RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02778
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060201

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Infantryman, medically separated for “chronic low back pain” and “chronic neck pain, rated 10% and 10%, respectively, with a combined disability rating of 20%.  

CI CONTENTION:  “Please consider a 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 – 20051011	VARD - 20060710	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5243	10%	DDD Lumbosacral Spine	5243	20%	20060103	
			S1 Left Motor Neuropathy and Dysesthesia	8520	10%		
Chronic Neck Pain	5237	10%	DD & DJD Cervical Spine with Retrolisthesis of C3, C4	5243	20%		
Benign Prostatic Hypertrophy	Not Unfitting	Benign Prostatic Hypertrophy	7527	20%		
Left Knee Retropatellar Pain Syndrome		Left Knee Strain with Retropatellar Pain Syndrome	5299-5014	10%		
Right Shoulder Pain		Right Shoulder Arthroscopy	5201	NSC		
Mild Sleep-Disordered Breathing		Sleep Disorder	6847	NSC		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:

Chronic Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), dated 7 July 2005, the CI noted low back pain since 10 September 2003, when he bent over to lift a rucksack and felt as if his back tightened up.  He denied weakness, loss of bladder or bowel control, pain that radiated, fever, numbness or tingling.  Treatment consisted of Toradol (ketorolac, a nonsteroidal anti-inflammatory drug (NSAID)) and Methocarbamol (a muscle relaxer).  X-rays of the lumbar spine in November 2003 were normal.  An MRI in January 2004, showed multilevel degenerative disc disease in T7-8, T8-9 and a small central disc protrusion at L5-S1 with an annular tear at T8-9 and T9-10 without spinal stenosis.  Physical therapy (PT) evaluation in March 2003, revealed no loss of flexion or extension in standing.  Back pain persisted and an examination in July 2004, revealed mild tenderness in the thoracic and lumbar regions with a limited range of motion (ROM).  Chiropractic evaluation in December 2004, noted the CI felt as if both feet were in ice water and his scrotum “shrivel up” after an injection for pain.  Chiropractic care did not appear to help the CI’s low back/leg problem, but he did report improvement in his mid-back and neck pain (see below).  The CI reported right leg weakness and his bowel movements were affected with an urge to evacuate, which was hard for him to control.  A note in January 2005, indicated the CI had left leg pain and a nerve block provided short term diminution of pain.  In February 2005, a note indicated that epidural steroid and facet injections only made the CI worse with intolerable side effects.  A repeat MRI in January 2004, demonstrated stable mild disc desiccation and a stable, small mild central disk protrusion that contacted, but did not deviate the originating S1 nerve root.  No annual tear as suggested on the previous examination was present.  An occupational therapy evaluation indicated the CI was able to lift 30 pounds.  Following chiropractic intervention, the CI was evaluated by a physical medicine specialist in March 2005, for left leg and buttock pain, who noted the CI’s symptoms waxed and waned from extreme painful radiculopathy to pins and needles in the bottom of his feet and numbness or tingling in his scrotum as well as along his penis.  On examination the CI had a non-antalgic gait, and he denied any noticeable weakness in the lower extremities.  The CI was able to touch his toes without difficulty, but he had pain with standing from the forward flexed position.  Neurologic evaluation was unremarkable, although he had paresthesias in a glove-like distribution in his left lower extremity.  Electrodiagnostic studies in April 2005, revealed evidence of a left S1 radiculopathy.  At an MEB consultation examination in May 2005, the CI had a non-antalgic gait.  On forward bending and extension of the lumbar spine he had good mobility with pain at the end-points and he was able to touch his toes without difficulty.  Muscle strength was normal as was sensation, except for paresthesias of the lateral aspect of the left foot.  At the NARSUM examination the CI walked with a cane.  There was mild spasm of the paravertebral muscles of the lumbar spine.  Thoracolumbar flexion was full, extension 13 degrees 3 times, right and left side bending and right and left rotation were full.  Straight leg raising was negative bilaterally (to indicate nerve root irritation)  Neurologic evaluation was unremarkable.  At the time of the NARSUM the CI complained of constant burning in his lower lumbar spine at a level of 5/10 (10 being the worst pain) with sitting for greater than 15 minutes, standing more than 10 minutes, or lifting more than 30 pounds.  No surgery was recommended.  An addendum in October 2005 indicated the CI desired evaluation of muscle atrophy.  Measurements revealed the quadriceps were 38.0 cm each; and the right calf was 34 cm and the left calf was 34.5 cm.

At the MEB examination the CI reported on the DD Form 2807-1 Report of Medical History, dated 7 April 2005, lower back problems (nerve damage), extreme loss of strength and ability to sit or stand for more than 10 minutes, and no change or escape from pain, even with meds (diclofenac, an NSAID) and Percocet (oxycodone, a narcotic and acetaminophen, a pain reliever).  The examiner noted on the DD Form 2808 Report of Medical History, dated 7 April 2005, tenderness to pressure of the paraspinal thoracic and lumbar muscles, and a decrease of ROM of the lower back.  A permanent L3 profile was issued for low back pain (herniated disc) on 15 June 2005, with limitations of all physical fitness testing and military functional activities except wearing a protective mask and all chemical defense equipment.  Additional limitations included no running, no jumping, no marching, no backpack, no armored vest, no sit-ups, no pushups, no standing in formation for more than 10 minutes without a break, and no lifting 30 pounds or more.  Swimming was permitted for alternate physical fitness testing.  The commander’s statement, dated 6 October 2005, indicated the CI was moved into a strictly administrative role after the obvious pain and discomfort he was subjected to during previous training missions, and he displayed discomfort after prolonged periods of sitting.

At the VA Compensation and Pension (C&P) examination dated 3 January 2006, approximately one month before separation, the CI reported he had the inability to do the job he was trained for as a diesel mechanic because of neck (see below) and back pain.  He had no incapacitating episodes of back pain in the prior 12 months.  He used Oxycontin (oxycodone, a narcotic) and methocarbamol (a muscle relaxer) daily for the back, neck (see below) and radicular pain.  He denied the use of splints, braces or other assistive devices for the back or neck conditions.  On examination his calf circumference was 33.5 cm bilaterally and the quadriceps muscles were of equal circumference.  Leg raises were negative (to determine nerve root irritation).  Cremasteric reflexes were diminished on the left and absent on the right.  He had a bent-forward-at-the-waist, swaying gait.

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

Thoracolumbar ROM
(Degrees)	NARSUM ~7 Mo. Pre-Sep
	VA C&P ~1 Mo. Post-Sep
	
Flexion (90 Normal)	Full 	40	
Extension (30)	15 (13/13/13)	-20	
R Lat Flexion (30)	Full	10	
L Lat Flexion (30)	Full	10	
R Rotation (30)	Full	15	
L Rotation (30)	Full	15	
Combined (240)	--	110	
Comment	Mild spasm of the paravertebral muscles; non-antalgic gait	Spasm and pain with motion; swaying gait	
§4.71a Rating	PEB 10%	VA 20%	

The Board directed its attention to its rating recommendation based on the above evidence.  The FPEB assigned a 10% rating using code 5243 (intervertebral disc syndrome) for chronic low back pain secondary to L5/S1 disc protrusion with evidence of multilevel thoracolumbar degenerative disc disease.  The VA assigned a 20% rating using code 5243 for degenerative disc disease lumbosacral spine.  The Board sought a route to a higher rating; however, in the absence of ankylosis, forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees or the combined range of motion of the thoracolumbar spine not greater than 120 degrees, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour or episodes of incapacitation was unable to do so based on the NARSUM examination; however, the VA examination was more proximate to separation, although there was no clear cut explanation how or why there was a disparity in the ROMs between the full ROM and the 40 degrees over the 8 month period between the examinations.  Furthermore, the combined ROM was less than 120 degrees and there was spasm and pain with motion and a swaying gait that favors a 20% rating.  The Board members discussed the probative value of the VA versus the NARSUM examination and noted the VA examination was not only more proximate to separation, it was more accurate based on goniometric measurements required by VASRD §4.46.  The Board then considered whether an additional rating could be recommended under a peripheral nerve code.  Although the pain component of the neuropathy is appropriately subsumed in the spine rating IAW VASRD §4.71, which states that “rating is performed with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease,” there was no sensory component with any significant functional implications and no motor weakness was in evidence.  Therefore, a radiculopathy could not be recommended for additional disability rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the chronic low back pain condition.  

Chronic Neck Pain.  The CI reported thoracic/cervical pain during physical fitness testing in January 2001.  A note in September 2004, indicated the CI had numerous instances where his head struck vehicle interiors while riding over rough terrain as a gunner, driver and vehicle commander.  In October 2004, the CI felt a pop in the lower cervical areas followed by an electric shock symptom in his head.  For an instant his vision blackened and he saw stars and was disoriented for several minutes.  The chiropractic assessment was cervical segmental dysfunction.  An X-ray series of the cervical spine in April 2005 demonstrated a small ossific (bony) density at the anterior and superior aspect of the endplate compatible with an avulsion (broken off) bone fragment and a mild retrolisthesis (back sliding of a vertebra) of C3 on C4.  In May 2005, cervical extension was 30 degrees three times with pain at the limit; the other motions were normal.  A chiropractic note indicated “cervical is EN but he is experiencing a prodromal symptom prior to right arm numbness.”

At the MEB medical examination, dated 7 April 2005, approximately 10 months before separation, the CI did not specifically report neck pain.  The medical examiner noted on the DD Form 2808 Report of Medical Examination the CI’s neck was tender to pressure on the paraspinal muscles and the ROM was full in six planes and was “right vascular, motor and sensation intact in the upper extremity.”  A profile was not issued for the chronic neck pain.  The NARSUM dated 7 July 2005 indicated the CI had thoracic spine and neck pain for the prior year and had been treated by a chiropractor.  Examination of the cervical spine showed mild tenderness to palpation of the paraspinal muscles.  Cervical extension was 30, 30, 30 degrees limited by pain with a full ROM of the neck in flexion, side-bending, and rotation.  Motor strength in the upper right extremity was 5/5 and sensation was intact; and, there was no significant point tenderness.  The diagnosis of degenerative cervical and thoracic disk disease with mild retrolisthesis at C3-C4 was made, which was noted to meet retention standards.  The commander’s statement, dated 6 October 2005, indicated prolonged periods of upright activity while wearing equipment seemed to aggravate the CI’s back and he displayed obvious discomfort after prolonged periods of sitting.

At the VA C&P examination dated 3 January 2006, approximately one month before separation, the CI reported back and neck problems in the prior two years and denied use of splints, braces or other assistive devices for his neck or back condition.  The CI was limited in looking above his head or overhead and had pain down the right arm to between the thumb and index finger and dorsum of his right hand.

The ROM evaluations 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)	NARSUM ~7 Mo. Pre-Sep
	VA C&P ~1 Mo. Post-Sep
	
Flex (45 Normal)	Full ROM	(45)50	
Extension (45)	30 (30/30/30)	-30	
R Lat Flexion (45)	Full ROM	(45)50	
L Lat Flexion (45)	Full ROM	(45)50	
R Rotation (80)	Full ROM	45	
L Rotation (80)	Full ROM	45	
Combined (340)	325	255	
Comment	Extension limited by pain; tenderness to palpation of paraspinal muscles	Pain and tingling down the right arm; pain at the end of rotation and less pain on lateral flexion	
§4.71a Rating	PEB 10%	VA 10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5237 (cervical strain) for chronic neck pain secondary to degenerative disc disease with paraspinal muscle tenderness but no spasm, radiculopathy or significant loss of spinal motion.  The VA assigned a 10% rating using code 5243 (intervertebral disc syndrome) for degenerative disc and degenerative joint disease cervical spine with retrolisthesis of C3-C4.  The Board sought a route to a higher rating; however, in the absence of 
forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis was unable to do so.  Additionally, there were no episodes of incapacitation.  The Board then considered whether an additional rating could be recommended under a peripheral nerve code.  Although the pain component of the neuropathy is appropriately subsumed in the spine rating IAW VASRD §4.71, which states that “rating is performed with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease,” there was no sensory component with any significant functional implications and no motor weakness was in evidence; therefore, a radiculopathy could not be recommended for additional disability rating.  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 chronic neck pain condition.  

Contended PEB Conditions: The Board’s main charge is to assess the fairness of the PEB’s determination that benign prostatic hypertrophy, left knee retropatellar pain syndrome, right shoulder pain, and mild sleep-disordered breathing were not unfitting.  They were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  

Benign Prostatic Hypertrophy.  A retrograde urethrogram was unremarkable in August 2004.  The CI indicated it felt like there was something up inside the urethra.  He had a history of “blood in the urine and infection with a history of flank pain.”  He denied any discharge, pain or fever.  At the VA examination the CI reported nocturia (nighttime urination) and frequency during the day.  On examination the prostate was enlarged at 30 grams and slightly tender, but benign with no palpable urine in the bladder.  Flomax (tamsulosin to relax the bladder neck) was moderately helpful for the frequency and nocturia.

Left Knee Retropatellar Pain Syndrome.  The CI reported left knee pain initially in November 2000 after running.  In March 2002 the CI had knee pain after jumping from a seven foot wall and the left knee gave out and locked up if he bent it too much.  An X-ray of the left knee was unremarkable in April 2005.  At the VA examination the CI reported his knee did not swell, lock or give way.  He did not wear a brace or splint or use a cane or crutch.  Flexion was to 135 degrees without pain and extension was to 0 degrees without pain.  Patellar motion was crepitant bilaterally, right worse than left.  There was no instability or evidence of a meniscal tear.  Repetition did cause escalating pain in the right patella, but there was no mention of left patella pain.

Right Shoulder Pain.  The CI had a 3 year history of right shoulder pain after an injury while playing football.  He had right shoulder arthroscopic subacromial decompression in June 1998.   At the VA examination he reported he did not have any residual of pain weakness, or other symptoms.  He was able to flex to 180 degrees and abduct to 180 degrees with pain.  There was no weakness, impingement, or tenderness to palpation.

Mild Sleep-Disordered Breathing.  In May 2005 the CI reported sleepiness during the day, unrefreshing sleep, difficulty getting sleep, mind racing, subjective pain during sleep, struggling respirations, difficulty with sleep maintenance, and jerking movements during sleep.  The CI was diagnosed with mild sleep disordered breathing and he was advised to limit caffeine and narcotic usage and to get 7 to 8 hours of sleep on a regular basis.  The CI began using CPAP (continuous positive airway pressure).  He noted no difference in his daytime fatigue, but thought his snoring had gotten better.

The aforementioned was 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 chronic low back pain condition, the Board unanimously recommends a disability rating of 20%, coded 5243 IAW VASRD §4.71a.  In the matter of the chronic neck pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended benign prostatic hypertrophy, left knee retropatellar pain syndrome, right shoulder pain, and mild sleep-disordered breathing conditions, the Board unanimously recommends no change from the PEB determination as not unfitting.  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; 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	RATING	
Chronic Low Back Pain 	5243	20%	
Chronic Neck Pain 	5237	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140611, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20160010991, 

Dear 

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDSA) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay. Enclosed is a copy of the Board's recommendation and record of proceedings for your information.

The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.

The accepted DoD PDSA recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances. These agencies wtll provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits. Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted. Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO}, 

A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely!