RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02726
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041216

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Health Care Specialist, medically separated for “chronic neck pain with radiation into upper extremities,” with a disability rating of 10%.

CI CONTENTION:  The CI made no specific contention in her application.  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 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 – 20040929	VARD - 20050825	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain with Radiation into Upper Extremities	5299-5237	10%	C6-C7 Left-Sided Disc Protrusion	5237	10%	20050811	
			Radiculopathy, Left Upper Extremity associated with C6-C7 Left-Sided Disc Protrusion	8510	0%	20050811	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Neck Pain with Radiation into Upper Extremities.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic neck pain with radiation into the upper extremities began in February 2004 after conducting physical training.  The CI denied any specific injury or trauma.  Radiographic studies (X-rays) on 20 February 2004 showed straightening of the spine (loss of normal lordotic curvature).  The radiologist opined that this could have been positional or due to muscular spasm.  Neutral, flexion and extension X-rays on 5 and 7 April 2004 were normal.  Magnetic resonance imaging (MRI) on 7 April 2004 showed a C5-C6 disc protrusion that caused mild left neural foramen (nerve root opening) stenosis (narrowing).  Except for mild disc desiccation, the balance of the MRI was unremarkable.  Despite treatment, the cervical spine 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 “c-spine pain and cervical neural foraminal stenosis” for PEB adjudication.

The range of motion (ROM) examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Cervical ROM
(Degrees)	PT ~8 Mos.
Pre-Sep	PM ~7 Mos.
Pre-Sep	NARSUM  ~7 Mos. Pre-Sep	PT ~5 Mos.
Pre-Sep	PT ~4 Mos.
Pre-Sep	VA C&P ~8 Mos. Post-Sep	
Flexion (45 Normal)	45	FAROM 	15 (10/12/15)	AROM
WNL	AROM
WNL	35	
Combined (340)	235		180			295	
§4.71a Rating	10%	0%	30%	0%	0%	10%	

At the 26 April 2004 physical therapy (PT) appointment, 8 months prior to separation, the CI reported constant neck pain down to her mid scapular area.  The pain was sharp in nature and was relieved with medication.  Pain intensity was 8/10 at rest with exacerbations reaching 10/10.  She experienced numbness and tingling in her left arm, with most of the numbness in the hand.  On examination, the CI exhibited painful limited ROM (see chart above).  Her seated posture was poor, with forward head position.  Upper extremity neurological testing was normal and a slump test (assesses neural tension) was positive for neck pain.  

At the 6 May 2004 physical medicine (PM) examination, 7 months prior to separation, the CI complained of constant neck pain, worse at night when lying supine.  She reported radiating pain noted as above.  Pain was relieved somewhat with medication.  Physical examination showed normal neurologic testing.  Testing of the CI’s cervical spine documented full active ROM.  

The MEB NARSUM examination on 12 May 2004 (7 months prior to separation) noted complaints of severe neck pain varying from dull to aching to sharp with radiation into the mid-spine and into the back of her head.  She had occasional radiating pain into the left upper extremity with paresthesia (abnormal sensation, tingling, burning, and prickling).  Pain was constant, rated 8-10/10, exacerbated by strenuous activity and neck motion, relieved somewhat by cold and heat, and caused difficulty with sleeping.  The neck exam revealed multiple trigger points throughout the cervical spine region, cervical paraspinal muscles, and trapezius muscle.  Spurling’s and compression tests (assess cervical nerve root compression by a herniated disc) were positive.  Strength, sensation, and deep tendon reflexes (DTRs) were normal except for trace DTRs in upper extremities.  The ROM measurements are recorded per chart above.  

At the 11 August 2005 VA Compensation and Pension (C&P) evaluation, 8 months after separation, the CI reported neck pain with some transient numbness in the left index finger and thumb.  The CI was able to perform all activities of daily living without problems.  The physical examination documented a normal gait.  The neck exam revealed minimal tenderness, no muscle spasm, and no scoliosis.  The DTRs and sensation were normal except for decreased two-point discrimination in the left hand.  The goniometer measured ROM showed limited and painful motion (see chart above).    

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck pain 10% under an analogous 5237 code (cervical spine strain), citing muscle spasm which distorts natural cervical curve.  The VA also assigned a 10% rating using the 5237 code for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; and, combined ROM of the cervical spine greater than 170 degrees but not greater than 335 degrees.  The ROM values in 3 proximate exams (PM and PT of 5 and 4 months before separation) were normal and did not attain the minimum 10% rating based upon the General Rating Formula for Diseases and Injuries of the Spine.  

The Board agreed that a 10% rating was justified for limitation of flexion (greater than 30 degrees but not greater than 40 degrees) and combined ROM (greater than 170 degrees but not greater than 335 degrees) based upon PT examination (8 months prior to separation) and VA C&P examinations.  It was noted that loss of normal lordotic curvature was present in an isolated X-ray consistent with the 20% rating (i.e. for muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis).  The Board noted the ROM values in the MEB NARSUM examination met the threshold for a 30% rating.  

In assigning probative value to these somewhat conflicting examinations, the Board noted that the MEB NARSUM measurements were inconsistent with the other proximate examinations.  In addition, the CI’s Commanding Officer noted the CI continued to perform her duties within the limits of her profile, had not lost motivation and continued to provide excellent leadership to those soldiers under her command.  Members agreed that the pre-separation examinations as noted as well as the post-separation VA C&P examination were more consistent with outpatient notes and more reflective of the CI’s cervical spine disability picture at the time of separation.  The Board therefore, assigned more probative value to the pre-separation PT and PM examinations demonstrating a 10% rating.  While the CI may have experienced radiating pain from the neck condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There is no evidence in this case that there was radiculopathy with associated functional impairments separately functionally impairing.  Finally, there was no documentation of incapacitating episodes which would provide for a higher rating under that formula for intervertebral disc syndrome (IVDS).  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 neck condition.  

BOARD FINDINGS:  In the matter of the chronic neck pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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 20140522, 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 AR20160010985 (PD201402726)

I have reviewed the enclosed Department of Defense Physical Disability Board of
Review (000 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