RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03929
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070208

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Abrams Mechanic, medically separated for “neck pain secondary to multilevel degenerative disc disease (DDD);” “chronic low back pain (LBP) secondary to DDD;” “right leg pain status post (S/P) fasciotomy;” “chronic left leg pain S/P tibia-fibula fracture;” and “right hand pain,” with a combined disability rating of 20%.  

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 based upon a 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 - 20061214	VARD - 20080725	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain…	5299-5243	10%	Cervical Radiculopathy, LUE	8514	20%	20080501	
			Cervical Radiculopathy, RUE	8514	20%		
			Cervical Spine …	5239	10%		
Chronic LBP…	5237	10%	Lumbar Disc Disease	5237	10%		
			Radiculopathy, LLE	8521	10%		
Chronic L Leg Pain… 	5099-5003	0%	S/P Fracture, L Ankle,   	5271	20%		
R Hand Pain… 	5099-5003	0%	Residuals, Fracture, R Wrist	5215	10%		
			Arthritis, R Hand	5099-5010	NSC		
R Leg Pain…	5399-5310	0%	No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

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 initially began in 1995.  The first clinical record in evidence is an emergency room (ER) note in March 2003 in which he reported neck pain after doing dips during training.  He denied hitting his neck or head, but noted that he had injured it in a car accident when younger.  An X-ray showed severe spasm.  In physical therapy (PT) on 7 November 2005 the CI was found to have signs of a right cervical radiculopathy.  An X-ray was consistent with spasm and some changes of degenerative joint disease (DJD).  He was referred to orthopedics and evaluated on 16 November 2005.  His motor and reflex examinations were normal, but two point discrimination was reduced for the entire right upper extremity (RUE) and compression of the cervical spine (Spurling maneuver) was positive.  An MRI on 30 November 2005 showed multi-level DDD.  The CI was referred for electrodiagnostic studies (EDX) on 10 January 2006.  On examination, the reflexes were symmetric and strength normal.  The EDX were negative for radiculopathy, but did show a neuropathy of the median nerve of the RUE, at the carpal tunnel (carpal tunnel syndrome).  (As discussed below, the CI injured his right wrist in 2004).  He was referred to neurosurgery where he was noted to have decreased light touch of the entire right hand (not consistent with either a radiculopathy or with a median neuropathy).  His strength was normal, but reflexes diminished in both upper extremities.  Atrophy was absent.  He was diagnosed with neck pain and DJD of the neck.  In family practice on 5 April 2006, he was noted to have symmetric reflexes and normal strength.  The EDX studies were repeated and showed both bilateral median nerve dysfunction as well as right C7 and C8 radiculopathy.  A CT scan on 17 June 2006 was essentially normal with maintenance of normal disc spaces.  Despite treatment, there was no surgical indication and the cervical spine condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty. The CI was referred for an MEB.  The MEB forwarded “neck pain/cervicalgia” for PEB adjudication.  

At the MEB NARSUM examination dated 30 October 2006, approximately 3 months prior to separation, the CI reported pain, frequent numbness and tingling that went down his right arm.  On examination, tenderness was present without spasm.  He was neurologically intact.  The range of motion (ROM) was reduced and painful as charted below.  At the MEB neurological examination dated 7 December 2006, approximately 2 months prior to separation, the CI reported pain in his right forearm and hand.  He reported that he was unable to turn wrenches and squeeze a spray bottle and had pain with repetitive use.  The examination showed a reduced right hand grip 4/5.  The reflexes were symmetrical and +1.  Sensation was reduced to light touch, pin prick in the dorsum of the hand, forearm, and palm.  Fine motor skills were normal.  Atrophy was absent.  

At the VA Compensation and Pension (C&P) examination on 1 May 2008, performed 15 months after separation, the CI reported that he was working as a tire and lubrication mechanic at a tire store.  He denied limitations in the activities of daily living.  He reported chronic pain in the neck which radiated down both arms.  It was associated with tingling of the little fingers bilaterally (the ulnar nerve, not the median nerve, and C8).  On examination, the sensory, motor, and reflex examinations were normal.  Tenderness and spasm were absent.  ROM was limited and painful.  

The 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)	MEB ~3 Mo. Pre-Sep	VA C&P ~15 Mo. Post-Sep	
Flex (45 Normal)	45	40	
Combined (340)	305	315	
Comment	Tenderness c-spine; painful motion.	Deluca + pain limited motion;	
§4.71a Rating	10%	10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5243 code (Intervertebral disc syndrome).  The VA assigned a 10% rating using the 5239 code (spondylolisthesis or segmental instability) based on the VA C&P examination approximately 15 months after separation, citing cervical spine forward flexion greater than 30 degrees but not greater than 40 degrees.  The VA also assigned 20% ratings for cervical radiculopathy of the left upper extremity (LUE) and RUE, coded 8514 (incomplete paralysis of the radial nerve).  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 the NARSUM and VA examinations proximate to separation.  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 to warrant consideration of rating under the alternate VASRD formula.  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 neck condition.  

The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  In January 2006, the CI was noted to have normal strength and an EDX negative for RUE radiculopathy.  His motor function was normal 1 month later in neurosurgery and 3 months later in primary care.  One week later, EDX studies showed evidence for a chronic right C7 and C8 radiculopathy.  The NARSUM did not document a motor loss; rather, the CI was noted to be “neurologically intact.”  However, an addendum 5 weeks later noted a reduced right hand grip with pain while the muscles of fine coordination were preserved, as were muscles of the upper arm and forearm.  Atrophy was absent.  The C&P examination noted that the CI was working as a tire and lubrication mechanic, which he began 4 months after separation, and that his neurological examination was normal.  The weakness of RUE was limited to the grip, sparing the other muscles of the RUE.  The medical officer opined that this is more consistent with a peripheral problem than a radiculopathy.  There was considerable variability in examinations with some both before and after the MEB NARSUM addendum documenting normal strength.  The Board considered the totality of the evidence and determined it does not support a finding of a LUE or RUE radiculopathy as separately unfitting conditions at separation.  

Chronic LBP.  According to STRs and the MEB NARSUM, the LBP condition began in 1996 after the CI was hit by a car as a pedestrian.  A radiographic (X-ray) study in August 1998 was normal.  The CI was also seen for this condition in 2001, then the records fall silent until 5 April 2006, 10 months prior to separation, when he reported ongoing pain radiating down his left lower extremity (LLE).  It was noted that he had surgery of the LLE the prior December (discussed below).  The neurological examination was normal.  Two days later, EDX testing showed chronic left L5 radiculopathy and an underlying distal polyneuropathy.  On 17 April 2006 in the ER, the CI was noted to have normal strength and reflexes, but decreased sensation of the LLE.  The CI was again seen in primary care 2 weeks after the EDX study and had a normal neurological examination with intact motor function, symmetric reflexes, and without sensory loss.  At the MEB NARSUM examination, approximately 3 months prior to separation, the CI reported frequent numbness and tingling that went down both legs with increased pain if he stood or sat for any prolonged period of time greater than 30 minutes.  The ROM was reduced and painful.  The NARSUM addendum, 2 months prior to separation, recorded that there was no atrophy.  The physical examination showed a symmetric reflex examination.  Sensation was decreased on the LLE to light touch and pinprick along the left calf and left quadriceps (L4-S2 dermatomes), but not of the anterior tibialis or foot (L5).  His strength was 4/5 for left ankle dorsi-flexion (L4-S2) and left knee extension (L2-L4).  

At the VA C&P examination, the CI reported that he continued to work as a mechanic, drove his own car, and denied incapacitation.  He endorsed ongoing back pain with radiation to both lower extremities (BLE), more so on the left.  He wore a back brace at work at least 8-10 hours a day.  He stated that it reduced his productivity at work, but did not affect the activities of daily living.  On examination, his gait was normal and without an assistive device.  His posture was erect.  Spasm and tenderness were absent.  Reflexes and the motor examination were normal.  Sensation was decreased to pin prick and vibration in the LLE from mid-calf downward (this involves multiple peripheral nerves and dermatomes).  Provocative testing for nerve root irritation reproduced his LBP, but did not evoke radicular symptoms.  The ROM was reduced and painful.  The 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)	MEB ~3 Mo. Pre-Sep	VA C&P ~15 Mo. Post-Sep	
Flexion (90 Normal)	90	80	
Combined (240)	220	220	
Comment	Painful motion; tenderness.	Painful motion.	
§4.71a Rating	10%	10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5237 code (lumbosacral strain).  The VA also assigned a 10% rating using the 5237 code based on the VA C&P examination 15 months after separation, citing forward flexion of the spine greater than 60 degrees but not greater than 85 degrees.  The evidence does not support a higher 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 LBP condition.  

The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The VA assigned a 10% rating to the left lower extremity under the 8521 code (paralysis of: external popliteal nerve [common peroneal]) based on the VA C&P examination approximately 15 months after separation, citing incomplete paralysis of foot movements which was mild.  As noted in the discussion of the neck condition, the CI had a variable examination, but the motor function was noted to be normal more often than not.  The weakness noted on the left leg was limited to extension.  Within months of separation, he was working as a mechanic.  The C&P examination recorded a normal gait and posture with a normal motor examination.  The totality of the evidence does not support a finding of a LLE radiculopathy as separately unfitting condition at separation.  

Right Leg Pain Condition.  According to the STR and MEB NARSUM, the CI presented for an ultrasound for evaluation of a soft tissue lump which appeared in his right calf with activity.  This was noted on the ultrasound, but no diagnosis was made.  The CI had a fasciotomy in February 1999 for exercise induced compartment syndrome, but these records are not in evidence.  The CI next presented RLE pain on 18 May 2001.  A note dated 16 November 2001 recorded that the CI had been observed lifting his tool box and both working on and climbing onto vehicles without any difficulty while in the field.  He was referred to orthopedics and thought to have symptoms consistent with exercise induced compartment syndrome, but the diagnostic evaluation was inconclusive.  He was seen several more times for RLE pain; the last clinical appointment in evidence for the RLE pain was 13 December 2003, over 3 years prior to separation.  The NARSUM noted that the CI had met a medical board in 2002 and was returned to duty.  This is not in evidence.  He reported that his symptoms had worsened since that time, especially with running.  On examination, the right calf was diffusely tender, but the ROM of the knee and ankle were normal.  Atrophy was not present and sensation and motor function were preserved.  The CI was not evaluated for the RLE condition by the VA Compensation and Pension examination; however, it was noted that his gait was normal as was motor function.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the right leg pain condition at 0%, coded 5399-5310 (analogous to Group X muscle function) at the slight level of impairment.  The VA did not rate the condition.  The Board noted that the function of the RLE was consistently recorded as normal and that there were no clinical records in evidence for treatment of the RLE condition for the last 3 years on active duty.  The Board did not find evidence sufficient to support a moderate level of impairment and a 10% 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 right leg pain condition.  

Chronic Left Leg Pain Condition.  According to STRs and the MEB NARSUM, the CI was wrestling with his brother in December 2004 and injured his left foot and ankle.  An initial X-ray of the ankle was normal, but the calcaneus was thought to possibly be fractured.  He was also noted to have a proximal fracture of the fibula (the smaller lower leg bone, close to the knee).  The knee itself was otherwise normal on X-ray.  The suspected calcaneal fracture was confirmed on repeat X-rays 4 days later as well as a CT scan.  The remainder of the foot was normal on the imaging studies.  On 4 January 2005 the CI had surgery for the fibular fracture.  Two screws were placed 4 and 8 inches above the ankle joint and subsequently removed.  These records are not in evidence.  A follow up X-ray showed good alignment and some bone loss.  The medical officer observed that this is an expected finding with the disuse from hardware placement and non-weight bearing after surgery.  A follow up CT scan noted that the foot fracture was of the talus, the heel bone in front of the calcaneus, rather than the calcaneus.  The record falls silent from June 2005 until March 2006 when he reported ongoing LLE pain during a follow-up appointment for an unrelated condition.  An orthopedic evaluation on 8 May 2006 noted that the CI was tender over the ankle and that his pain was decreased by wearing cross-training sneakers.  A repeat CT scan on 10 May 2006 was suggestive of old fractures of the calcaneus and talus.  It was noted that there were no other abnormalities implying that the previous bone loss was no longer present.  An MRI 2 weeks later was normal with intact ligaments.  At the MEB examination (recorded on DD Form 2807 Report of Medical History and DD Form 2808 Report of Medical Examination) dated 30 May 2006, 9 months prior to separation, the CI made no specific comment on the LLE.  The ankle (inside) was noted to be tender and motion reduced in dorsi-flexion (toes up) and plantar flexion (toes down).  At the NARSUM, the CI reported pain with walking, running, and jumping which precluded working as a mechanic.  The ROM was reduced to 15 degrees dorsi-flexion (normal is 20) and 40 degrees plantar flexion (normal is 45).  The addendum noted that the CI had normal strength for plantar flexion, but reduced (4/5) strength for dorsi-flexion.  

At the VA C&P examination, the CI reported that he was working as a mechanic.  The histories of the right and left leg were somewhat mixed together, but he reported ongoing left foot pain.  As already noted, his gait and posture were normal.  Motor function was normal.  Examination of the knee showed a stable joint with flexion limited to 120 degrees by pain.  The ROM of the ankle was limited to 0 degrees of dorsi-flexion and 25 degrees of plantar flexion.  The medical officer observed that this is not consistent with a normal gait.  The surgical scars were well healed.  X-rays of the left knee and ankle were normal.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating, coded 5099-5003 (analogous to degenerative arthritis) for chronic pain without loss of associated joint motion.  The VA rated the ankle at 20%, based on the marked limitation in motion on the C&P examination, coded 5271 (limitation in motion).  As noted, the limitation in motion recorded is not consistent with the observed normal gait or the reported lack of limitations in the activities of daily living.  The probative value of this examination is accordingly reduced.  In addition, the examination was 15 months after separation, also reducing its probative value.  The limitation in motion on the MEB NARSUM examination does support a 10% rating using the 5271 code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left leg pain condition, coded 5271.  

Right Hand Pain Condition.  According to STRs and the MEB NARSUM, the right hand dominant CI reported a one month history of bilateral hand pain at a 6 January 2003 primary care appointment.  He was next seen for right wrist pain on 10 April 2004 when he reported trauma the prior day.  An X-ray showed a fracture which was confirmed on a CT scan.  He was treated with a long arm cast followed by splinting and occupational therapy (OT).  In physical therapy (PT) on 2 November 2005, over 18 months after the initial injury, he was noted to have a variable examination and the source of his pain was unclear.  There were no further clinical records in evidence prior to separation.  The MEB examination was noted to be normal.  The NARSUM addendum recorded a decreased grip and sensory abnormalities as documented above.  Atrophy was not present.  At the VA C&P examination, the CI reported working as a mechanic.  The pain reduced his productivity and was aggravated by activity and vibration.  On examination, his motion was limited by pain to 60 degrees of dorsi-flexion and palmar flexion.  The neurological examination was normal.  X-rays were normal.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the right hand pain condition at 0%, coded 5099-5003 (analogous to degenerative arthritis).  The VA rated the condition at 10%, coded 5215 (limitation in motion of the wrist).  The limitation in motion is not compensable, but it was painful supporting a 10% rating under the 5003 code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right wrist condition, coded 5099-5003.  

BOARD FINDINGS:  In the matter of the chronic neck pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic LBP condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic right leg pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left leg pain condition, the Board unanimously recommends a disability rating of 10%, coded 5271 IAW VASRD §4.71a.  In the matter of the right hand 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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date prior to medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Neck  Pain	5299-5243	10%	
Chronic LBP	5237	10%	
Right Leg Pain	5399-5310	0%	
Chronic Left Leg Pain	5271	10%	
Right Hand Pain	5099-5003	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140801, 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 XXXXXXXXXXXXXXXXXX, AR20160013323  (PD201403929)

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