RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02894
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060120

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E5, Healthcare Specialist, medically separated by the Informal Physical Evaluation Board (PEB) for “chronic neck pain” and “chronic back pain,” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  “Now rated 100% unemployable by VA.”  The applicant’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 - 20051129	VARD - 20070511	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain… 	5299-5242	10%	DDD & DJD, Cervical Spine…	5242-5239	10%	20060620	
			Radiculopathy, RUE	8515	0%		
			Radiculopathy, LUE	8515	0%		
Chronic Back Pain…	5299-5242	10%	DDD & DJD, Lumbar Spine…	5242-5239	10%		
			Radiculopathy, RLE	8520	0%		
			Radiculopathy, LLE	8520	0%		
Metatarsalgia	Not Unfitting 	Metatarsalgia, Bilateral Feet…	5279	10%		
Dysthymia		Post-Traumatic Stress Disorder and Dysthymia…	9433-9411	30%	20061024	
ADD w/ Hyperactivity						
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Cervical Spine.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s neck pain began around 2002 with no specific injury or trauma, and was aggravated by a fall during a 2004 deployment.  Imaging studies in June 2005 showed multi-level (C3-7) degenerative disc disease (DDD) without significant neural compromise.  Multiple neurological examinations were normal, with none to the contrary, and the orthopedic consultant opined that surgery was not indicated.  Despite conservative treatment, the neck pain could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty, so he was referred for MEB.  The MEB forwarded “cervical spondylosis” (degenerative changes in the spine) for PEB adjudication.  The range of motion (ROM) examinations in evidence which the Board weighed in arriving at its rating recommendation are summarized in the chart below.  

Cervical ROM
(Degrees)	PT ~7 Mos. 
Pre-Sep	PT ~3 Mos. 
Pre-Sep	PT ~3 Mos.
Pre-Sep	VA ~5 Mos. 
Post-Sep	
Flexion (45 Normal)	45 	35	40	45	
Combined (340)	295	280	255	320	
§4.71a Rating	10%	10%	10%	10%	

At the time of a physical therapy (PT) appointment on 24 June 2005 (7 months prior to separation), the CI reported intermittent pain rated at 2/10 severity, which had recently been 7/10.  Pain intermittently radiated into the arms.  The neck pain was aggravated by running, lifting, standing, or sitting, and was eased by sleeping.  On examination, posture was observed as being forward for the head and shoulders.  Upper extremity strength, sensation, and reflexes were all normal.  A PT examination dated 13 October 2005 (3 months before separation) recorded the ROM charted above.  The MEB examination on next day, recorded on DD Forms 2807 and 2808, reported cervical spine tenderness and painful motion without ROM limitation.  At a PT visit on 17 October 2005, the CI complained of neck pain with associated left upper extremity pain, numbness, and tingling.  The neck pain was exacerbated by prolonged sitting, standing, or any impact activity, and relieved by lying down.  On examination, strength, reflexes, and sensation in the upper extremities were intact.  The ROM measurements are charted above.

The MEB NARSUM examination on 30 October 2005 (4 months prior to separation) noted aggravation of the pain with load-bearing gear and the physical rigors of deployment, and did not comment on radicular symptoms.  The physical examination recorded the absence of spasm and normal neurological findings (5/5 strength, intact sensation and reflexes).  

At the VA Compensation and Pension (C&P) examination on 19 June 2005, performed 5 months after separation, the CI reported a dull, aching sensation that was always present.  With activity the pain would radiate into his arms, the left arm greater than the right.  The CI reported numbness and tingling in both hands, and no changes in grip strength or fine motor movements; but, some difficulty driving and rotating his head with headaches towards the end of the day.  Pain was reported as 10/10 severity once per month lasting 4-5 hours, and relieved with non-prescription medications.  The pain caused difficulty lifting, pushing, or pulling.  The physical exam recorded normal posture and gait.  The neck was supple and the neurological examination was normal.  The VA ROM measurements are charted above.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated 10% under code 5299-5242 (analogous to degenerative arthritis of the spine), citing limitation of forward flexion at 35 degrees.  The VA assigned a 10% rating under code 5242-5239 (degenerative arthritis of the spine – spondylolisthesis or segmental instability), citing painful motion.  The VA also assigned 0% for radiculopathy of each of the upper extremities under code 8515 (paralysis of the median nerve), citing lack of objective symptoms for the minimum compensable rating.  The Board agreed that a 10% rating was justified for the presence of tenderness as reported on three of the four examinations proximate to the date of separation, with the exception being the 13 October 2005 PT examination.  While tenderness was not reported, the painful motion reported on that PT examination also supported a 10% rating.  There was no muscle spasm or guarding severe enough to result in abnormal gait or spinal contour, thus the next higher 20% rating was not justified by either criterion.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  

The Board also considered whether additional disability rating was justified for the lower extremity radiculopathies.  The CI had reported radiating pain with sensory symptoms but no subjective weakness and there was confirmed disc disease but, neurological examinations indicated normal strength, reflexes, and sensation in the upper extremities.  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 nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  The sensory symptoms did not affect the CI’s job and there was no subjective or objective motor impairment.  The critical decision is whether or not there was a significant neurologic impairment which would impact military occupation specific activities.  There is 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, 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 of the cervical spine condition.  

Lumbar Spine.  The CI’s low back pain began as early as 2000 with no specific injury or trauma, and was aggravated by the same deployment incident noted above.  Imaging of June 2005 revealed DDD (L4/5 without significant neural compromise), and there was no surgical indication.  Despite conservative treatment, the condition could not be adequately rehabilitated and the CI was referred for a MEB, which in turn forwarded “lumbar spondylosis” for PEB adjudication.  The ROM examinations in evidence which the Board weighed in arriving at its rating recommendation are summarized in the chart below.  

Thoracolumbar ROM
(Degrees)	PT ~3 Mos. 
Pre-Sep	MEB ~3 Mos.
Pre-Sep	PT ~3 Mos. 
Pre-Sep	VA ~5 Mos. 
Post-Sep	
Flexion (90 Normal)	75 	Grossly normal with painful motion.	90	90 	
Combined (240)	205		230	240
(painful motion)	
§4.71a Rating	10%	10%	10%	10%	
       
At a PT appointment on 13 October 2005 (3 months before separation) the CI reported baseline pain rated 3/10 and the ROM measurements charted above.  The MEB examination the following day reported spine tenderness and painful motion, with no ROM limitation.  At a PT appointment on 17 October 2005, the CI complained of back pain with radiation into the shins and feet, which was exacerbated by prolonged sitting, standing, or any impact activity.  On examination gait was normal; and, strength, reflexes, and sensation in the lower extremities were intact.  

The MEB NARSUM examination on 30 October 2005 described constant back pain radiating into both legs associated with sensory symptoms but no subjective weakness.  The physical examination recorded the absence of spasm and normal neurological findings (5/5 strength, intact sensation and reflexes).  Provocative testing for nerve root irritation was negative.

At the VA Compensation and Pension (C&P) examination on 19 June 2005 (5 months after separation) the CI reported an aching sensation that was always present.  With activity the pain would radiate into his legs and feet, the left greater than the right.  The CI reported numbness and tingling in both lower extremities.  Pain was rated 4/10 with frequent flares to 8/10, and caused difficulty with twisting, pushing, or pulling.  The CI was able to walk more than one mile at his own pace, go up or down 2 flights of stairs, get in or out of a car without problems, and ride in a car for 2 hours before needing to stretch.  He reported being able to stand not longer than 30-45 minutes, and was unable to run or participate in impact sports.  The physical examination recorded a normal gait and spinal contour, and the lower extremities demonstrated normal strength, sensation and reflexes.  The VA ROM measurements are charted above.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the lumbar spine 10% coded 5299-5242 (same as cervical), citing limitation of forward flexion.  The VA rated 10% coded 5242-5239 (same as cervical), citing painful motion.  The VA additionally rated bilateral lower extremity radiculopathies 0% each under 8520 (paralysis of the sciatic nerve), citing lack of objective symptoms for the minimum compensable rating.  The Board agreed that a 10% rating was justified for the presence of painful motion on all examinations proximate to the date of separation.  There was no muscle spasm or guarding severe enough to result in abnormal gait or spinal contour, so the next higher 20% rating was not justified on this basis.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  

The Board also considered whether additional disability rating was justified for the upper extremity radiculopathies.  The relevant functional evidence mirrored that for the cervical spine, and the Board’s conclusions and rationales were the same as those elaborated for the cervical radiculopathies.  The Board similarly agreed that additional disability rating was not justified for the lumbar radiculopathies.  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 chronic low back pain.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that metatarsalgia, dysthymia, and attention deficit disorder with hyperactivity were each not unfitting.  The metatarsalgia (pain and inflammation in the ball of the foot) was permanently profiled as “plantar fasciitis”, but was not implicated in the commander’s statement.  An MEB podiatry addendum indicated that the condition met retention standards and should not be boarded, and the MEB determined that metatarsalgia met retention standards.  This condition was reviewed and considered by the Board.  There was no performance-based evidence from the record that metatarsalgia significantly interfered with satisfactory duty performance.  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 fitness determination for the metatarsalgia, so no additional disability rating is not recommended.  

The dysthymia and attention deficit disorder with hyperactivity were addressed by an MEB psychiatric addendum and were judged to meet retention standards.  The diagnosis of dysthymia was profiled S3 in August 2005, but the profile was dropped after the psychiatric addendum, and the permanent profile, 15 November 2005, in effect at separation was S1.  No mental health diagnosis or impairment was implicated in the commander’s statement.  These conditions were reviewed and considered by the Board.  There was no performance-based evidence from the record that any mental health condition significantly interfered with satisfactory duty performance.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded there was insufficient cause to recommend a change in the PEB fitness determination for the mental health conditions, so no additional disability rating is recommended.
BOARD FINDINGS:  In the matter of the lumbar spine condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the cervical spine condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended metatarsalgia, dysthymia and attention deficit disorder with hyperactivity conditions, the Board unanimously recommends no change from the PEB 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 20140215, 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 AR20160011 086 (PD201402894)

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.

CF:
( ) DoD PDBR
( ) DVA