RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00206
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050725

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Reserve E5, Unit Supply Specialist, medically separated for “mid to upper back pain with left upper extremity pain” with a disability rating of 10%.  

CI CONTENTION:  The CI contents that she was given a higher rating for her condition by the VA.  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 - 20050627	VARD - 20051118	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mid to Upper Back Pain with Left Upper Extremity Pain	5237	10%	Mild Herniated Nucleus on C4-7 w/ Neural Foraminal Stenosis Claimed as Disc Bulge and Mild Scoliosis	5238	20%	20050421	
Scoliosis	Not Unfitting					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Mid to Upper Back Pain with Left Upper Extremity Pain and Scoliosis.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s neck and upper back pain and left extremity pain condition began in February 2004 after insidious onset during deployment to Kuwait.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “cervical neuroforaminal stenosis” and “scoliosis, 15 degrees” for PEB adjudication.  

Magnetic resonance imaging (MRI) in August 2004 showed straightening of the cervical spine with loss of normal anterior lordosis – para spinal spasm.  There was mild disc bulge at C4-C5 and C6-C7 levels causing minimal indentation over the thecal sac, mild narrowing of the neural exits on the right side by osteophyte / disc complex; and mild stenosis.  There was mild thoracic spine scoliosis with concavity to the right.  Electrodiagnostic studies conducted on 17 February 2005 were negative for radiculopathy.  

At the MEB examination on 26 April 2005, 3 months prior to separation, the CI reported constant sharp neck and back pain with numbness and tingling in the left arm, cervical disc bulge, and mild lumbar scoliosis.  Physical examination showed reduced cervical range of motion (ROM) and slight lumbar scoliosis.  The MEB NARSUM examination on 27 May 2005, 2 months prior to separation, noted complaints of mid-to-upper back, left shoulder and hand pain; with left arm and hand tingling.  Physical examination showed reduced cervical ROM and slight lumbar scoliosis.  Formal cervical ROM from physical therapy on 16 May 2005 showed painful motion with cervical flexion to 40 degrees (normal 45) and combined 245 degrees (normal 340).  Passive cervical ROM indicated “58 degrees flexion” after repetition with a note that all motions WNL except for extension limited by muscle guarding.”  Lumbar ROMs were accomplished with an inclinometer and indicated painful motion with forward flexion of 60 degrees (normal 90) and combined greater than 120 degrees but not greater than 235 degrees.  There were non-organic signs of superficial tenderness; rotation, simulation test; overreaction: patient positive for Gowers sign but had no problems with a normal transfer; and straight leg raising, distraction test (predominantly thoracolumbar findings).  

At the 21 April 2005 VA Compensation and Pension (C&P) evaluation, performed 3 months before separation, the CI reported a history of sharp pain starting from the left side of the neck and going to the left upper extremity since December 2003.  She also reported associated features of headache and occasional numbness and weakness of the left upper extremity.  Physical examination revealed normal posture and “ok” gait.  There was painful neck motion and cervical spasm with an altered cervical spine contour.  Cervical ROM was flexion to 45 degrees (normal) and combined 310 degrees (normal 340).  There were trigger points (tenderness) on the left side of the neck, with normal muscle power of the left arm (5/5), normal reflexes, and inconsistent sensory deficit on testing.  There was mild scoliosis of the upper thoracic spine.  There were no signs of intervertebral disk syndrome (IVDS).  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the “mid-to-upper back pain with left upper extremity pain” condition 10% coded 5237 (lumbosacral or cervical strain), citing cervical disc bulging with cervical spinal stenosis and “mild left cervical flexion was 58 degrees [passive].  All passive range of motion was normal except for extension which was limited by guarding.”  The PEB referenced MEB diagnosis #1 which was cervical neuroforaminal stenosis.  The PEB also specified that MEB diagnosis #2 “scoliosis, 15 degrees” [thoracolumbar/back] was not unfitting, not rated.  This was likely rating of the cervical (neck) condition with application of AR 635-40 in effect at the time, as VASRD ratings use active ROM.  

The VA rated the “mild herniated nucleus on C4-7 with neural foraminal stenosis claimed as disc bulge and mild scoliosis” condition 20% coded 5238 (spinal stenosis), based on the VA C&P examination 3 months before separation, citing altered contour due to straightening of paracervical muscles and loss of anterior lordosis and the 20% rating criteria.  The VA spine examination focused on the cervical spine, but noted mild scoliosis of the upper thoracic spine.  There was no VA rating for any thoracolumbar spine condition.  It was noted that the later VARDs added a left upper extremity radiculopathy (10% coded 8515) effective in 13 March 2006 with increase to 20% and addition of a separate back rating effective March 2010.  
The Board first discussed if the cervical spine (cervical ROM and pathology) or the thoracolumbar spine (“mid to upper back pain”) was the PEB rated condition.  It was adjudged that the PEB considered the cervical spine as unfitting and rated the cervical spine potentially considering the mid to upper back pain as radiating pain from the cervical spine condition.  The PEB clearly indicated that the [thoracic] scoliosis was not unfitting.  The Board adjudged that there was not a preponderance of the evidence for considering the thoracolumbar spine (scoliosis) unfitting.  The Board then addressed rating the cervical spine condition including radiating pain.  There was no limitation of cervical spine motion to support higher than the 10% rating awarded by the PEB; however, the MEB NARSUM and VA C&P examinations noted the presence of muscle spasm and abnormal spinal contour.  A 20% rating was therefore warranted.  There was no evidence of incapacitating episodes that required physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula for intervertebral disc syndrome.  

There was no associated radiculopathy for separate peripheral nerve rating.  While the CI may have experienced radiating pain from the neck condition to the mid and upper back and left arm, 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 objective evidence of a radiculopathy with functional impairments such as weakness with a direct impact on fitness that were separately functionally impairing for duty.  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 recommends a disability rating of 20% for the “mid-to-upper back pain w/ left upper extremity pain” condition, coded 5237.  

BOARD FINDINGS:  In the matter of the “mid-to-upper back pain w/ left upper extremity pain” condition, the Board unanimously recommends a disability rating of 20%, coded 5237 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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Mid to Upper Back Pain with Left Upper Extremity Pain	5237	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150316, w/attachments
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

21 DEC 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160018537 (PD201500206)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization of the individual’s separation.  This decision is final.  

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.   

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:

CF: 
(  ) DoD PDBR
(  ) DVA