RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01424
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060515

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Army National Guard E1, Aviation Regiment, Initial Entry Trainee, medically separated for “low back pain” and “neck pain,” rated 10% and 10%, respectively with a combined disability rating of 20%.

CI CONTENTION:  “Review 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 - 20060418	VARD - 20061019	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain	5299-5237	10%	Degenerative Disc Disease, Cervical Spine	5299-5242	NSC	20060811	
Chronic Low Back Pain	5299-5237	10%	Scoliosis	5242	NSC	20060811	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  NSC%	

ANALYSIS SUMMARY:  

Chronic Neck and Back Pain Diagnosis.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI reported a history of back pain that began prior to his entrance into military service.  The back pain was attributed to injuries related to construction work.  Subsequently, while in Basic Training and Advanced Individual Training (AIT), the CI developed recurrent mid back and neck pain.  No specific injury or trauma was reported.  Radiographic studies of the lumbosacral spine on 18 November 2005 were normal.  Studies on 6 December 2005, of the thoracic spine, showed degenerative spur off the vertebral body at the level of T9 and T11 on the right side.  Despite physical therapy, rest, and nonsteroidal anti-inflammatory medicine, the back and neck conditions could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “cervicalgia” and “mechanical back pain” for PEB adjudication.  

Chronic Neck Pain.  The MEB NARSUM examination in February 2006, 3 months prior to separation, noted complaints of neck pain not relieved by conservative treatment.  Paresthesias to the upper extremities were reported.  Physical examination showed full range of motion and tenderness over the spinous processes and paravertebral muscles.  No evidence of spasms were reported.  Upper extremity strength was 5/5 bilaterally.  Sensation was intact with reflexes 2+ and equal.  Physical therapy range of motion (ROM) recorded 2 months prior to separation, documented flexion to 60 degrees (45 normal) and extension to 45 degrees (normal).

At the 11 August 2006 VA Compensation and Pension (C&P) evaluation, performed 3 months after separation, the CI reported constant moderate to severe neck pain described as dull and  throbbing.  Pain was aggravated with activity/weather which led to migraine headaches.  Numbness and tenderness was reported to both hands and fingers radiating up the arms resulted in the CI dropping things.  Pain intensity was 3-10/10.  Over-the-counter and prescribed medications were used for pain control.  Physical examination showed extremity strength 5/5.  C-spine was negative for swelling, erythema, and deformity.  ROM flexion and extension were normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 10%, coded 5299-5237 (analogous with cervical strain), citing tenderness over the neck muscles on palpation with “70 degrees of forward flexion with pain.”  The VA did not service connect (NSC) the neck pain coded 5242 (degenerative arthritis of the spine), based on the VA C&P examination 3 months before separation, citing the “presumption that the condition existed prior to service and was not service aggravated.”

Although there was insufficient limitation of motion to support a minimum rating, the Board agreed a 10% rating was justified for the presence of painful motion and tenderness.  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.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula, 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 concluded that there was insufficient cause to recommend a change in the PEB adjudication for the neck condition.  

Chronic Back Pain Diagnosis.  The MEB NARSUM examination documented the CI’s report of an inability to perform duty functions.  CI reported no radicular pain or paresthesias/weakness to lower extremities.  No bowel or bladder dysfunction was reported.  Physical examination showed tenderness to palpation along the paravertebral muscles ranging from the mid to lower end of the lumbar spine.  No tenderness over the spinous processes was reported.  Lower extremity muscle strength was 5/5 bilaterally, sensation was intact, deep tendon were reflexes 2+.  Straight leg raise test (ligament stability test) was negative at 60 degree bilaterally.  PT ROM recorded 2 months prior to separation documented forward flexion to 90 degrees (normal), and extension to 20 degrees (30 normal).

At the 11 August 2006 VA Compensation and Pension (C&P) evaluation the CI reported dull/aching sensation that increase in intensity with activity.  No radiation of the pain was reported.  Flares occurred 2 times per week lasting 2 hours and rated 10/10.  Some difficulty was reported when going from a sitting to standing position.  No bowel or bladder problems reported.  Physical examination showed negative straight leg raise bilaterally.  No swelling erythema or deformity.  ROM recorded 85 degrees flexion (90 normal) and 20 degrees extension (30 normal).

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the back condition 10%, coded analogously 5237 (lumbosacral or cervical strain) citing tenderness to palpation, flexion with pain at 100 degrees, and normal gait.  The VA rated the back condition NSC coded 5242 (Degenerative arthritis of the spine) based on the VA C&P examination citing NSC based on the presumption of the sound condition that the condition existed prior to service and was not service aggravated..

Although there was insufficient limitation of motion to support a minimum rating, the Board agreed a 10% rating was justified for the presence of painful motion and tenderness  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.  

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 recommends no change in the PEB adjudication.  In the matter of the back condition and IAW VASRD §4.71a, the Board 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 20150618, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170006596, XXXXXXXXXXXXXXXXXX 

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Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.

Sincerely,					       
						      					
Enclosure