RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00312
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070917

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Reserve E7, Recruiter, medically separated for “chronic neck pain” and “chronic low back pain,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  The CI requests consideration of all conditions.  His 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 - 20070124	VARD - 20080714	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain ...	5237	10%	Cervical Spine DDD w/ Radiculopathy	5237	10%	20080229	
Chronic Low Back Pain ...	5237	0%	Lumbar Spine DDD	5237	10%	20080229	
Chondromalacia, Right Knee	Not Unfitting	Chondromalacia, Right Knee	5257	10%	20080229	
Gastroesophageal Reflux Disease	Not Unfitting	Barrett’s Esophagus / Hiatal Hernia/ Gastroesophageal Reflux Disease	7346	10%	20080229	
Hiatal Hernia	Not Unfitting					
Barret’s Esophagus	Not Unfitting					
Bilateral High Frequency Hearing Loss	Not Unfitting	Hearing Loss, Left Ear	6100	0%	20080710	
		Hearing Loss, Right Ear	6100	NSC	20080710	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:

Chronic Neck Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI suffered an atraumatic onset of chronic neck pain around the year 2000.  This was associated with intermittent radicular symptoms (bilateral arm radiation and sensory complaints).  Magnetic resonance imaging (MRI) revealed multilevel degenerative disc disease (DDD); e.g., “very mild ... minimal” bulges at C3-5 and C6/7 without significant neural encroachment.  Electrodiagnostic testing (EMG) demonstrated “mild dermatomal involvement” in a right C5/6 distribution.  There were multiple outpatient STR entries that documented normal neurological examinations (5/5 strength, intact sensory, normal reflexes), and no contrary entries.  There were multiple entries that documented grossly normal range of motion (ROM), and some noting non-specifically decreased ROM; but, no entries indicated significantly severe ROM limitation.  Measured ROM by physical therapy (PT) in August 2006 (13 months before separation) was flexion to 35 degrees (normal 45) and combined ROM of 215 (normal 340).  There was STR documentation of normal spinal contour and no documentation of incapacitating episodes.  Surgery was discussed, but reasonably deferred, and a protracted trial of conservative treatment did not result in sufficient improvement to allow unrestricted duty.  The MEB forwarded “chronic cervical spine pain” and “C4/5, C5/6, C6/C7 intervertebral disk bulge with radiculopathy” to the PEB.  

The NARSUM examination on 28 July 2007 (2 months before separation) documented neck pain with intermittent upper extremity radiation (more often on the right, no mention of motor or sensory symptoms) without elaboration of pain severity or functional limitations.  The physical examination recorded “mild cervical straightening” without corroborating spasm or guarding, tenderness, “normal” ROM; and, detailed normal neurological findings (5/5 motor all groups, intact sensation, symmetric reflexes).  

A VA Compensation and Pension (C&P) examination on 29 February 2008 (5 months after separation) documented neck pain rated 5/10 with bilateral radiation (greater in the right arm, no mention of motor or sensory symptoms), aggravated “by all types of movement,” and specified no history of incapacitating episodes.  The physical examination recorded tenderness with no spasm and normal neurological findings.  The measured ROM was flexion to 40 degrees and combined ROM of 270 degrees, specifying painful motion.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated 10% under code 5237 (cervical or lumbar strain), citing the VASRD §4.71a criterion of tenderness.  The VA (based on the C&P evidence) rated 10% under code 5237, citing painful motion. The VA did not service connect claims for right and left upper extremity radiculopathies, citing the absence of confirmatory examination findings or diagnosis.  There was no ROM evidence supporting a rating higher than 10%, and insufficient evidence for abnormal gait or spinal contour to support a 20% rating.  There was no documentation of incapacitating episodes or diagnosis of intervertebral disc syndrome that would provide for a higher rating under that formula.  The Board considered whether separate rating could be recommended for the radicular symptoms; but, given that the presence of radiating pain is subsumed under the §4.71a general spine formula, and that there were no objective motor or sensory deficits establishing a functional link to fitness, members agreed that additional service rating could not be 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 of the cervical spine condition.  

Chronic Low Back Pain.  The CI suffered an onset of chronic back pain with lifting in 2001.  This was associated with intermittent right lower extremity (RLE) radiation and paresthesias.  An MRI identified multilevel DDD (minor bulges at L3/4 and L4/5 without neural encroachment and desiccation only at L5/S1).  There were multiple outpatient STR entries that documented normal neurological examinations (5/5 strength, intact sensory, normal reflexes), with no contrary entries; and, an EMG of the RLE was normal.  There were multiple entries that documented grossly normal ROM, and one noting non-specifically decreased ROM and painful motion; but, there were no entries indicating significant ROM limitation.  Measured ROM by PT (August 2006, 13 months before separation) was flexion to 65 degrees (normal 90) and combined ROM of 175 (normal 240).   There was ample STR documentation of normal gait and spinal contour, but one entry noted a “slow” gait without corroborating spasm or guarding.  There was no STR documentation of incapacitating episodes.  Surgery was not recommended, and a protracted trial of conservative treatment did not result in sufficient improvement to allow unrestricted duty.  The MEB forwarded “chronic lumbosacral spine pain,” “L3/L4, L4/L5 intervertebral disk bulge with radiculopathy,” and “L5/S1 [DDD]/desiccation” for PEB adjudication.

The NARSUM did not elaborate pain severity, any associated neurological symptoms, or any functional limitations associated with the back.  The physical examination likewise did not specifically address lumbar findings, although the normal neurological findings described above for the cervical spine incorporated the lower extremities.

The post-separation VA C&P examination documented back pain rated 4/10 with RLE radiation (“some numbness in the groin” but no mention of weakness), aggravated by driving and sitting; and, specified no history of incapacitating episodes.  The physical examination recorded “antalgic gait seemingly from his right lumbar spine ... [but] ... not seen consistently throughout the exam,” tenderness with no spasm, and normal neurological findings.  The measured ROM was flexion to 70 degrees and combined ROM of 170 degrees, specifying pain at end ranges.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 0% rating under code 5237 acknowledged service ROM evidence that met §4.71a criteria for a 10% rating, and possibly relied on provisions of AR 635-40 (B-29, e).  The VA’s 10% rating under code 5237 cited painful motion. The VA did not service-connect claims for right and left upper extremity radiculopathies, citing the absence of confirmatory examination findings or diagnosis.  The service and VA ROM evidence supported a 10% rating, but nothing higher.  There was insufficient evidence for abnormal gait or spinal contour to support a 20% rating, and there was no basis for a rating under the §4.71a formula for incapacitating episodes.  As elaborated in the cervical recommendation, there was no justification for additional rating of radiculopathy.  After due deliberation, considering all evidence and with deference to reasonable doubt, the Board recommends a disability rating of 10% for the lumbar spine condition coded 5237.

Contended PEB Conditions (Right Knee, Gastroesophageal Reflux Disease [GERD], Hiatal Hernia, Barrett’s Esophagus, and Bilateral High Frequency Hearing Loss).  The knee condition was chronic, dating to an injury in early training.  It was profiled L2, a profile level that does not mandate MEB referral and is not generally associated with unfitting conditions.  All of the gastrointestinal diagnoses were identified over 2 years prior to separation (linked to non-steroidals for the cervical condition) and remained stable on medication.  The above hearing deficit was identified 18 months before separation and required hearing aids.  None of these conditions were clinically acute during the MEB period.  Other than the knee as above, none were profiled.  None were implicated in the commander’s performance statement.

The Board’s main charge was to assess the fairness of the PEB’s determinations that the above conditions were not unfitting.  Members agreed that there was no performance-based evidence indicating that any of the above conditions interfered with duty requirements to an extent that would have prohibited further military service.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determinations for the right knee, GERD, hiatal hernia, Barrett’s esophagus, and hearing loss conditions; thus, they were not eligible for rating.

BOARD FINDINGS:  In the matter of the lumbar spine condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the cervical spine condition, the Board unanimously recommends a Service disability rating of 10%, coded 5237 IAW VASRD §4.71a.  In the matter of the contended right knee chondromalacia, gastroesophageal reflux disease, hiatal hernia, Barrett’s esophagus, and bilateral high frequency hearing loss 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 recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Disc Disease with Chronic Pain, Cervical Spine	5237	10%	
Disc Disease with Chronic Pain, Lumbar Spine	5237	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150511, 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

27 DEC 2016

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXX, AR20160018677 (PD201500312)

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