RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03125
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070614

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Patriot Launching Station Enhanced Operator/Maintainer) medically separated for chronic neck pain and left carpal tunnel syndrome, rated 10% and 0%, respectively.  

CI CONTENTION:  The CI elaborated no specific contention in his application.  His 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 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 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:  

IPEB – Dated 20070410	VA* - (~1 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain	5243	10%	Cervical Disk Disease with Degenerative Joint Disease (DJD) and DDD	5242	20%	20070719	
			Radiculopathy of the Left Upper Extremity associated with Cervical Disk Disease with DJD and DDD	8615	10%	20070719	
Left Carpal Tunnel Syndrome	8599-8515	0%	No VA Placement	
Other MEB/PEB Conditions x 2 (Not In Scope)	Other x 6 	
COMBINED RATING:  10%	COMBINED RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20070906 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Chronic Neck Pain.  The CI insidiously developed neck pain associated with numbness, tingling, and weakness in his left (non-dominant) arm in 2006.  A radiologic work-up in September 2006 revealed multi-level DDD of the cervical spine with disc herniations at C3-C4 and C7-T1 coupled with spinal stenosis.  The CI described a loss of grip in his left hand and reported a history of dropping items with his left hand.  His symptom aggravators include standing, bending, and kneeling and are alleviated by lying in recliner chair.  Specialty referral offered a surgical option, but was refused by the CI.  Electro-diagnostic studies revealed clear evidence of left-sided median neuropathy consistent with a secondary condition of CTS.  There was no evidence of a cervical radiculopathy.  In January 2007, the CI was permanently profiled with a diagnosis of ‘neck arthritis with nerve compression and left arm weakness.’  He was referred to a medical Evaluation Board (MEB) which was conducted on 27 March 2007.

At the 29 January 2007 MEB examination (5 months pre-separation), the CI’s chief complaint was “neck pain and left arm weakness.”  He endorsed constant neck pain averaging a 4-6/10 pain scale.  Symptom aggravators included bending, reaching, wearing protective gear, as well as walking, standing or sitting for prolonged periods.  The MEB physical exam (PE) revealed decreased and painful motion of the cervical spine as well as radicular symptoms into his left hand and wrist.  Guarding was present.  His diagnosis was unchanged.  

At the 19 July 2007 VA Compensation and Pension (C&P) examination (1 month post- separation), the CI reported constant neck pain extending in-between his shoulder blades and occasionally shooting down his left arm to his elbow.  The VA PE revealed painful and limited cervical spine range of motion (ROM).  There was no vertebral tenderness, paraspinal muscle spasms, or atrophy present.  The goniometric 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)	
MEB ~5 Mo. Pre-Sep
	
VA C&P ~1 Mo. Post-Sep
	
Flexion (45 Normal)	 25/25/25	25	
Combined (340)	110	150	
Comment	painful motion	painful motion 	
§4.71a Rating	20%	20%	

The Board directed its attention to its rating recommendation based on the above evidence.  Although citing different VASRD codes, the PEB noted pain and tenderness for a 10% rating and the VA noted limited motion for a 20% rating.  Both pre and post separation exams clearly reflected impaired ROM of the cervical spine (flexion as well as combined) to support a 20% VASRD rating.  Absent additional evidence of ankylosis, no higher rating under §4.71a was applicable.  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 neck condition.  Despite abnormal neuromuscular findings in the left arm and hand, all Board members additionally agreed that the electro-diagnostic studies clearly revealed the absence of a cervical radiculopathy and the presence of a left sided CTS which accurately corresponded to the CI’s presenting symptoms.  The CTS will be separately reviewed below.  

Left (non-dominant) Carpal Tunnel Syndrome.  The examinations for the unfitting neck condition noted above are also applicable to the associated CTS condition.  The CI’s complaint of left hand weakness with paresthesia was originally thought to be secondary to his cervical DDD with nerve compression; until, electro-diagnostic studies (performed 6 weeks [March 2007] after the NARSUM) revealed CTS affecting the left median nerve.  The condition was not specifically listed on the permanent profile nor implicated in the commander’s statement for these documents were authored prior to the CTS diagnosis.  At the MEB examination the CI reported left arm weakness as well as finger tremors upon positional changes of his left arm or shoulder.  The PE revealed decreased strength in the left hand as evidenced by a reduced grip, finger abduction, and wrist flexion.  A strength comparison test performed on 15 February 2007 revealed a 78% and 64% decrease in grip and pinch strength as calculated from expected normal values.  

At the C&P examination the CI reported daily numbness and tingling in three fingers in his left hand.  The VA PE revealed slight decreased pin-prick sensation into the 3rd, 4th, and 5th fingers of his left hand.  “Muscle strength was normal bilaterally.”  As a follow-up to previously performed electro-diagnostic studies, an Orthopedic evaluation was conducted on 13 November 2007 (5 months post-separation) whereby the CI endorsed abnormal sensation in the left upper extremity and the PE findings were abnormal to both sensory and motor deficits noting increased paresthesia and ‘mildly’ diminished fist grip on the left.  The electro-diagnostic study interpretation included mild compression in the carpal tunnel without evidence of atrophy or fasciculations.

The Board directed its attention to its rating recommendation based on the above evidence.  Utilizing an analogous peripheral nerve code of 8599-8515 (median nerve; incomplete paralysis) the PEB rated the left CTS at 0% citing decreased grip strength and normal motor activity.  The VA (although listing the symptoms under the neck condition) also utilized a nerve code of 8615 (neuritis; median nerve) citing a ‘mild’ condition, rated 10%.  Board members first agreed that the utilization of a peripheral nerve code, specifically the median nerve, for the identified CTS was appropriate given the pathology in this case.  The VASRD rating levels under 8515 for the non-dominant extremity are mild (10%), moderate (20%), and severe (40%).  Board members carefully reviewed the three listed examinations that spanned a 10 month period (5 months pre-separation to 5 months post-separation) and acknowledged the presence of both sensory and motor abnormalities on PE; thereby the ‘wholly sensory’ caveat under VASRD §4.124a is not applicable.  Members deliberated and agreed that despite the deficit in grip and pinch strength as recorded at the NARSUM, the CI’s symptoms improved over time whereas subsequent examinations frequently noted ‘mild’ in describing either presenting symptoms or interpretation of the electro-diagnostic studies.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board agreed that the ‘mild’ descriptions as noted in the case file directly supported the ‘mild’ impairment rating under §4.124a and therefore recommends a disability rating of 10% for the left CTS condition.  

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  As discussed above, PEB reliance on the AR 635-40 for rating the neck condition was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the neck condition, the Board unanimously recommends a disability rating of 20%, coded 5243 IAW VASRD §4.71a.  In the matter of the left CTS condition, the Board unanimously recommends a disability rating of 10% coded 8515 IAW VASRD §4.124a.  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 Neck Pain	5243	20%	
Left Carpal Tunnel Syndrome	8515	10% 	
COMBINED	30% 	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140626, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB							
MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite XXX, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXX, AR20160004038 (PD201403125)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:
						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA