RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03606
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090126

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Unit Supply Specialist, medically separated for “degenerative arthritis of the cervical spine, degenerative disc disease (DDD) and disc herniation” and “degenerative arthritis of the thoracic spine, spondylosis” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI requests the Board 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 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 - 20081010	VARD - 20090429	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Degenerative Arthritis of the Cervical Spine	5242	10%	Degenerative Joint Disease and DDD of Cervical Spine	5010-5243	10%	20090417	
Degenerative Arthritis of the Thoracic Spine	5242	10%	Lumbar Strain	5010-5237	10%		
Raynaud’s Phenomenon	Not Unfitting	Raynaud’s Phenomenon Bilateral Hands	7117	0%		
Restrictive Lung Disease		No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Degenerative Arthritis of the Cervical Spine.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s degenerative arthritis of the cervical spine (neck) condition began in August 2007 when the CI began noticing progressively worsening neck pain.  He denied any specific injury or trauma.  A magnetic resonance imaging (MRI) study on 7 December 2007 showed degenerative disc disease at C4-C5 with broad-based disc bulge with mild cord abutment at that level.  Despite treatment, including a series of epidural steroid injections into the cervical spine, the neck 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 “chronic cervicalgia secondary to degenerative disease and disk herniation” 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 ~9 Mo. Pre-Sep	MEB ~4 Mo. Pre-Sep	VA C&P ~3 Mo. Post-Sep	
Flexion (45 Normal)	56, 58, 60 (45) 	48, 50, 48 (45)	65 (45)	
Combined (340)	300	215	285	
Comments	Pain limited motion; negative DeLuca	Painful limited motion; positive DeLuca – but not quantified	Neg. DeLuca < ROM due only to pain and didn’t raise level of compensability.  Painful decreased motion	
§4.71a Rating	10%	10-20%	10%	

During the MEB examination dated April 2008, 9 months prior to separation, the CI reported constant neck pain at the base of the cervical spine and upper thoracic spine, which was throbbing in nature.  Physical examination showed tenderness along the cervical paraspinal muscles, painful motion with limited lateral flexion, and normal muscle strength (5/5) in the bilateral upper extremities.  At the physical therapy (PT) examination on 28 April 2008, 9 months prior to separation, the CI reported pain at  3/10 intensity with daily flare ups lasting an hour with intensity of 6-7/10.  Precipitating factors include sitting > 30 minutes, lifting > 25-30 pounds, physical activity (sit-ups, push-ups, running, flutter kicks), and quick movements.  Pain was alleviated by changing positions.  Physical examination showed no localized tenderness about the cervical spine, no muscle spasms or guarding, normal gait, and no abnormal spinal contour.  ROM measurements were recorded per chart above.  Painful motion was noted, but repetitive motion did not translate into additional loss of function (negative DeLuca).  The MEB NARSUM examination on 25 September 2008, 4 months prior to separation, noted complaints of chronic neck pain exacerbated by heavy lifting and relieved by medication.  Pain at baseline was 4/10, increasing to 8/10 with flares.  Physical examination showed tenderness at the C5-C7 paraspinal muscles.  Painful motion was noted and ROM measurements were recorded per chart above.  Gait was normal and there was no abnormal spinal contour.  Strength was 5/5 in bilateral upper extremities and reflexes and sensation were normal.  At the 17 April 2009 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported chronic neck pain that did not radiate into his upper extremities.  The CI avoided sleeping on his right side due to his neck pain.  He noted lifting more than 45 pounds caused increased pain.  The CI reported incapacitating episodes over the past 12 months based on his epidural steroid injections, stating he was placed on quarters for 48-72 hours each time he received an injection.  From February to November 2008, he estimated 25-30 days at bed rest with respect to these injections.  On physical examination, the gait was normal.  There was no muscle spasm and no tenderness.  ROM measurements were recorded per chart above.  
After repetitive use, there was a slight decrease in ROM in some planes of movement (flexion decreased but remained within normal limits; and right lateral flexion) due solely to pain and not attributable to fatigue, weakness, or lack of endurance.  Neurologic examination of the upper extremities showed normal strength, sensation, and reflexes.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5242 code (degenerative arthritis of the spine), citing tenderness, and combined ROM of 220 degrees.  The VA also assigned a 10% rating under the 5010-5243 codes (arthritis due to trauma-intervertebral disc syndrome) based on the VA C&P examination 3 months after separation, citing painful or limited motion of a major joint.  The VA rater specifically ruled out the application of DeLuca criteria, noting additional loss of ROM due to repetitive movement (as found by VA exam) did not result in ROM loss which would have been additionally compensable (neither flexion nor combined ROM decreased to a level above the 10% level of compensability).  The VA rater additionally ruled out application of the alternate rating criteria under incapacitating episodes.  The Board agreed that a 10% rating, but no higher, was justified for combined ROM (greater than 170 degrees but not greater than 335 degrees) reported on all exams proximate to separation.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  

The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  Radiographic studies supported some level of radicular nerve irritation or involvement, but physical examinations (PT, MEB NARSUM, and VA C&P) proximate to separation revealed no objective findings of radiculopathy that would impact duty performance.  While the CI may have suffered additional pain from the 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).”  Therefore the critical decision is whether or not there was a significant neurologic impairment which would impact military occupation-specific activities.  There was 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.  The Board considered whether a higher rating (§4.7) was achieved by using the alternate rating formula based on incapacitating episodes due to intervertebral disc syndrome (IVDS).  Although the CI had intervertebral disc disease there were no incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula (for IVDS).  The CI was prescribed quarters following epidural steroid injections, however such prescription within the commonly established practice pattern of military medicine is to protect the member from having to perform activities outside the prescribed profile restrictions and not specifically for bed rest.  Furthermore, and more probative to rating in this case, a review of the evidence showed 2 times within the 12 months prior to the CI’s date of separation where he was given 48-72 hour quarters following an epidural steroid injection.  This would equate to less than 1 week total over the 12 months prior to separation and thus the alternate IVDS rating formula would provide no advantage to the CI.  The Board considered the preponderance of evidence which showed no ratable loss of motion after repetitive use and therefore assessed higher probative value to the multiple exams which showed no additional disability rating was warranted for application of DeLuca.  

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 degenerative arthritis of cervical spine condition.  

Degenerative Arthritis of Thoracic Spine.  According to STR and the MEB NARSUM, the CI’s degenerative arthritis of thoracic spine (back) condition began in August 2007 when the CI began noticing progressively worsening back pain.  He denied any specific injury or trauma.  
An MRI on 9 March 2008 showed a normal lumbar spine with no noted pathology.  Despite treatment, including a series of epidural steroid injections into the lumbar spine, the back 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 “chronic thoracic back pain secondary to spondylosis” 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

Thoracolumbar ROM
(Degrees)	PT ~9 Mo. Pre-Sep	MEB ~4 Mo. Pre-Sep	VA C&P ~3 Mo. Post-Sep	
Flexion (90 Normal)	72, 71, 76 (75)	92,90, 89 (90)	85     	
Combined (240)	195	210	230	
Comments	Pain limited motion	Pain limited motion; Negative DeLuca	Pain limited motion; negative DeLuca	
§4.71a Rating	10%	10%	10c%	

During the MEB examination, the CI reported constant low back pain that was throbbing and radiating in nature.  Pain was exacerbated by prolonged standing, lifting, bending over, flutter kicks, and sit-ups.  Physical examination showed tenderness along the thoracolumbar paraspinal muscles, and painful motion with limited extension.  Neurologic examination was normal (normal bilateral lower extremity strength, sensation and reflexes and negative straight leg raise).  At the PT examination on 28 April 2008, 9 months prior to separation, the CI reported pain at 3/10 intensity with daily flare-ups lasting an hour with intensity of 6-7/10.  Precipitating factors include sitting > 30 minutes, lifting > 25-30 pounds, physical activity (sit-ups, push-ups, running, flutter kicks), and quick movements.  Pain was alleviated by changing positions.  Physical examination showed no localized tenderness about the lumbar spine, no muscle spasms or guarding, normal gait, and no abnormal spinal contour.  ROM measurements were recorded per chart above.  Painful motion was noted, but repetitive motion did not translate into additional loss of function (negative DeLuca).  The MEB NARSUM examination noted complaints of chronic back pain which was exacerbated by heavy lifting and relieved by medication.  Pain at baseline was 4/10, increasing to 8/10 with flares.  Physical examination showed tenderness at the T7-T9 paraspinal muscles.  Painful motion was noted and ROM measurements were recorded per chart above.  Gait was normal and there was no abnormal spinal contour.  Strength was 5/5 in bilateral lower extremities and reflexes and sensation were normal.  At the VA C&P examination the CI reported chronic back pain that did not radiate into his lower extremities.  He noted lifting more than 45 pounds caused increased back pain.  The CI reported incapacitating episodes over the past 12 months based on his epidural steroid injections, claiming he was placed on quarters for 48-72 hours each time he received an injection.  The examiner noted that according to the medical board, the CI received three epidural injections into the mid back and each time, according to the CI, he was told to be at bed rest for “42-72 hours” after the mid back injections.  On physical examination, the gait was normal and he used no assistive devices.  There was no muscle spasm and no tenderness.  ROM measurements were recorded per chart above.  After repetitive use, there was a slight decrease in ROM in some planes of movement (flexion actually improved to 95 degrees; extension decreased to 25 degrees) due solely to pain and not attributable to fatigue, weakness, or lack of endurance.  Neurologic examination of the upper extremities showed normal strength, sensation and reflexes.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the degenerative arthritis of thoracic spine condition 10% coded 5242 (degenerative arthritis of the spine), citing tenderness, and combined ROM of 213 degrees.  

The VA also rated the degenerative arthritis of thoracic spine condition 10% coded 5010-5237 (arthritis due to trauma-lumbosacral strain), based on the VA C&P examination 3 months after separation, citing forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees.  The VA rater specifically ruled out the application of DeLuca criteria.  The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and/or combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the all exams proximate to separation.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no evidence of intervertebral disc syndrome (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula (for IVDS).  There was no evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve rating.  

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 degenerative arthritis of thoracic spine condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that restrictive lung disease and Raynaud’s phenomenon conditions were not unfitting.  

Restrictive Lung Disease.  A high resolution chest diagnostic imaging (CT) study was normal with no evidence of interstitial lung disease (ILD).  A transthoracic echocardiogram (TTE) was normal.  The 9 September 2008 pulmonology MEB addendum reported that repeat pulmonary function tests (PFTs), which included spirometry and diffusing capacity of lungs for carbon monoxide ([DLCO] measure of gas transfer from lungs [alveoli] to blood [red blood cells]),  were interpreted as normal (FEV-1 of 80% predicted, FEV-1/FVC of 83%, and DLCO of 78% predicted).  The impression listed mild restrictive lung disorder with mild reduction in DLCO, both of which have resolved.  The examiner documented the CI met retention criteria according to AR40-501 with regards to his lung process, which was now normalized.  The restrictive lung disease was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  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 contended restrictive lung disease condition and so no additional disability rating is recommended.  

Raynaud’s Phenomenon.  The 4 September 2008 rheumatology consultation documented the CI only manifested Raynaud's phenomenon (recurrent finger and toe vasospasm in response to cold or stress) with a high antinuclear antibodies ([ANA] facilitate diagnosis of autoimmune diseases) titer and no specific diagnosis could be made based on these 2 findings.  He had normal nailbed capillaroscopy.  His normal high resolution chest CT and normal TTE argued against ILD or pulmonary hypertension, either of which could suggest an underlying connective tissue disease.  There was nothing else on history, physical examination, or labs (serologies) to suggest scleroderma, myositis, systemic lupus erythematosus (SLE), Sjogren's or any other connective tissue disease.  The examiner documented the CI met retention criteria according to AR40-501 with regards to Raynaud's phenomenon and positive ANA.  The Raynaud’s phenomenon was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  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 contended Raynaud’s phenomenon condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the degenerative arthritis of cervical spine condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the degenerative arthritis of thoracic spine condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended restrictive lung disease and Raynaud’s phenomenon 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 20140707, with attachments
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 300, Arlington, VA  22202-3557

29 NOV 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
AR20160017688 (PD201403606)

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.

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA