RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00992
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060221

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Patriot Fire Control Enhance Operator/Maintainer, medically separated for “chronic atraumatic upper back pain,” with a disability rating of 0%.

CI CONTENTION:  The CI’s is for his lower neck/back pain that has limited on what jobs he can perform.  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 – 5299-5237	VARD – 19960323  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Atraumatic Upper Back Pain	5299-5237	0%	No VA Placement	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  %	

ANALYSIS SUMMARY:  

Chronic Atraumatic Upper Back Pain.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in after wearing battle gear for extended periods of time.  The CI had intermittent episodes of lower back pain and neck pain in 1993, 1999 and 2000.  Magnetic resonance imaging (MRI) of the cervical spine in July 2000 revealed no evidence of a fracture or disc disease.  A small posterior projection of bone with impression upon the posterior aspect of the cord was intrinsically normal.  There was also a small hemangioma in the body of C5 of no clinical significance.  On 29 November 2004 the CI reported upper back pain between the shoulders during an FTX (field training exercise) making it difficult to wear gear.  On examination there was tenderness to pressure over bony prominences of T1-T7 without scapular winging and with a full range of motion (ROM).  Treatment consisted of Motrin (a nonsteroidal anti-inflammatory drug (NSAID)), Valium (diazepam, a muscle relaxer), and a profile.  The CI experienced back pain in April 2005 at which time examination revealed tenderness on  palpation of the upper back of the upper paraspinal regions bilaterally.  Computerized tomography (CT) of the thoracic spine on 5 April 2005, ordered for progressive sharp T2-T4 radical pain that progressed despite intensive physical therapy, revealed very mild degenerative changes of the spine.  On 6 July 2005 the CI had a bone scan, ordered for left sided low back pain, which revealed no evidence of a reactive bone abnormality involving the thoracic spine, but did demonstrate mild, symmetric stress reactions in both acromioclavicular joints.  An MRI on 28 June 2005 of the cervical spine demonstrated normal disk contours at all levels without any spinal or neuroforaminal stenosis.  Examination on 1 August 2005 indicated no neurological symptoms, but revealed stiffness and clicking in the upper and middle back.  

Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “chronic upper back pain most likely myofascial in origin” for PEB adjudication.  The MEB NARSUM examination on 30 September 2005, 5 months prior to separation, the CI reported constant pain and aggravated by running greater than 1 mile, sit-ups, push-ups, prolonged standing, lifting greater than 15 pounds, flak vest, and Kevlar.  Physical examination showed no deformity, ecchymosis or erythema.  The CI was very tender to palpation at the paraspinal musculature upper thoracic spine on the right side with spasms.  There was normal motor, sensation, strength in bilateral lower and upper extremities, and reflexes.  Testing for radiculopathy was negative.  At the MEB examination (recorded on DD Forms 2807-1 and 2808) dated 4 October 2005, 4 months prior to separation, the CI reported he had “sharp stabbing pains all over his upper back and one that always hurt.”   The examiner noted tenderness to palpation of the upper thoracic spine paraspinous muscles.  There was no VA Compensation and Pension (C&P) evaluation proximate to separation.

The ROM examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  
Thoracolumbar ROM
(Degrees)	NARSUM Addendum ~ 4 Mos. Pre-Sep
	
Flexion (90 Normal)	90(95, 100, 100)	
Extension (30)	20 (20, 20, 20)	
R Lat Flex (30)	30 (50, 45, 45)	
L Lat Flex (30)	30 (40, 40, 45)	
R Rotation (30)	25 (25, 25, 25)	
L Rotation (30)	30 (30, 30, 30)	
Combined (240)	225	
Painful motion	None 	
Tenderness	Present 	
*Spasm or guarding	Present 	
**Altered Gait 
  due to *	Not Addressed	
**Altered contour due to *	Not addressed	
***Incapacitating episodes IVDS	Not Addressed	
Misc. Functional Loss	Not Addressed	
Comments	Tenderness; combined ROM < 235; inclinometer used	
§4.71a Rating	10%	

Cervical ROM
(Degrees)	NARSUM Addendum~4 Mos. Pre-Sep
	
Flexion (45 Normal)	(45)80,80,80	
Extension (45)	(45)55,60,60	
R Lat Flex (45)	30,30,30	
L Lat Flex (45)	                            30,30,30	
R Rotation (80)	(80)90,90,90	
L Rotation (80)	8,80,80	
Combined (340)	310	
Painful motion	Absent 	
Tenderness	Not addressed	
*Spasm or guarding	Not addressed	
**Altered Gait 
  due to *	Not addressed	
**Altered contour due to *	Not addressed	
***Incapacitating episodes IVDS	Not addressed	
Misc. Functional Loss	Not addressed	
Comments	Inclinometer used; no pain	
§4.71a Rating	0%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating for the chronic atraumatic upper back pain condition under an analogous 5299-5237 code (Lumbosacral or cervical strain), citing ROM within acceptable parameters.  The Board agreed that a 10% rating, but no higher, was justified for tenderness and a combined ROM (greater than 120 degrees but not greater than 235 degrees) as reported on the MEB NARSUM examination.  Although there was muscle spasm, it was not severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  Cervical spine ROM’s were normal except bilateral flexion, which was slightly decreased.  Therefore, the neck/cervical spine clinical and imaging findings are not consistent with a separate unfitting condition or a rating.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS), or evidence of ratable peripheral nerve impairment which would provide for additional rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the chronic atraumatic upper back pain condition, coded 5299-5237.  

BOARD FINDINGS:  In the matter of the chronic atraumatic upper back pain condition, the Board unanimously recommends a disability rating of 10%, 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	
Chronic Atraumatic Upper Back Pain	5299-5237	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150608, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170005394, XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure