RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03725
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060108

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

CI CONTENTION:  The CI identifies a higher ratings from the Veterans Affairs for the cervical spine and the lumbar spine 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 on 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 - 20051121	VARD - 20080118	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain	5299-5237	10%	Degenerative Disc Disease & Degenerative Joint Disease, Cervical Spine	5243-5242	20%	20061213	
Chronic Low Back Pain	5299-5237	10%	Degenerative Disc Disease & Degenerative Joint Disease, Lumbosacral Spine	5243-5242	20%		
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Neck Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s neck condition began as early as July 2003 with no specific injury or trauma identified.  Scant treatment notes in 2004 indicated that the CI was diagnosed with a herniated cervical disc.  Electrodiagnostic studies in March 2004 showed no evidence of cervical radiculopathy.  An orthopedic evaluation in May 2004 showed full neck range of motion (ROM) with a normal upper extremity exam bilaterally.  There had been little improvement with conservative treatment, 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 neck pain” for PEB adjudication.

During the MEB examination (recorded on DD Forms 2807 and 2808) dated 12 October 2005 (3 months prior to separation), the examiner reported no spasm and mild tenderness to the cervical spine.  Neck ROM was reported as “90% with pain.”  The MEB NARSUM examination on 13 October 2005, 3 months prior to separation, noted complaints of increasing neck pain that radiated into the shoulders, with generalized “throbbing and shaking” that radiated into both arms.  Physical examination showed discomfort and pain behavior with changes of position and during physical evaluation.  Neurologic functions of the upper extremities (strength, reflexes and sensation) were reported as normal.  There were reported tender points on the neck and upper portion of the shoulders and an absence of spasm was noted.  Neck ROM was reported as 45 degrees (normal 45) and combined ROM as 240 degrees (normal 340).  Radiographic imaging (MRI and X-ray) studies completed in October 2005 showed degenerative changes including boney outgrowths (osteophytes) and “mild” disc desiccation, and a congenital “mildly” narrow spinal canal, and no evidence of cervical instability.  

At the 13 December 2006 VA Compensation and Pension (C&P) evaluation, 11 months after separation, the CI reported two incapacitating episodes during active duty, but could not remember when they occurred or their duration.  Physical examination revealed the CI walked “in a normal fashion.”  Neurologic function was normal.  There was no radiation of pain during ROM evaluation, but there was “clear cut discomfort” increasing with repetition.  Tenderness and “minimal” spasm were reported on the cervical spine.  Neck ROM was repeated five times for each plane of motion, with flexion recorded as 30 degrees (normal 45) and combined ROM as 160 degrees (normal 340) after repetition.  Cervical spine X-rays showed degenerative disc disease and degenerative joint disease.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck pain 10% rating under an analogous 5237 code (lumbosacral strain), citing the combined ROM of 280 degrees and the presence of tenderness.  The VA rated the neck pain condition 20% coded 5243-5242 (intervertebral disc syndrome–degenerative arthritis of the spine), citing limitation of flexion greater than 15 degrees but not greater than 30 degrees and the combined range of motion not greater than 170 degrees.

The Board agreed that a 10% rating, but no higher, was justified for a combined ROM (greater than 170 degrees but not greater than 335 degrees) and tenderness reported on the NARSUM examination.  There was no evidence of muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour in the STR or at the MEB or NARSUM examinations, thus the next higher 20% rating was not justified on this basis.  In assigning probative value to these somewhat conflicting examinations, the Board noted that the C&P examination was 11 months after separation and felt to be compromised by remoteness from the date of separation.  The MEB and NARSUM examinations were more consistent with other treatment notes in record and more reflective of the degree of disability at the time of separation.  The Board therefore judged that the Service examinations proximate to separation had greater probative value for its rating recommendations and relied more heavily on the measurements from those two examinations.  Although the CI had intervertebral disc disease there were no incapacitating episodes requiring bed rest prescribed by a physician “having a total duration of at least 2 weeks” documented prior to or proximate to separation to warrant a 20% rating under the alternate VASRD formula based on incapacitating episodes.  There was no evidence of ratable peripheral nerve impairment related to the neck condition which would provide for additional 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 chronic neck pain.  

Chronic Low Back Pain (LBP).  According to STR and the MEB NARSUM, the CI’s back condition began as early as July 2003 with no specific injury or trauma identified.  Scant treatment notes in 2004 indicate that the CI was diagnosed with herniated lumbar discs.  Electrodiagnostic studies in March 2004 showed no evidence of lumbar radiculopathy.  An orthopedic evaluation in May 2004 showed normal lumbar curvatures without tenderness to palpation (TTP).  Back flexion was 85 degrees (normal 90) with pain.  Lower extremity (LE) reflexes were normal with positive straight leg raise testing (SLR) bilaterally.  There had been little improvement with conservative treatment and due to his physical limitations the CI was unable to perform the duties of his specialty and was referred for a MEB.  The MEB process was initiated, but was prolonged as noted above.   Electrodiagnostic studies performed in August 2005 showed no evidence of a lumbar radiculopathy.  According to the NARSUM neurosurgical assessment, surgery would not be helpful.  Despite treatment, 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 a Medical Evaluation Board (MEB).  The MEB forwarded “chronic back pain” for PEB adjudication.

The MEB NARSUM examination on 13 October 2005, 3 months prior to separation, noted complaints of localized LBP.  The CI reported numbness and tingling in the back of his thighs.  He denied bowel or bladder symptoms.  Physical examination showed normal neurological findings in the LEs and SLR increased back pain at greater than 60 degrees.  There was “some discomfort and pain with transfers and during the examination.”  TTP was noted, but no muscle spasm.  Back ROM was reported as active flexion to 70 degrees (normal 90) and combined ROM of 210 degrees (normal 240).    Radiographic studies of the lumbar spine (X-ray and CT scan) ordered by the MEB examiner showed degenerative changes with bulging intervertebral discs.  

At the 13 December 2006 VA Compensation and Pension (C&P) evaluation, 11 months after separation, the CI reported four episodes of incapacitation, three while on active duty, but could not recall how long he was on bedrest or incapacitated.  He described LBP that went down both LEs and affected his activities of daily living.  He avoided any high-impact activity.  Physical examination showed normal neurological examination of the LEs.  The CI was reported to walk in “a normal fashion.”  There was TTP and “minimal” muscle spasm present in the lumbosacral area of the spine.  Thoracolumbar ROM testing was repeated five times in each plane of motion, and was recorded as forward flexion at 60 degrees (normal 90) and combined ROM at 125 (normal 240).  There was no radiating pain provoked during the examination.  Lumbosacral spine X-rays showed degenerative disc disease and degenerative joint disease.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10% coded analogous to 5237 (lumbosacral strain), citing limitation of combined motion and the presence of tenderness.  The VA rated the back condition 20% coded 5243-5242 (intervertebral disc syndrome – degenerative arthritis of the spine), based on the VA C&P examination 11 months after separation, citing limitation of flexion (greater than 30 but not greater than 60 degrees.    

In assigning probative value to these somewhat conflicting examinations, the Board noted that the C&P examination was 11 months after separation and felt to be compromised by remoteness from the date of separation.  The MEB and NARSUM examinations were more consistent with other treatment notes in record and more reflective of the degree of disability at the time of separation.  The Board therefore judged that the Service examinations proximate to separation had greater probative value for its rating recommendations and relied more heavily on the measurements from those two examinations.  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 combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the MEB and NARSUM examinations.  There was no evidence of muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour in the STR or at the MEB or NARSUM examinations, thus the next higher 20% 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.  Although the CI had intervertebral disc disease there were no incapacitating episodes requiring bed rest prescribed by a physician “having a total duration of at least 2 weeks” documented prior to or proximate to separation of to warrant a 20% rating under the alternate VASRD formula based on incapacitating episodes.  The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The CI reported numbness and tingling of the backs of both legs, but all examinations, including the C&P examination noted normal neurological examinations of the lower extremities and two EMGs in record showed no evidence of lumbar radiculopathy.  While the CI may have experienced radiating pain from the back condition, 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 Board therefore concluded that an 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 for the chronic low back pain.  

BOARD FINDINGS:  In the matter of the neck condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the low back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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 20140721, 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 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXX, AR20160014874 (PD201403725)

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.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA