RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02284
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080618

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Automated Logistics Specialist, medically separated for “chronic neck pain,” with a disability rating of 20%.  

CI CONTENTION:  The CI made no specific contention.  Her 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 - 20080220	VARD - 20090218	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain	5237	20%	Cervicalgia with Protrusions at C3-4 and C5-6	5243	0%	20080516	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Neck Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s neck condition began in March 2006 after she fell off a truck.  She was not seen until a week later when she complained of pain radiating into all extremities along with numbness.  It was noted that there was no immediate neck pain at the time of the incident.  The CI was also seen in the emergency room the same morning.  On examination, she had muscle tenderness but did not have cervical spine tenderness.  An X-ray was normal.  Neither head trauma nor loss of consciousness were recorded at either evaluation.  The next record in evidence was almost 1 year later, on 27 February 2007.  At a physical therapy appointment, she reported continued neck and upper back pain since the fall.  On examination, she was neurologically intact and had full range of motion (ROM) of the neck other than right rotation which was 75 percent of normal.  Repeat X-rays were normal other than an inadequate view of C1-C2 (positioning).  She continued medications and treatment in physical and chiropractic therapy but had persistent pain.  A cervical MRI performed on 8 May 2007 showed degenerative disc disease at C3-4 and C5-6 as well as a slight malformation in the cerebellum.  In primary care on 10 May 2007, she was noted to have a normal neurological examination as well as normal ROM.  A 22 May 2007 thoracic MRI was normal.  At the 1 June 2007 neurological examination the CI reported headaches related to neck pain and left arm numbness.  The headaches were thought to be related to her neck pain.  Her left arm numbness was “likely due to ulnar nerve sensitivity though no lesion was present.”  The radiating symptoms into the left arm corresponded with C-6 vertebra irritation on the left side.  On examination, she had decreased sensation on the left side of the thoracic nerves.  The motor function, sensation, and reflexes associated with the cervical spine were normal.  

The 9 September 2007 MEB NARSUM examination, 9 months prior to separation, noted complaints of constant dull pain on the right side of the neck with sharp pain on movement.  The physical examination showed functional ROM of her cervical spine.  There was tenderness over the upper right paraspinal muscles.  Compression of the neck vertebrae was negative for nerve root symptoms, but did cause right-sided neck pain.  The neurological examination and gait were normal.  At the 2 February 2008 physical therapy MEB ROM examination, 4 months prior to separation, flexion was restricted to 25 degrees (45 normal), the combined ROM was 260 degrees (340 normal) and motion was painful.  

At the 16 May 2008 VA Compensation and Pension (C&P) evaluation, 1 month before separation, the CI reported neck pain and intermittent tingling and numbness on her fourth and fifth left fingers.  The neurological examination, gait, and ROM were normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 20%, coded 5237 (cervical strain), citing limited flexion between 16-30 degrees.  The VA rated the neck condition 0%, coded 5243 (intervertebral disc syndrome), citing normal ROM at the C&P examination.  The Board agreed that the limitation of flexion recorded on the ROM measurements in physical therapy in February 2008 supported a 20% rating.  There was no documentation of incapacitating episodes which would provide for a higher rating.  Additionally, 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 pain 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.  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 20150527, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170005404, 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,