RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04124
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090929

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Basic Trainee, medically separated for “neck pain” and “back pain,” rated 10% and 10%, respectively, 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 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 - 20090729	VARD – 20130405 and 20130511	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Neck Pain	5237	10%	Mild Levoscoliosis, Mild Disc Disease and Central Stenosis, Cervical Spine	5242	20%	STR	
Back Pain	5237	10%	L5-S1 Disc Degeneration with Disc Protrusion to the Left	5242	20%	STR	
Chronic Right Foot Pain	Not Unfitting	3RD Metatarsal Stress Fracture 	5284	NSC	STR	
Chronic Left Foot Pain	Not Unfitting	No VA Placement 	
GERD	Not Unfitting	No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Neck Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s neck pain began in October 2008 during Basic Training (BT), without any specific injury or trauma.  The CI reported intermittent neck pain without radiation or weakness.  Cervical spine radiologic (X-ray) studies on 6 November 2008 revealed mild facet arthritis, but were otherwise normal.  Magnetic resonance imaging (MRI) studies on 21 August 2009 showed “minimal” cervical scoliosis, “mild” degenerative disc disease (DDD) and “mild” spinal arthritis.  There was “mild” neuroforaminal stenosis on the left, without central spinal canal stenosis.  An orthopedic consultation noted no neurological deficits of the upper extremities.  Despite treatment, the cervical spine condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and he was referred for a MEB.  The MEB forwarded “recurrent neck pain due to myofascial pain and cervical facet arthropathy” for PEB adjudication.

At the MEB NARSUM examination on 14 April 2009, 5 months before separation, the CI reported intermittent neck pain without radiation or weakness and with flare-ups caused by some activities.  There were no hospitalizations or surgeries for this condition.  The physical examination showed tenderness to palpation (TTP) over the right paracervical muscles, with no abnormal spinal contour or muscle spasm.  The range of motion (ROM) was flexion of 30 degrees (normal 45) and combined ROM of 140 degrees (normal 340).  Physical therapy (PT) ROM measurements performed on 12 June 2009 were flexion of 20 degrees and combined ROM of 115 degrees.  Some guarding was noted but no muscle spasms.  The MEB physician, who was in attendance at the PT ROM evaluation, added a memorandum to the PEB on the same date and indicated that the CI was able to flex his neck to 45 degrees without pain during the examination (with worse ROM noted with specific testing).  The physician also made reference to orthopedic notes dated 1 June 2009 which documented full ROM (the PEB referenced this orthopedic entry as well, however it was not found in the STR).  The MEB NARSUM examiner further noted that a 6 April 2009 physical medicine consultation revealed no evidence of cervical radiculopathy through electrodiagnostic studies.  An orthopedic consultation on 8 May 2009, which showed no evidence of cervical radiculopathy or peripheral neuropathy, was also cited.  

There was no evidence in record that a VA Compensation and Pension (C&P) examination was performed within 12 months of separation or prior the original VA Rating Decision in 2013.

At an outpatient PT evaluation on 10 September 2010, 11 months after separation, the CI reported constant neck pain that radiated to both upper extremities with numbness and tingling.  The examination noted that the CI walked with a guarded gait, guarded his neck movements and had decreased lordosis of the lumbar and cervical spines.  Cervical ROM was flexion of 30 degrees and the combined ROM was incomplete.  A cervical spine MRI performed on 22 October 2010 showed DDD, without disc protrusions, with left-sided neuroforaminal stenosis, but no central spinal canal stenosis.  At a neurosurgical examination in December 2010, performed 15 months after separation, the CI reported neck pain radiating into his bilateral arms in a non-radicular pattern.  The physical examination showed normal strength, sensation, and reflexes of the upper extremities.  The neurosurgeon stated that the CI “ambulates well” and concluded that “the patient exam is within normal limits.”  

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 10% rating using the 5237 code (cervical spine strain), citing insufficient pathology to explain the limited motion and guarding.  The VA assigned a 20% rating in the VA Rating Decision dated 5 April 2013 using the 5242 code (degenerative arthritis of the spine).  The VA cited evidence from service medical records as well as an MRI (23 August 2009) and a nerve conduction study (25 February 2011) from private providers; however, there were no C&P examinations as noted above. Although there was limitation of cervical motion noted at examinations before and after separation, in the memorandum to the PEB, the MEB physician highlighted that the CI had better ROM when distracted or not being formally tested for ROM.  Therefore the Board agreed that a 10% rating was justified for the presence of painful motion and tenderness as adjudicated by the PEB and not a higher rating based on limitation of motion.  There was no muscle spasm or guarding severe enough to result in abnormal gait or spinal contour at the MEB NARSUM or PT ROM evaluations.  The outpatient PT examination noted above was approximately 11 months after separation and the Board judged that the “guarding” without muscle spasm was insufficient evidence to support a 20% rating at the time of 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 (IVDS).  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 that formula.  The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  Although the CI reported neck pain and radiating bilateral upper extremity pain, numbness, and tingling at the PT and neurosurgical examinations (11 and 15 months post-separation), at the MEB NARSUM examination, the CI reported neck pain without radiation or neurological symptoms.  Electrodiagnostic studies in April 2009 showed no evidence of cervical radiculopathy.  The Board therefore concluded that 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 neck condition.  

Back Pain.  According to the STR and MEB NARSUM, the CI’s back pain began in October 2008 while engaged in BT without any specific injury or trauma.  The CI complained of constant pain in his mid and lower back.  Thoracic spine X-rays performed in November 2008 revealed degenerative arthritis and no other major thoracic spine findings; there was no central spinal canal stenosis.  The CI was placed in the Physical Training and Rehabilitation Program (PTRP) and on convalescent leave for 2 weeks.  There were no hospitalizations or surgeries for this condition.  Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and he was referred for a MEB.  The MEB forwarded “chronic mid back pain due to thoracic degenerative disk disease” and “chronic lumbar pain due to lumbar degenerative disk disease” for PEB adjudication.

At the MEB examination (recorded on DD Forms 2807 and 2808) dated March 2009, 6 months before separation, the CI reported injuring his back in BT and had recurrent back pain along with numbness and tingling down his legs and feet.  A PT examination on 26 March 2009, 6 months before separation, noted localized tenderness and spasms of the thoracic musculature, without an abnormal gait or abnormal spinal contour.  The ROM was flexion of 85 degrees (normal 90) and combined ROM of 215 degrees (normal 240).

At the MEB NARSUM examination on 14 April 2009, 5 months before separation, the CI reported constant chronic and mid-lower back pain, with radiation to both lower extremities (LEs) and numbness of his feet; he had flare-ups with activity.  The examiner documented a normal gait and TTP over the mid-thoracic paravertebral musculature, without muscle spasm, guarding or abnormal spinal contour.  The ROM was flexion of 85 degrees (normal 90) and combined ROM of 215 degrees (normal 240) with painful motion and tenderness.  Lower extremity strength, sensation, and reflexes were normal bilaterally and straight leg raise testing (for radicular symptoms) was negative bilaterally.  The MEB NARSUM examiner referenced a physical medicine consultation on 6 April 2009 in which electrodiagnostic studies revealed no evidence of thoracic or lumbar radiculopathy.  Thoracic and lumbar spine MRIs on 21 August 2009, 1 month before separation, showed DDD and spinal arthritis.  There was a disc bulge at L5-S1 which contacted the left S1 nerve root.

There was no evidence in record that a VA Compensation and Pension (C&P) examination was performed within 12 months of separation or prior the original VA Rating Decision in 2013.

At an outpatient primary care visit on 19 October 2010, 13 months after separation, the CI stated that PT had helped his lower back pain (LBP).  He reported some right LE pain, but no numbness and tingling; he had two episodes of urinary incontinence and was referred to a neurosurgeon.  Thoracic and lumbar spine MRIs, on 22 October 2010 (from a civilian medical facility), were interpreted as normal thoracic spine and DDD at L5-S1 with a “mild” disc bulge, without nerve impingement or central spinal canal stenosis.  At a neurosurgical evaluation for cervical pain in December 2010, 15 months after separation, the CI reported lower back pain with bilateral leg pain radiating to his toes with no relief from PT.  The examiner documented normal gait as well as normal strength, sensation, and LE reflexes.  At an examination in January 2011, performed 16 months after separation, the CI reported chronic LBP with muscle spasm and morning stiffness.  The examiner noted TTP and trigger points in the lumbar paraspinal region and upper back.  The CI’s gait was normal, and muscle tone and bulk were normal and symmetric.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain), citing “forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; and VASRD 4.10, 4.40, 4.45, and 4.59.  The VA rated the back condition 20%, coded 5242 (degenerative arthritis of the spine), citing “painful motion upon examination” with muscle spasm severe enough to result in abnormal gait or and an abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis.  The VA cited evidence from service medical records as well as an MRI (23 August 2009) and a nerve conduction study (25 February 2011) from private providers; however, there were no C&P examinations as noted above.  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 service PT and MEB NARSUM examinations proximate to separation.  Although there was muscle spasm noted at the PT evaluation it was not 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 considered whether a higher rating (§4.7) was achieved by using the alternate VASRD rating formula based on incapacitating episodes due to IVDS.  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 that formula.  The CI was placed on convalescent leave for 2 weeks, but participated in PTRP and was not prescribed bed rest.  The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  Electrodiagnostic studies in April 2009 showed no evidence of thoracic or lumbar radiculopathy and while the CI reported radiating LE 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).”  There was no evidence of any decreased LE strength, sensation, or abnormal reflexes to support recommending a peripheral nerve impairment due to the LBP condition as separately unfitting.  The Board therefore concluded that 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 back pain condition.  

Contended PEB Conditions:  Right Foot Pain, Left Foot Pain and Gastroesophageal Reflux (GERD). The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  There was imaging evidence of a right metatarsal stress fracture, but this condition was resolving at the time of separation. There was no evidence of ratable pathology of the left foot in record.  The right and left foot pain conditions were listed on the permanent profile, however, they were not implicated in the commander’s statement.  On the MEB Form DD 2807, Report of Medical History, the CI checked “no” to foot pain or problems with feet, or cracked or fractured bones.  After separation, the VA did not service connect the metatarsal stress fracture condition of the right foot.  The Board concluded that there was not a preponderance of the evidence to support recommending either the right or left foot condition as unfitting at the time of separation.  The GERD condition 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 any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the neck and back conditions and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudications.  In the matter of the contended right foot pain, left foot pain and GERD 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 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 AR20160011837 (PD201404124)

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