RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00004
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20090210

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an O3, Combat Engineer, medically separated for “chronic neck pain” with a disability rating of 20%.

CI CONTENTION:  He was given higher VA rating for his 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 - 20081024	VARD - 20090430	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain	5299- 5237	20%	Cervical Spine Degenerative Disc Disease with Cervicalgia	5243	20%	20081216	
Left Hip Bursitis	Not Unfitting	Left Hip Bursitis	5019-5252	10%	20081216	
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 in December of 2006 during field training exercises without history of specific injury or trauma.  Radiologic studies demonstrated desiccated disks, and osteophyte complexes at various levels in the cervical spine, but no canal or neural foraminal compromise.  Electrodiagnostic studies showed no evidence of cervical radiculopathy.  There was no surgical indication.  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 MEB.  The MEB forwarded cervicalgia due to degenerative disc disease and multiple osteophyte complexes for PEB adjudication.

The commander’s statement on 11 August 2008 (6 months prior to separation) reported that bilateral hand numbness and tingling worsened over the previous 6 months.  It was characterized as “affecting his performance” because in March 2008 he “complained about his hands going numb.”  At the orthopedic MEB consultation evaluation on 3 September 2008 (5 months prior to separation) the CI denied any history of hand weakness or current numbness and tingling.  Physical examination showed “full active range of motion [ROM]” of the cervical spine, though measurements were not provided.  Upper extremity muscle strength and sensation were intact.  Gait was normal.  The MEB NARSUM examination on 17 September 2008 noted complaints of constant neck pain which became worse wearing a Kevlar helmet, rucksack or with physical activities.  He also complained of intermittent numbness of both hands, but denied any history of weakness.  Physical examination showed cervical spine tenderness but no spasm or scoliosis.  Upper extremity muscle strength was normal.  The goniometric-repetitive ROM was flexion to 30 degrees (normal 45) and combined ROM of 155 (normal 340); painful motion not addressed.

At the 16 December 2008 VA Compensation and Pension (C&P) examination, performed 2 months before separation, note complaints of neck pain that interfered with sleep, and occasional hand numbness.  Physical examination revealed neck spasm, weakness, and tenderness.  Gait, spine curvature and upper extremity strength were normal.  Cervical spine ROM was flexion 20 degrees (normal 45) and combined ROM of 240 degrees (normal 340) with painful motion.  Upper extremity muscle strength and sensation were intact, although fingertip numbness was elicited by wrist maneuvers.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 20%, analogous coded 5237 (cervical spine strain), citing combined ROM less than 170 degrees.  The VA also rated the neck condition 20%, coded 5243 (intervertebral disc syndrome) based on the VA C&P examination 2 months before separation, citing limitation of motion.

The Board agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 15 degrees but not greater than 30 degrees) noted by the MEB and VA examiners, or for combined ROM (not greater than 170 degrees) reported by the MEB examiner.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  The Board considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The CI reported intermittent numbness of his hands while wearing his ballistic helmet and equipment, and the commander’s statement implied that hand numbness imposed occupational difficulty.  However, subsequent examinations recorded numbness as either absent, intermittent or occasional.  No examiner suggested that numbness represented an occupational impairment.  Electrodiagnostic studies showed no evidence of neuropathy or radiculopathy attributable to the neck condition, and there were no neurologic examination findings (such as weakness) that were consistent with functional impairments.  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.

Contended PEB Conditions:  Left Hip Bursitis.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended 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 the condition 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 the contended condition and so no additional disability rating is recommended.

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 contended left hip bursitis condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20141217, 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

08 DEC 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160018449 (PD201500004)

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