RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00031
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030825

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Light Wheel Vehicle Mechanic, medically separated for “neck pain” with a disability rating of 10%.

CI CONTENTION:  “Review all conditions.”  The CI’s 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 - 20030630	VARD - 20030911	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Neck, Right Arm and Shoulder Pain	5099-5003	10%	Chronic Myofascial Pain Syndrome	5290-5021	10%	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Neck as well as Right Arm and Shoulder Pain.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s neck condition began in 1995 while getting off a school bus when a car hit the school bus.  The CI underwent 12 hours of hospitalization for observation of his head and neck injuries.  The CI subsequently dropped out of school and competitive sports due to the injuries.  However, the CI improved to the point that he was able to enlist.  He did well through basic training, but while in AIT (advanced individual training), he developed marked neck and arm pain which caused him to lose consciousness while working under a multi-purpose military truck.  On examination, no objective findings for the source of the discomfort was made.  The CI went on to do well and re-enlisted in 2002.  
Sometime after his re-enlisted, while participating in a training exercise, the CI reported working on a 5 ton truck, he pulled on a wrench and as a bolt turned, he had instantaneous right arm, shoulder and neck pain.  Treatment consisted of injections, muscle relaxants, and physical therapy.  X-ray studies on 31 January 2003, showed an old, slightly displaced avulsion fracture, anterior superior edge of C5, otherwise the study was normal.  On 25 February 2003 the CI reported pain in the right arm for 53 days and stated Flexeril (cyclobenzaprine, a muscle relaxer) did not work.  He noted right arm weakness and paresthesias along C7-8 distribution.  A mild tremor was noted.  The CI was seen on 26 March 2003 by a physical medicine and rehabilitation specialist (PM&R) whose impression was chronic mechanical cervical pain and secondary right myofascial pain.  The examiner noted that pain from those “structures was commonly associated with tremor.”  The CI was referred for physical therapy.  At an occupational therapy visit on 7 April 2003 right shoulder flexion was 90 degrees (normal 180) and abduction was 70 degrees (normal 180) and grip strength on the right was 60 and the left 130.  On 11 April 2003 the PM&R (Physical Medicine and Rehabilitation) physician indicated the CI was without any relief from physical therapy.  

During the 16 April 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported pain from the neck and arm caused different severe effects and prevented him from sleeping comfortably, eating properly or even performing his job duties.  Physical examination showed a full range of motion (ROM), strength 5/5, sensation intact, and reflexes 2+.  An MEB consultation by a PM&R specialist indicated the CI reported the CI’s pain severity ranged between 5-8/10 (10 being the worst pain).  Physical examination showed the spinal contours were grossly within normal limits.  He had tenderness to palpation over the spinous processes of C5-6 as well as over the right trapezius reproducing different aspects of his pain as well as the radicular symptoms.  The range of motion (ROM) measurements using a bubble goniometer showed forward flexion 60 degrees, extension 40 degrees, and right and left lateral flexion each 30 degrees.  He had a negative Spurling’s test (to determine nerve root irritation) and an unremarkable neurologic evaluation with normal symmetric tone, strength of 5/5 in the upper and lower extremities, and normal deep tendon reflexes.  The examiner’s diagnosis was chronic myofascial neck pain.

The 14 May 2003 MEB NARSUM examination, 3 months prior to separation, noted complaints of pain radiating from the cervical spine to the trapezius gradually affecting the entire extremity of  and triggering a tremor of the right upper extremity.  Exacerbating factors include any running, pushups, sit-ups, and flutter kicks, wearing LBE (load bearing equipment), a flak vest, a rucksack, or lifting greater than 20 lbs.  Relief was gained by performing neck ROM.  The CI reported dropping items from his right hand when symptoms were present.  Anti-inflammatory medications were used but did not provide lasting relief of symptoms.  Physical examination was performed at during the PM&R MEB consultation examination on 16 April 2003 as noted above.  There was no VA examination in evidence proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 10%, coded 5099-5003 (arthritis, degenerative), citing pain moderate and frequent.  The VA also rated the neck condition 10%, coded 5290-5021 (limitation of motion cervical spine-myositis) based the STR, citing painful or limited range of motion.  Interim spine rules in effect from 23 September 2002 through 25 September 2003 use the rating formula for spine conditions based on the VASRD prior to 23 September 2002.  Therefore, the VASRD coding and rating standards for the spine, which must be applied to the panel’s recommendation IAW DoDI 6040.44, differ from the current §4.71a general rating formula for the spine.  Code 5290 (spine, limitation of motion of, cervical) has three rating options:  1) severe-30%, 2) moderate 20%, and 3) slight 10%.  Based on the PM&R findings the cervical ROMs were not inconsistent with a slight limitation of motion which warrants a 10% rating.  What the interim spine rules did include was a modification of the requirements for the intervertebral disc syndrome by shifting from radiculopathy criteria to incapacitating episodes criteria.  
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 neck condition.  

BOARD FINDINGS:  In the matter of the neck as well as right arm and shoulder pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are 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 20151209, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	

AR20170013189, 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,