RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02562
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090109

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E4, Infantryman, medically separated for “cervical strain” and “lumbar strain,” rated 10% and 0%, respectively, with a combined disability rating of 20%.  

CI CONTENTION:  The CI made no specific contention.  The 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 - 20081128	VARD - 20090527	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cervical Strain	5237	10%	Cervical Strain	5237	NSC	STR	
Lumbar Strain	5237	10%	Lumbar Strain	5237	NSC	STR	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:  

Cervical Strain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s neck condition began in October 2007 after heavy lifting.  Magnetic resonance imaging (MRI) studies in July 2008 were normal.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic neck pain” for PEB adjudication.  At the time of the orthopedics clinic appointment on 20 March 2008, the CI reported neck and low back pain that was worse with prolonged standing, walking, and sitting.  Pain was described as starting in his neck and shooting down through his entire spine, with reported decreased sensation in the left lateral deltoid, right dominant hand ulnar 2nd digit numbness, and worse with elbow flexion.  Physical examination showed tenderness to palpation over the entire spine and paraspinal muscle spasm.  Gait was normal, and there was full range of motion (ROM), normal upper extremity strength, normal reflexes, and negative Hoffman’s sign (for cervical myelopathy).  There was reported decreased sensation to the left arm, with a positive elbow flexion test (a provocative test for radicular symptoms) and positive Tinel’s at the cubital tunnel (a nerve irritation test at the elbow).  

During the MEB NARSUM examination on 16 October 2008 (3 months prior to separation) the CI reported; “My neck and back hurts.”  Physical examination showed tenderness to palpation from C2-C7 with no muscle spasms.  ROM measurements showed a flexion of 35 degrees (45 normal) and a combined ROM of 310 (normal 340).  Reflexes were normal with no neurosensory deficits.  The left elbow had a surgical scar consistent with an ulnar transposition surgery [April 2008 surgery for cubital tunnel syndrome], and the area was tender.  The examiner reported that the CI was also involved in a motor vehicle accident on 23 September 2008 that aggravated the neck and as discussed below, lower back pain.  There was no VA Compensation and Pension (C&P) examination proximate to separation available for review.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 10%, coded 5237 (cervical spine strain), citing limitation of motion and consideration of functional loss.  The VA denied service-connection for the neck condition citing that the VA required a thorough VA C&P examination to determine if the neck disability still existed or to have evidence of a disability.  A subsequent VARD in 2013 rated the neck at 10% (effective November 2012) based on a C&P examination in October 2013 and VA treatment notes, citing ROM limitations and painful motion.  The Board agreed that a 10% rating, but no higher, was justified for the limitation of flexion (greater than 30 degrees but not greater than 40 degrees) and/or combined ROM (greater than 170 degrees but not greater than 335 degrees) reported on the MEB NARSUM examination proximate to separation.  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.  

The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  There was a history of surgery for left cubital tunnel syndrome and no associated cervical radiculopathy for separate peripheral nerve rating.  While the CI may have experienced radiating pain from the neck condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There was no objective evidence of a cervical radiculopathy with functional impairments such as weakness with a direct impact on fitness that were separately functionally impairing for duty.  The Board therefore concluded that additional disability 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 cervical strain condition.  

Lumbar Strain.  According to STR and the MEB NARSUM, the CI’s back condition also began in October 2007 after heavy lifting.  Radiographic (X-ray) studies of the lumbar spine showed mild scoliosis and minimal levoscoliosis of the upper thoracic spine.  Evaluation by orthopedics found no surgically correctable problems in his lower back.  Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and he was referred for MEB.  The MEB forwarded “chronic low back pain due to facet arthropathy L3-L4, L5-S1 and disc bulge L5-S1” for PEB adjudication.  

At the time of the orthopedics clinic appointment on 20 March 2008, the CI reported neck and low back pain that was worse with prolonged standing, walking, and sitting.  Pain was described as starting in his neck, and “shooting down” through his entire spine.  Physical examination showed a normal gait.  There was tenderness to palpation over the entire spine with paraspinal muscle spasm.  There was reported decreased sensation to the inner thigh.  ROM was full, and there was normal lower extremity strength, normal reflexes, and negative testing for radiculopathy.  

At the time of the Physical Therapy (PT) clinic appointment on 31 July 2008, the CI reported low back pain.  Pain was described as constant and dull and sometimes sharp earlier in the morning.  Pain was located around the T10-11 and shot down to L5.  The CI also reported that sitting for an extended period caused both feet to “feel like they fall asleep” and that he had tingling to his anterior thighs and right posterior leg all the way down to his foot approximately once or twice a day.  The examiner reported that an MRI of the thoracic spine in July 2008 was unremarkable.  Physical examination showed ROM measurements were within normal limits with increased pain upon extension and right side bending.  There was positive provocative testing for radicular symptoms (bilateral slump test) with tingling in the feet.  Bilateral sacroiliac joint compression was negative, supine to sit, leg length discrepancy was negative.  

As noted in the cervical spine discussion above, the CI also reported that his back hurt during the MEB NARSUM examination on 16 October 2008 (3 months prior to separation).  Physical examination showed a normal gait and the CI was able to heel to toe walk.  There was tenderness to palpation from the L2-S1 range, no muscle spasms, normal reflexes, and negative testing for lower extremity radiculopathy.  There were no neurosensory deficits.  ROM measurements showed a normal flexion of 90 degrees and a combined ROM of 235 (normal 240).  The examiner noted that MRI studies on 26 August 2008 showed mild facet arthropathy from L3-L4 thru L5-S1, small circumferential disc bulge at the L5-S1 level without central canal or neuroforaminal stenosis.  As stated above, the examiner reported that the CI was also involved in a motor vehicle accident on 23 September 2008 that aggravated the neck and lower back pain.  X-ray studies on 1 October 2008 showed a subtle levoscoliosis and no signs of acute fracture.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain), citing limitation of motion and consideration of functional loss.  The VA denied service-connection for the back condition citing that the VA required a thorough C&P examination to determine if the back disability still existed or to have evidence of a disability.  Subsequent VARD in 2013 rated the back at 10% (effective November 2012) based on C&P examination in October 2013 and VA treatment notes, citing ROM limitations and painful motion.  The 2013 VARD also rated the left lower extremity radiculopathy at 10%, coded 8520 (sciatic nerve), citing mild incomplete paralysis.  

The Board agreed that a 10% rating, but no higher, was justified for the limitation of combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the MEB NARSUM examination proximate to separation.  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.  

The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  There were episodic symptoms of paresthesias with no associated fixed neurologic deficits proximate to separation.  While the CI may have experienced radiating pain from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There was no objective evidence of a radiculopathy with functional impairments such as weakness with a direct impact on fitness that were separately functionally impairing for duty.  The Board therefore concluded that additional disability 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 lumbar strain condition.  

BOARD FINDINGS:  In the matter of the cervical strain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the cervical strain 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 20151125, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170004633, XXXXXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	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