RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2015-00653
BRANCH OF SERVICE:  Army 	 SEPARATION DATE:  20051108

Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Automated Logistical Specialist, medically separated for “chronic subjective neck pain” and “chronic subjective low back pain,” rated 10% and 0%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI requests the Board 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 - 20051005	VARD - 20070830	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Subjective Neck Pain, without Neurologic Abnormality	5299-5237	10%	Muscle Strain of the Mid to Low Back	5242-5237	10%	20070630	
Chronic Subjective Back Pain, without Neurologic Abnormality	5299-5237	10%	Neck Condition	5237	NSC		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

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 2004 after lifting heavy items in a warehouse.  Her pain persisted despite medications and duty modifications.  In Orthopedics on 3 May 2005, 6 months prior to separation, she was noted to have tenderness of the cervical muscles, but normal, pain free motion of the neck.  The neurological examination and X-rays were also intact.  
A magnetic resonance imaging (MRI) study on 9 May 2005 recorded multilevel degenerative disc disease (DDD) and degenerative joint disease (DJD).  Electrodiagnostic testing (EDX) on 13 June 2005 showed a left C5 radiculopathy with a normal right upper extremity (RUE).  The CI was then seen again in Orthopedics on 30 June 2005 and entered into the MEB process.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated 24 August 2005, just over 2 months prior to separation, the CI reported numbness in the left arm.  On examination, she had a normal neurological examination and gait.  Tenderness and spasm were absent.  Range of motion (ROM) measurements showed normal motion other than rotation which was limited by pain.  The MEB NARSUM examination was dated 29 August 2005, 2 months prior to separation.  It referenced the above DD Form 2808 examination.  The MEB forwarded neck pain for PEB adjudication.  At the VA Compensation and Pension (C&P) evaluation performed on 30 June 2007, 20 months after separation, the CI reported neck pain.  Full ROM was noted and painful motion was not documented.  The Board observed that the examination was outside the normal 12-month post-separation window and of lesser probative value for rating purposes.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck pain condition 10%, coded 5299-5237 (analogous to cervical strain).  The VA determined that the neck condition was not service-connected based on the VA C&P examination 20 months after separation, citing no current evidence of a diagnosable neck condition.  The limitation in motion supports a 10% rating.  No route to a higher rating for the neck was found.  The Board noted that while there was evidence of a radiculopathy on EDX studies, the neurological examination was consistently normal.  The presence of an unfitting radiculopathy at separation is not supported by the evidence.  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.  

Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in March 2004 after heavy lifting and persisted despite limited duty and medications.  In Orthopedics on 3 May 2005, 6 months prior to separation, she was noted to have spasm of the paraspinal muscles, but normal, pain-free motion of the back.  The neurological examination and X-rays were also normal.  An MRI on 10 May 2005 recorded multilevel DDD.  Electrodiagnostic testing (EDX) on 13 June 2005 showed a left L4 and right L4-5 radiculopathy.  The CI was then seen again in orthopedics on 30 June 2005 and entered into the MEB process.  At the MEB examination the CI reported back pain.  On examination, she had a normal neurological examination and gait.  Tenderness, atrophy, and spasm were absent.  The ROM testing done in physical therapy showed normal motion other than flexion which was limited by pain.  The MEB NARSUM examination referenced the above DD Form 2808 examination.  The MEB forwarded back pain for PEB adjudication.  At the VA Compensation and Pension (C&P) evaluation the CI reported back pain.  The CI was 3 months pregnant at the time of the examination.  Flexion was reduced by pain; the remaining values were not assessed secondary to pain.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back pain condition 10%, coded 5299-5237 (analogous to lumbosacral strain).  The VA also rated the back condition 10% coded 5242-5237 (degenerative arthritis of the spine-lumbosacral strain) citing limitation in motion.  The limitation in motion supports a 10% rating.  No route to a higher rating for the back was found.  The Board noted that while there was evidence of a radiculopathy on EDX studies, the neurological examination was consistently normal.  The presence of an unfitting radiculopathy at separation is not supported by the evidence.  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 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.  In the matter of the back 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 20150609, with 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

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170002435 (PD201500653)

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