RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00003
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040506

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Automated Logistics Specialist, medically separated for “chronic neck pain” with a disability rating of 10%.   

CI CONTENTION:  The CI indicated her injuries, surgeries, and disease were all sustained while on duty.  She was unable to work, and was found not eligible for retirement.  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20040129	VARD - 20050112	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain…	5299-5237	10%	DDD, C-Spine	5010-5242	10%	20030527	
Left Ankle Pain 	Not Unfitting	Recurrent Left Ankle Sprains 	5271	10%	20030527	
Dyspareunia, S/P Abdominal Hysterectomy  	Not Unfitting	Total Abdominal Hysterectomy	7618	30%	20030608	
GERD, H-Pylori Positive	Not Unfitting	Irritable Bowel Syndrome and GERD	7346-7319	0%	20030527	
Mitral Valve Myxomatous
Thickening	Not Unfitting	Supra Ventricular Tachycardia, Mitral Valve Prolapse…	8877-7000	NSC	20030528	
Major Depression 	Not Unfitting	Major Depression	9434	50%	20030714	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Chronic Neck Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s neck condition began as early as 1998 after heavy lifting.  The February 2002 X-rays demonstrated mild degenerative changes and the April 2002 MRI showed mild disk bulging at C5-6 and C6-7 without herniation, but the March 2002 nerve conduction studies of the upper extremities were normal.   

At the 27 May 2003 VA Compensation and Pension (C&P) examination, 11 months before separation, the CI reported neck pain radiating to the left triceps causing a tingling sensation.  Physical examination showed tenderness of the neck.  Range of motion (ROM) after three repetitions was recorded as flexion to 45 degrees (normal) and combined ROM of 320 degrees (normal 340), with painful motion.  The MEB NARSUM used examination data from this VA C&P examination.

During the 15 June 2004 primary care clinic appointment, 1 month after separation, the CI complained of chronic neck pain.  Physical examination recorded “ROM of all joints WNL [within normal limits],” with a tight trapezius muscle on the left side.  The CI did not rotate her head naturally.  On 21 June 2004, the physical medicine & rehabilitation (PMR) examination showed tenderness and crepitus of the cervical spine, but there were no ROM “limitations in spite of pain.”  Strength was recorded as 5/5 (normal). 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition at 10%, coded 5299-5237 (analogous to cervical strain), citing localized tenderness.  The VA also rated the neck 10%, dual coded 5010-5242 (arthritis due to trauma – degenerative arthritis of the spine), based on the C&P examination, citing pain on motion and combined ROM of 330 degrees.

The panel agreed that a 10% rating, but no higher, was justified for combined ROM (greater than 170 degrees but not greater than 335 degrees), as reported on the VA C&P examination.  The presence of painful motion and tenderness also warranted a rating of 10%, but this provided no rating benefit to the CI.  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 the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the neck condition.  

Contended PEB Conditions:  Dyspareunia, S/P Abdominal Hysterectomy, GERD, Mitral Valve Myxomatous Thickening with Mitral Regurgitation, and Major Depression.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  None of the conditions were profiled, implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions, so no additional disability ratings are recommended.  

Contended PEB Condition: Left Ankle Pain.  The panel next assessed the fairness of the PEB’s determination that the left ankle was not unfitting.  The CI’s initial left ankle injury was in 1990, when she sustained multiple ankle strains and inversions causing ankle instability.  Following ankle stabilization surgery and extensive physical therapy, she underwent an MEB because of constant pain and decreased ROM.  A PEB in June 1998 found that she was fit for duty, and her profile was updated on 19 September 2002 with an L3 and fit for duty notation.  The CI’s commander mentioned the left ankle history and profile limitations in the commander’s performance statement, and the MEB judged the left ankle condition to meet retention standards.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the left ankle condition, so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the neck condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended left ankle, dyspareunia, GERD, mitral valve myxomatous thickening and major depression, the panel recommends no change from the PEB determinations as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161213, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180015447, 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,					       

Enclosure