5 months before separation, the CI complained of persistent neck pain with intermittent tingling in the left hand.  The neck examination revealed tenderness in the mid to lower cervical spine.  Active ROM was flexion of 60 degrees, extension 45, and bilateral rotation 80; painful motion was not addressed.  The Spurling’s sign was negative.  Strength, sensation, and deep tendon reflexes were normal and pathologic reflexes were absent.  

At the 28 May 2003 VA Compensation and Pension (C&P) examination, 2 months before separation, the CI complained of lower neck pain, decreased ROM, left upper extremity slight weakness, and left hand radiculopathy (2nd and 3rd finger numbness and tingling).  Pain was exacerbated by prolonged sitting, activity, repetitive bending, and lifting and relieved by stretching.  The physical examination documented a normal gait.  The cervical spine examination revealed tenderness and no muscle spasm.  Pain limited cervical spine ROM was 68 degrees of flexion, 18 extension, 36 right lateral flexion, 41 left lateral flexion, 30 right rotation, and 39 left rotation.  Muscle bulk was greater than average throughout and strength was normal except for 4+/5 left arm strength.  The sharp pain sensation was reduced (3-8/10) in the left forearm, hand, and fingers.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck (upper back and lower neck) condition 10% analogously coded 5299-5295 (lumbosacral strain) citing chronic upper back and lower neck myofascial pain, multilevel degenerative disc disease with spinal stenosis by imaging, some left hand tingling intermittently, no other motor or reflex changes, and characteristic pain on motion.  The VA rated the neck condition 20% coded 5290 (spine, limitation of motion of, cervical) based on the C&P examination 2 months before separation.  In accordance with DoDI 6040.44, the Board is required to recommend a rating IAW the VASRD in effect at the time of separation, which was the 2003 VASRD standards for the spine.  

The Board majority agreed there was no vertebral fracture (5285), complete spine ankylosis (5286), cervical spine ankylosis (5287), dorsal spine ankylosis (5288), or limitation of dorsal spine motion (5291) for consideration under the respective codes.  While there were diffuse degenerative changes, multilevel central canal stenosis, multilevel neuroforaminal narrowing, and reported radiation to the left upper extremity, the electromyogram showed no evidence of a left cervical radiculopathy.  There was no neuropathy, characteristic pain, muscle spasm, absent deep tendon reflexes, neurological findings appropriate to disc site, or recurring attacks for consideration under intervertebral disc syndrome (5293).  Board majority agreed that the ROM values more closely approximated the slight (10%) than the moderate (20%) rating under cervical spine limitation of motion (5290).  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful 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 neck condition.

Back (Thoracic Mid-Back).  According to STR and MEB NARSUM, the CI also injured his back when he fell off a ladder approximately 7 months prior to MEB referral.  At a physical medicine evaluation the CI complained of constant 4/10 neck pain which radiated to the mid back.  The physical examination revealed multiple myofascial trigger points at the (left greater than right) upper back and neck muscle regions.  There was pain at the mid-back and neck base with neck extension and flexion.  The MEB NARSUM recorded no back subjective complaints.  The examiner did not document a thoracic or lumbar spine examination.  The deep tendon reflexes were symmetrical and there was no evidence of focal motor or sensory loss throughout.

At the 28 May 2003 VA C&P examination, 2 months before separation, the CI complained of chronic back pain.  Cervical spine pain was the most severe but the thoracic and the lumbosacral spines were also involved.  The lower back problem was characterized as “minor” compared with the neck problem.  The thoracic spine pain occurred midline just below the scapula and did not radiate to the right or left.  Pain was exacerbated by activity, running, repetitive lifting, and bending and relieved by stretching.  He reported the back tended to lock-up when sleeping or running.  He denied lower extremity weakness or incontinence of urine or stool.  The physical examination documented a normal gait.  The dorsal and lumbar spine examinations were “unremarkable” and there were no muscle spasms.  Dorsal lumbar spine ROM was 90 degrees of flexion, 20 extension, 90 flexion, 36 right lateral flexion, 48 left lateral flexion, and greater than 70 degrees bilateral rotation with painful motion.  Straight leg raise tests (assess for herniated disc causing sciatic nerve root [L5-S1] radiculopathy) were negative.  Muscle bulk was greater than average throughout and strength and deep tendon reflexes were normal.  A lower back X-ray showed degenerative disease but no impingement or significant spinal stenosis.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back (mid-back) condition 10% analogously coded 5295 (lumbosacral strain) citing thoracic (mid-back) myofascial pain, mild degenerative joint and disc disease, no radiculopathy, no spasm, and characteristic pain on motion.  The VA rated the thoracolumbar spine 20% coded 5292 (spine, limitation of motion of, lumbar).  In accordance with DoDI 6040.44, the Board is required to recommend a rating IAW the VASRD in effect at the time of separation, which was the 2003 VASRD standards for the spine.

The Board agreed there was no vertebral fracture (5285), complete spine ankylosis (5286), dorsal spine ankylosis (5288), lumbar spine ankylosis (5289), limitation of dorsal spine motion (5291), limitation of lumbar spine motion (5292), intervertebral disc syndrome (5293), sacroiliac injury/weakness (5294), or lumbosacral strain (5295) for consideration under the respective codes.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  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 low back condition.

Contended PEB Conditions:  Right Knee and Left Shoulder.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  While the right knee was implicated in the commander’s statement, the left shoulder was not.  The contended conditions were not profiled and were not judged to fail retention standards.  All were reviewed 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.  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:  In the matter of the neck (upper back and lower neck) condition and IAW VASRD §4.71a, the Board majority recommends no change in the PEB adjudication.  In the matter of the back (thoracic mid-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 and left shoulder conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  The single voter for dissent recommended a combined disability rating of 30% and 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 20140604, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MINORITY OPINION:  The minority member disagrees with the majority’s recommendation that neck (upper back and lower neck) be assigned a 10% at separation.  The minority recommends a 20% rating.

Applicable 2003 VASRD code 5290 (spine, limitation of motion of, cervical):

5290 Spine, limitation of motion of, cervical:
Severe.........................................................................................................	30
Moderate....................................................................................................	20
Slight...........................................................................................................	10

As documented in the Record of Proceedings above, the minority voter finds the physical medicine and MEB NARSUM examinations 5 to65 months before separation were incomplete and therefore have less probative value.  These examinations reveal ROMs that are either “normal” to “slight” 10% painful cervical spine limitation of motion; illustrated below.  The minority voter finds that the VA C&P examination, 2 months before separation, was comprehensive, more proximate to separation and had higher probative value.  This examination reflects a “moderate” 20% rating; also illustrated below.

Cervical ROM
(Degrees)	Physical Medicine
~6 Mo. Pre-Sep
Not Quantified Examination	MEB NARSUM
~5 Mo. Pre-Sep
Incomplete Examination	VA C&P
~2 Mo. Pre-Sep
Moderate Examination	
Flex	Full ROM	60 Normal	68 Normal	
Extension		45 Normal	18 Moderate	
R Lat Flexion		--	36 Slight	
L Lat Flexion		--	41 Slight	
R Rotation		80 Normal	30 Moderate	
L Rotation		80 Normal	39 Moderate	
Combined		Cannot be determined	215 Moderate	
Comment	Painful motion, Electromyogram showed no nerve root irritation or injury	Painful motion; No unfitting peripheral nerve (motor weakness)	No unfitting peripheral nerve (motor weakness)	
§4.71a Rating	0%	10% (PEB 10%)	20% (VA 20%)	

Based on §4.3 (reasonable doubt), the minority finds the VA C&P examination with the highest probative value, and recommends a disability rating of 20% for the neck (upper back and lower neck) condition, coded 5290.

RECOMMENDATION:  The Board minority, therefore, recommends 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 of his prior medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Upper Back and Lower Neck Myofascial Pain	5290	20%	
Thoracic (Mid-Back Pain) Myofascial Pain	5299-5295	10%	
COMBINED	30%	

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 XXXXXXXXXXXXXXXXXXXXX AR20160013866 (PD201402686)

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