RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04168
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070119

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Radio and Communications Security Repairer, medically separated for “chronic neck pain, status post C1 fracture …” with a disability rating of 10%.

CI CONTENTION:  Her neck fracture, right knee inflammation, lacerations to head, and forehead nerve damage should have been found unfitting.  The CI’s 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 - 20061205	VARD - 20070618	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain, Status Post C1 Fracture…	5235	10%	Degenerative Disc Disease C4-C5 with Right Paracentral Disc Protrusion and Myofascial Pain Syndrome of Paracervical and Upper Trapezius Muscles… 	5243	10%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Neck Pain.  According to service treatment records and the MEB narrative summary (NARSUM), the CI’s neck condition began in November 2004 after a motor vehicle accident.  Magnetic resonance imaging (MRI) showed degenerative disc disease and was consistent with clinical history of a C1 fracture.  There was no surgical indication.  Despite treatment, the CI’s neck condition could not be adequately rehabilitated to meet the physical requirements of her military specialty and so she was referred for a Medical Evaluation Board (MEB).  

At the MEB examination (recorded on DD Form 2807 and 2808) dated 11 May 2006, 8 months prior to separation, the CI reported that her upper back and neck pain were aggravated by weather changes, lifting, strenuous physical activity, and increased weight bearing.  She also reported frequent muscle spasms and trouble sleeping due to her neck and back pain.  Physical exam of her neck was normal.  There was no limitation of movement and no tenderness.  

At the time of the physical therapy (PT) examination on 12 May 2006, 8 months prior to separation, the CI had slightly limited ROM. The examiner also noted muscle tightness, which may be indicative of muscle spasm.  

The MEB NARSUM examination on 15 June 2006 (7 months prior to separation) noted complaints of pain in the neck and upper back.  Physical exam showed pain limited motion as indicated in the chart above.  She also had tenderness of “multiple areas of the posterior paracervical and upper trapezius muscles with ‘trigger point’ tenderness with characteristic taut muscle bands, twitch reflex and referred pain primarily to the right shoulder.”  Her upper extremity strength, sensation and reflexes were normal.  Radiographs in May and June 2006 were summarized as showing anterior compression wedging of C5, degenerative intervertebral disc disease at C4-5 with right paracentral disc protrusion and C5-6 right uncinate hypertrophy with possible impression of the right C6 nerve root.  

There was no VA Compensation and Pension (C&P) examination proximate to separation.  The CI failed to show up to the exam scheduled on 16 March 2007.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5235 code (vertebral fracture or dislocation), citing painful limitation of motion and tenderness.  The VA also assigned a 10% rating using the 5243 code (intervertebral disc syndrome) for combined ROM of the cervical spine greater than 170 degrees but not greater than 335 degrees.  

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 PT and NARSUM exams.  There was no muscle spasm or guarding severe enough to result in abnormal gait or spinal contour, thus the next higher 20% 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.  

BOARD FINDINGS:  In the matter of the neck condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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

SAMR-RB

28 JUL 2016

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 AR2016001 0227 (PD201404168)

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