RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02192
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20031022

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Unit Supply Specialist, medically separated for “chronic neck pain” and “lower back pain,” each rated at 10%, with a combined  disability rating of 20%.

CI CONTENTION:  “Not all issues were addressed.”  The complete submission is at Exhibit A.

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination 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(s) at the time of separation.  The panel 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 panel 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 - 20030915	VARD - 20031113	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain	5099-5003	10%	Cervical Strain	5237	10%	20031002	
Low Back Pain	5299-5295	10%	Lumbar Strain with Thoracic Degenerative Changes	5243-5237	10%	20031002	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Neck Pain.  In accordance with DoDI 6040.44, the panel is required to recommend a rating IAW the VASRD in effect at the time of separation, which was the 2004 VASRD standards for the spine.  The PEB applied the 2003 VASRD based on the PEB date for both neck and back conditions.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s neck condition began approximately in 2001 after reclassifying into supply due to low back pain.  

The 23 June 2003 MEB NARSUM examination, 4 months prior to separation, noted complaints of chronic low back pain.  Physical examination was remarkable for decreased sensation to right C6 distribution pin prick of the right upper extremity and triceps reflexes were 1/4 and symmetric.  Upper extremity motor strength was 5/5.  Range of motion (ROM) and painful motion were not addressed.  

At the 2 October 2003 VA Compensation and Pension (C&P) evaluation, performed less than 1 month before separation, the CI reported cervical spine pain with radiation.  Physical examination showed a normal posture without spinal tenderness or spasm.  ROM was flexion 45 degrees (normal) and combined ROM was 310 degrees (normal 340) without painful motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 10%, analogously coded 5237 (cervical strain), citing the US Army Physical Disability Agency (USAPDA) pain policy citing slight pain.  The VA also rated the neck condition 10%, coded 5237 (lumbosacral strain) based on the C&P examination less than 1 month before separation, citing limited motion.  The panel agreed there was insufficient limitation of motion to support a minimum rating under the General Rating Formula for Diseases and Injuries of the Spine; however, a 10% rating was justified for functional loss (§4.40) due to the chronic pain documented throughout the STR.  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.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the low back pain condition.  

Low Back.  According to STR and the MEB NARSUM, the CI’s low back condition began in 1992 after completing jump school.  The CI reclassified into supply due to his back pain in 1998.  His back pain increased steadily with radiating pain into his lower extremities starting in 2001.  Radiographic imagining (MRI) was remarkable for degenerative spur at T11-T12, herniation seen of the T12-L1 disk, and Schmorl node of lower thoracic vertebrae from T8 to T11.  Surgery was not indicated.  

The MEB NARSUM examination noted complaints of chronic low back pain.  Physical examination showed reduced pin prick in an L5 distribution of the left lower extremity.  Left hamstring and quadriceps had 4+/5 muscle strength but other muscles 5/5 and symmetric.  Knee and ankle reflexes were 2/4 and symmetric.  There was no bowel or bladder impairments.  ROM and painful motion were not addressed.  At the 02 October 2003 C&P evaluation the CI reported lumbar spine pain with radiation.  Physical examination showed a normal gait and posture without spinal tenderness or spasm.  ROM was flexion 70 degrees (90 normal) and combined ROM was 220 degrees (normal 240) without painful motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, analogously coded 5299-5295 (lumbosacral strain), citing the USAPDA pain policy citing slight pain.  The VA also rated the low back condition 10%, analogously coded 5243-5237 (intervertebral disc syndrome-lumbosacral strain) based on the C&P examination less than 1 month before separation, citing limited motion.  The panel agreed there was insufficient limitation of motion to support a minimum rating under the General Rating Formula for Diseases and Injuries of the Spine; however, a 10% rating was justified for functional loss (§4.40) due to the chronic pain documented throughout the STR.  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.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the low back pain condition.  

BOARD FINDINGS:  In the matter of the chronic neck pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the low back pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There were no other conditions within the panel’s scope of review for consideration.  The panel, 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 20150812, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170010261, XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXX

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,