RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02380
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20091112

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E4, Infantryman, medically separated for “neck pain” and “low back 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 - 20090908	VARD – No VA Claim	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Degenerative Arthritis of the Cervical Spine	5242	10%	NA	
Chronic Low Back Pain	5299-5237	10%		
Right Shoulder Pain…	Not Unfitting		
Mild…Hearing Loss R Ear	Not Unfitting		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Degenerative Arthritis of the Cervical Spine.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s neck pain and low back pain (LBP) began in 2008, one year prior to being mobilized.  He had been in several motor vehicle accidents and also was preparing for Ranger School.  The CI was mobilized on 22 February 2009 and evaluated for neck and back pain within a few days.  X-rays, on 27 February 2009, of the neck and thoracic spine were normal.  He was referred to a local spine center and evaluated on 23 March 2009.  Examination of the neck and back revealed painful motion, but limitation in motion was not recorded and the neurological examination was normal.  MRIs were done for both the cervical and lumbar spine and were normal other than degenerative joint disease (DJD) at C3-4 with narrowing of the bony window for the nerve roots (foraminal narrowing).  The CI had persistent neck pain despite occupational therapy and was referred for an MEB.  The MEB forwarded “cervicalgia, non-radicular pain, myofascial pain” and “lumbago, non-radicular pain, myofascial pain” (sic) for PEB adjudication.  At the MEB examination (documented on DD Forms 2807-1 and 2808) dated 7 July 2009, normal neck range of motion (ROM) was noted but there was a decreased forward flexion for the back.  The neurological examination was normal.  Electrodiagnostic studies of both upper extremities on 15 July 2009, 4 months prior to separation, were normal.  The ROM testing in physical therapy, also on 15 Jul 2009, showed values that exceeded the VA standard for normal in flexion, extension, and lateral bending.  Rotation, repeated three times, was reduced to 65 on the right and 70 on the left (normal is 80).  The flexion rounded down to 45 degrees (normal) and the combined ROM was 315 (340 normal).  Motion was painful.  There was no local tenderness, muscle spasm, or guarding reported.  The gait and contour were normal.  Spasm, tenderness, and guarding were absent.  The MEB NARSUM examination on 11 August 2009, 3 months prior to separation, noted continued neck pain.  Incapacitation was not documented.  The examiner cited the above examinations for objective findings.  The CI did not file a VA disability claim; therefore, a VA Compensation and Pension (C&P) examination is not available for this Board’s analysis.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 10%, coded 5242 (degenerative arthritis of the spine), citing limitation of motion.  The painful and limited motion support a 10% rating.  No route to a higher rating was found.  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 LBP.  The history and findings are noted above as the CI was evaluated and treated for both the neck and back at the same clinical visits.  The ROM measurements in physical therapy for the thoracolumbar spine showed flexion rounding down to 90 degrees (normal) and the combined ROM was 225 degrees (normal 240).  As for the neck, motion was painful.  There was no local tenderness, muscle spasm, or guarding reported.  The gait and contour were normal.  Spasm, tenderness, and guarding were absent.  Two (of eight) signs of non-organic pain were present.  

The Board directed attention to its rating recommendation based on the above evidence. The CI did not file a VA disability claim for this condition either; therefore, there was no VA rating.  The PEB rated the back condition 10%, coded 5242 (degenerative arthritis of the spine).   The Board agreed that a 10% rating was supported by painful and limited motion.  No route to a higher rating was found.  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.  

Contended PEB Conditions:  Right Shoulder Pain and Mild Low Frequency Conductive Right Ear Hearing Loss.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  Neither of the conditions was implicated in the commander’s statement and both were judged to meet retention standards.  The Board noted that the hearing was essentially unchanged from the accession examination 6 years earlier and that the CI had not shown a duty impairment from it.  The shoulder showed full ROM and minimal tenderness on examination proximate to separation.  There was no performance-based evidence from the record that either of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for either of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the neck and back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended right shoulder and mild low frequency conductive right ear hearing loss conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 20150914, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

22 DEC 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160018778 (PD201502380)

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