RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	 CASE:  PD-2014-03690
BRANCH OF SERVICE:  Army 	 SEPARATION DATE:  20031020

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Administration Specialist, medically separated for “chronic neck and back pain without significant neurologic findings,” with a disability rating of 10%.

CI CONTENTION:  “Please 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 - 20030910	VARD - 20031124	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck and Back Pain without Significant Neurologic Findings	5099-5003	10%	Degenerative Joint Disease, Thoracolumbar Spine
(Historically Rated Under Code 5293)	5242	10%	20030919	
			Degenerative Joint Disease, Cervical Spine with Herniated Disc	5243	10%	20030919	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY: 

Chronic Neck Pain.  An early note in the service treatment record (STR) dated 20 October 1999 indicated the CI complained of neck pain for 4 days in the absence of trauma.  In March 2000 the CI had left neck stiffness for 3 days after weight lifting, which was treated with heat, Motrin (Ibuprofen, a nonsteroidal anti-inflammatory drug [NSAID]) and Robaxin (methocarbamol, a muscle relaxer).  Over time with chiropractic treatments the CI’s neck pain improved until November 2002 when he developed pain in the neck “down to the shoulder blades” while driving.  Treatment consisted of Tylox (oxycodone, a narcotic and acetaminophen, a pain reliever) and Motrin.  An X-ray series of the cervical spine in December 2002 demonstrated mild straightening of the normal cervical lordosis, which was felt to be related either to positioning and/or to muscle spasm.  The CI’s medication was changed to Naprosyn (naproxen, an NSAID), Flexeril (cyclobenzaprine, a muscle relaxer), and Valium (diazepam, a muscle relaxer); and improvement was noted.  On 11 December 2002 the CI indicated his neck pain was especially difficult in the morning when it was stiff thereby causing difficulty with driving and/or turning his head.  Additional chiropractic treatments and a home rehabilitation program afforded limited relief.  Magnetic resonance imaging in March 2003 performed for cervical radiculopathy with neck pain radiating down the right arm with paresthesias demonstrated a small disk herniation at C4/5 that produced minimal to mild spinal stenosis and disk degeneration at several levels.  A neurologist opined that the central bulging disc at C4-5 that indented the thecal sac, but not the [spinal] cord, was the source of cervical pain.  At a neurosurgical evaluation in April 2003, the CI reported a lot of neck “kinking,” but no bowel or bladder dysfunction.  The neurosurgeon’s impression was left ulnar nerve versus radial nerve symptoms.  An electromyogram was negative for right ulnar abnormality, was borderline normal for the right median nerve, and was abnormal consistent with a right partial C5-6 radiculopathy.  A CT [computerized axial tomography] myelogram in April 2003 revealed minimal cervical spondylosis (stiffening or arthritic changes) and a mild broad-based disk bulge at C4/5 level and a minimal broad-based disk bulge at the C5/6 level.  Following the CT myelogram the CI underwent chiropractic manipulation along with other treatment modalities including electrical stimulation and hot or cold pack applications.  A repeat CT scan in July was basically unchanged.  At an examination in September 2004 the CI reported he tried to pick up a piece for his truck and could not turn his neck thereafter.  On examination he had muscle spasm on the left side of his neck with painful movement on turning his neck to the left.  The examiner’s assessment was torticollis (twisted neck with head tilt) and treatment consisted of intramuscular toradol (ketorolac, an NSASID), Flexeril and tramadol (an opioid-like medication).  

At the MEB examination the CI reported on DD Form 2807-1 that was undated he had chronic neck and back pain (see below) and had been going to the chiropractor for approximately 2½ years.  He noted his neck locked up, which caused tingling and loss of movement in the right arm.  The medical examiner reported on DD Form 2808 dated 31 July 2003 slight discomfort with full forward flexion and extension of the cervical spine.  Deep tendon reflexes were 2/4 bilaterally.  The MEB narrative summary (NARSUM) dated 31 July 2003 noted on examination the CI’s neck was supple and the range of motion (ROM) was full as were the ROMs of the upper extremities.  Sensation was intact to light touch and pinprick bilaterally; and two point discrimination of the digits was also intact.  There was good muscle strength, grip strength and coordination.  Reflexes were 2/4 bilaterally, and there was no edema, effusion or muscle atrophy.  A permanent U3 profile was issued for chronic neck and upper back pain (see below) in August 2003 with limitations of all physical fitness tests, wearing a backpack, wearing a helmet and carrying more than 35 pounds as well as no running, jumping, swimming, overhead work, pushups or sit-ups.  The commander’s statement dated 14 August 2003 indicated the CI was physically capable of reasonably performing his duties as an administrative specialist; however, his chronic neck and upper back pain (see below) prevented him from performing all physical duties in the field and during deployment required by Army standards.

At the VA Compensation and Pension (C&P) examination dated 19 September 2003, a month prior to separation, the CI reported constant dull aching pain in the neck since 2002.  The pain did not travel to other parts of the back and there were no episodes of incapacitation or loss of any time from work.  On examination there was no evidence of radiating pain on movement or muscle spasm.  ROM measurements were flexion 60 degrees, extension 40 degrees, right lateral flexion 40 degrees, left lateral flexion 34 degrees, right rotation 78 degrees, and left rotation 76 degrees.  Pain was present at the ends of motion and ROM was additionally limited by pain.  At a pain management clinic on 18 March 2004, 5 months after separation, an examination was unremarkable and the examiner did not find any significant disability at that time.  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)	MEB ~3 Mo. Pre-Sep
	VA C&P ~1 Mo. Pre-Sep
	
Flex (45 Normal)	FROM	(45)60	
Extension (45)	FROM	40	
R Lat Flexion (45)	FROM	40	
L Lat Flexion (45)	FROM	(35)34	
R Rotation (80)	FROM	(80)78	
L Rotation (80)	FROM	(75)76	
Combined (340)	-	315	
Comment	Sensation intact	No radiating pain on movement; no spasm; no tenderness	
§4.71a Rating	-	VA 10%	

Back Pain.  A note dated 4 March 2002 indicated the CI had lower back discomfort and chiropractic treatment was carried out, while another note on the same date pointed out the CI had chronic lower back pain in the prior few weeks.  On examination the CI had a full ROM with negative straight leg raises (to determine nerve root irritation) and a negative FABER test (to determine hip abnormalities).  Neurologic evaluation was unremarkable without weakness or sensory deficits.  The impression was mechanical low back pain.  Naproxen and Robaxin, prescribed originally for the neck pain (see above), were continued.  At a follow-up visit in September 2002 the CI noted he saw a chiropractor and had treatments on a regular basis.  On examination he had a normal gait with a decreased ROM with pain at the endpoint of side bending and rotation, but not with flexion and extension.  A note dated 11 December 2002 indicated the CI had been complaining of insidious lower back pain, which was non-radiating and without weakness or paresthesias in the lower extremities.  Because of chronic musculoskeletal low back pain and myofascial pain syndrome of the neck and cervical spine (see above), the CI had not done a full physical fitness test for a least a year.  In February 2003 he had stiffness in the lower thoracic region and had chiropractic treatment.  Mobic (meloxicam, an NSAID) and Elavil (amitriptyline for nerve pain) replaced other medications that were prescribed for the neck pain and chiropractic treatments continued on an as needed basis.  

At the MEB examination the CI reported on DD Form 2807-1 that was undated he had chronic neck and back pain and had been going to the chiropractor for approximately 2 years.  The medical examiner did not report any findings related to the back on DD Form 2808 dated 31 July 2003.  The MEB NARSUM dated 31 July 2003 noted that on examination there was a full ROM of the back and the extremities and there was a normal gait.  Reflexes were 2/4 bilaterally.  A permanent U3 profile was issued for chronic neck (see above) and upper back pain in August 2003 with limitations of all physical fitness tests, wearing a backpack, wearing a helmet and carrying more than 35 pounds as well as no running, jumping, swimming, overhead work, pushups, or sit-ups.  The commander’s statement dated 14 August 2003 indicated the CI was physically capable of reasonably performing his duties as an administrative specialist; however his chronic neck (see above) and upper back pain prevented him from performing all physical duties in the field and during deployment required by Army standards.  

At the VA Compensation and Pension (C&P) examination dated 19 September 2003, performed a month before separation, the CI reported recurrent pain in the mid upper back and dull aching pain and muscle spasms in the lower back.  The pain did not travel to other parts of the body and did not cause incapacitation, but he was unable to push, pull, or carry objects weighing 35 pounds.  However, the condition did not result in any time lost from work.  Examinations of the thoracic and lumbar spine were separately reported and each examination was equal to the other.  There were no complaints of radiating pain on movement; and there were no muscle spasms.  Straight leg raising was negative bilaterally.  The ROM measurements were flexion 95 degrees, extension 35 degrees, right lateral flexion 40 degrees, left lateral flexion 40 degrees, right rotation 35 degrees and left rotation 35 degrees.  There was no limitation of motion on repetition and there was no ankylosis or signs of an intervertebral disc syndrome.  Gross examination of the spine was within normal limits.  In October 2004, 12 months after separation, examination revealed mild muscle spasm of the paraspinous muscles of the right lower back and X-rays of the spine were reported to be normal.  

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)	MEB ~3 Mo. Pre-Sep
	
VA C&P ~1 Mo. Pre-Sep

(NOTE: Thoracic and Lumbar segments documented separately but ROMs identical in each plane – as reflected below)	
Flexion (90 Normal)	FROM	(90)95	
Extension (30)	FROM	(30)35	
R Lat Flexion (30)	FROM	(30)40	
L Lat Flexion (30)	FROM	(30)40	
R Rotation (30)	FROM	(30)35	
L Rotation (30)	FROM	(30)35	
Combined (240)	 FROM	240	
Comment	-	Normal gait; no limitation of motion on repetition	
§4.71a Rating	-	VA 10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5099-5003 for chronic neck and back pain without significant neurologic findings.  The VA assigned a 10% rating using code 5243 (Intervertebral disc syndrome) for degenerative joint disease of the cervical spine with a herniated disc and a 10% rating using code 5242 (Degenerative arthritis of the spine) for degenerative joint disease of the thoracolumbar spine (historically rated with code 5293).   

As noted above, the PEB combined chronic neck pain and back pain conditions under a single Service disability rating, coded analogously to 5003.  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  IAW DoDI 6040.44, if the PEB combined adjudication is not compliant with the 5003 combined rating criteria, each condition subsumed under the single Service disability rating must be reasonably justified as separately unfitting in order to remain eligible for Service rating.  The Board’s initial charge in this case was directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  The evidence for each condition was presented separately.  If Board members determine by performance based fitness criteria that the condition is reasonably justified as separately unfitting and is separately ratable; IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended.  IAW DoDI 6040.44 the combined rating for the conditions determined to be separately unfitting and ratable may not be lower than the single Service disability rating from the PEB.  
  
In this case, both neck pain and the back pain were profiled, considered to fail retention standards, and implicated by the NARSUM and in the commander’s statement.  Members agreed that neck pain and back pain are each separately unfitting.  The Board members first discussed the rating for the neck pain.  Use of code 5099-5003 with a 10% rating is reasonable and appropriate for a noncompensable ROM; with objective evidence of pain.  The Board sought a route for a higher rating, but was unable to find one in the absence of ankylosis, a forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degree or a combined range of motion of the cervical spine not greater than 170 degrees, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, or incapacitation.  The Board then considered whether an additional Service 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.

The Board next sought a rating for the back pain.  The Board members first discussed the disparity in the record related to the whether the pain involved the upper back or the lower back or both intermittently.  Several notes referred to the diagnosis of lower back pain; however, the NARSUM, the MEB referral, the profile and commander’s statement referred to upper back pain.  The VA examiner addressed and examined both the thoracic and lumbar segments independently, but rated the overall condition under the rubric of the thoracolumbar spine.  The Board considered a 10% rating using a 5099-5003 for a noncompensable ROM; with objective evidence of pain.  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, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, or episodes of incapacitation, no route was available.  The Board then considered whether an additional Service rating could be recommended under a peripheral nerve code.  Firm Board precedence requires a functional impairment linked to fitness to support a recommendation for addition of a peripheral nerve rating to Service disability in spine conditions.  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 recommended a disability rating of 10% for the neck pain condition and a disability rating of 10% for the back pain condition.  

BOARD FINDINGS:  In the matter of the neck pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the back pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  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, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Neck Pain 	5099-5003	10%	
Back Pain	5099-5003	10%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140723, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXXX AR20160009314 (PD201403690)

1. 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,
accept the Board's recommendation to modify the individual's disability rating to 20%
without re-characterization of the individual's separation. This decision is final.

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.

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:

CF:
( ) DoD PDBR
( ) DVA