RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00946
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051005

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Avionics Mechanic/Electrician, medically separated for “mechanical thoracolumbar spine pain” and “chronic neck pain,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI contends his back pain continues to worsen and he sought treatment for psychiatric care.  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 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 - 20050929	VARD – No VA Exam	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mechanical Thoracolumbar Spine Pain	5237	10%	No VA Examination				
Chronic Neck Pain	5237	10%					
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  NONE	

ANALYSIS SUMMARY:  

Thoracolumbar Spine Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in April 1998 after heavy lifting.  The CI tolerated the infrequent intermittent back pain until November 2004 when he slipped on stairs during a snow storm.  There was another fall in February 2005.  In addition to the back pain he developed left leg distal tingling and then some numbness.  His symptoms intensified while he was deployed and he was evacuated in May 2005.

A lumbar MRI on 15 May 2005 showed a bulging disk at L4-L5 and L5-S1 without herniation or foraminal narrowing.  Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and he was referred for an MEB.  

The MEB forwarded low back pain with no radiculopathy for PEB adjudication.  At the MEB examination (recorded on DD Forms 2807 and 2808) the CI reported severe back pain.  The physical examination (on DD Form 2808), 30 June 2005, noted spotty tenderness to palpation and no palpable muscle spasm.    Thoracolumbar range of motion (ROM) measurements after repetition showed flexion of 45 degrees (normal 90) and a combined ROM of 135 degrees (normal 240).   Motion was painful and strength was normal.  The CI reported pain with five different examination maneuvers not expected to elicit pain based on the known pathology.   At the MEB orthopedic consultation on 14 July 2005, the CI reported constant throbbing mid-back pain that radiated to his low back.  The CI rated his pain at 4 to 5/10.  The CI denied any lower extremity numbness or tingling or any radicular pain into the lower extremities.  On examination his gait was normal.  Thoracolumbar ROM measurements performed by the orthopedic surgeon showed flexion of 70 degrees (90 normal) and a combined ROM greater than 120 degrees (incomplete measurement).  Muscle strength was normal in the lower extremities with some cogwheel and breakaway weakness in the right lower extremity.  Reflexes were normal.  Sensation was decreased in the right lower extremity and normal in the left.  The CI presented to the clinic on 18 July 2005 for low back pain after moving furniture over the preceding weekend.  He was noted to be in no distress but no examination was recorded.  The MEB NARSUM examination on 13 September 2005, 1 month prior to separation, noted complaints of daily pain rated at 5/10, but increased to 8/10 2-3 times a month as a result of activity.  The physical examination referred to the MEB examination recorded on the DD 2808 noted above which was completed by the same examiner.   The CI indicated he did not have a VA disability rating.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the thoracolumbar spine condition 10%, coded 5237 (lumbar spine strain), citing tenderness to palpation and pain-limited motion.  There was no VA disability rating.  The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and a combined ROM (greater than 120 degrees but not greater than 235 degrees) which was reported on the MEB consultation examination proximate to separation.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  The Board noted the examination on the DD2808 showed limitation of motion that supported a 20% rating while the examination recorded 2 weeks later supported a 10% rating.  The Board noted that during the former examination the examiner noted evidence of symptom exaggeration.  The Board concluded that the latter examination, which was performed by an orthopedic surgeon, was more consistent with the anticipated severity based on the known clinical pathology.  The Board therefore relied more heavily on the orthopedic examination.  There was no evidence of intervertebral disc syndrome (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula (for IVDS).  There was no evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve rating.  While the CI may have experienced radiating pain from the back condition, 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 impairment (such as weakness) that directly impacted fitness for duty.  The Board therefore concluded that an 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 low back condition.  

Chronic Neck Pain.  As noted previously, the CI’s neck condition began in April 1998 after heavy lifting.  He was treated with temporary profiles.  When deployed to Iraq and he was evacuated in May 2005 due to his back condition.  A cervical MRI on 15 May 2005 was noted to demonstrate C5-C6 minimal degenerative joint disease without herniated disk and without foraminal narrowing.  EMGs completed on 15 May 2005 were reported to be normal.  Despite treatment, the neck condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and he was referred for an MEB.  The MEB forwarded neck pain…no radiculopathy for PEB adjudication.  At a spine center examination, 15 June 2005, the neck flexed with the chin reaching to within two fingerbreadths of the sternum (near 45 degrees) and extended 55 degrees.  At the MEB examination (recorded on DD Forms 2807 and 2808) the CI reported severe back pain with passing mention of neck pain.  The physical examination (on DD Form 2808), 30 June 2005, noted spotty tenderness to palpation along the spine and no palpable muscle spasm.  Cervical ROM measurements after repetition showed flexion of 30 degrees (normal 45) and a combined ROM of 195 degrees (normal 340).   Motion was painful and strength was normal.  At the MEB orthopedic consultation on 14 July 2005, the CI reported bilateral arm numbness from his shoulders to his fingers.  On examination by the orthopedic surgeon, the cervical spine showed flexion of 40 degrees (45 normal) and a combined ROM greater than 265 degrees (340 normal).  Motor strength and sensation were normal.  At a physical therapy appointment, 25 July 2005, the therapist recorded there was a complaint of intermittent neck pain with arm paresthesias in a non-specific / non-anatomic pattern which were unrelated to any specific position or activity.  On examination there was no muscle atrophy or weakness of the upper extremities.  Examination maneuver for evidence of cervical spine root irritation was negative.  The MEB NARSUM examination on 13 September 2005, 1 month prior to separation, noted complaints of daily pain rated at 5/10, but which increased to 8/10 2-3 times a month as a result of activity.  Physical examination referred to the MEB examination completed on the DD 2808 by the same examiner.  The CI indicated he did not have a VA disability rating.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 10%, coded 5237 (cervical spine strain), citing tenderness to palpation and pain-limited motion.  There was no VA disability rating.  The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 40 degrees) and combined ROM (greater than 170 degrees but not greater than 335 degrees) reported on the MEB consultation examination proximate to separation.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  The Board noted the examination on the DD2808 showed limitation of motion that supported a 20% rating while the examinations recorded 2 weeks before and 2 weeks afterwards supported a 10% rating.  The Board noted that during the examination recorded on the DD 2808, the examiner noted evidence of symptom exaggeration.  The Board concluded that the final examination, which was performed by an orthopedic surgeon, was more consistent with the anticipated severity based on the known clinical pathology.  The Board therefore relied more heavily on the orthopedic examination.  There was no evidence of intervertebral disc syndrome (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula (for IVDS).  There was no evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve rating.  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 low back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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 20150609, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander

08 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170000883 (PD201500946)

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