RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2017-00644
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070911

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E1, Trainee, medically separated for “cervicalgia” and “chronic bilateral eye pain,” rated 0% each, with a combined disability rating of 0%.  

CI CONTENTION:  “It causes many difficulties that sometimes prevents daily life.”  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 - 20070828	VARD - 20080529 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cervicalgia without Neurologic Deficit	5237	0%	Degenerative Arthritis of the Cervical Spine with Headaches 	5242	10%	20080117	
Bilateral Eye Pain with Exposure to Sunlight	5099-5003	0%	Light Sensitivity 	6099-6009	NSC	20080117	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10% 	

ANALYSIS SUMMARY:  

Cervicalgia.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s neck condition began in March 2007 during basic training.  Her condition was treated with physical therapy and Motrin (a nonsteroidal anti-inflammatory drug).  There were no radiculopathy symptoms.  She received physical therapy twice weekly with improvement noted, but her neck pain was aggravated with heavy lifting and excessive activity.  X-rays of the cervical spine on 7 June 2007 showed a slight reversal of the lordotic curvature centered about the C6-C7 level, which raised the possibility of cervical muscular spasm. 

The 10 August 2007 MEB NARSUM examination, approximately one month prior to separation, noted complaints of neck pain a quarter to a half of the day; however, she no longer took any medication.  Physical examination showed the right trapezius muscle was tender and tight.  The cervical spine range of motion (ROM) measurements after repetition recorded active flexion to 40 degrees (normal 45) and combined ROM of 295 degrees (normal 340) with no real limitation of motion.  X-rays of the thoracic spine dated 17 January 2008 were unremarkable.  X-rays of the cervical spine dated 17 January 2008 demonstrated a reversal of the normal lateral curvature of the cervical spine and evidence of advanced osteoarthritis of the facet joints extending from the level of C5-6 t0 C7-T1.  

At the 29 May 2008 VA Compensation and Pension (C&P) examination, 9 months after separation, the CI reported pain located at the base of her neck.  The pain occurred four times per week and each episode lasted for 10 hours.  Physical examination found evidence of degenerative arthritis of the cervical spine.  Cervical ROM measurements showed forward flexion to 40 degrees and combined ROM of 315 degrees with pain at the end of the motions.  There was no additional limitation of motion demonstrated on repetition, and there was no evidence of radiating pain on movement or muscle spasm, but there was tenderness of the right neck posteriorly.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the cervicalgia condition 0%, analogously coded 5237 (lumbosacral strain), citing no neurologic deficit, no tenderness or spasm, and ROM without limitation.  The VA rated the cervicalgia condition 10%, analogously coded as 5242 (degenerative arthritis of the spine), based on the C&P examination, citing limitation of forward flexion.  

There was no limitation of thoracolumbar spine motion to support a 10% rating under the General Rating Formula for Diseases and Injuries of the Spine; however, the NARSUM examination noted the presence of localized tenderness of the right trapezius muscle, which inserts on the cervical spine and the VA examination noted tenderness of the right neck posteriorly.  A 10% rating is therefore warranted.  There was no evidence of intervertebral disc syndrome which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula for that condition.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the cervicalgia condition, coded 5237.  

Bilateral Eye Pain.  According to the STR and MEB NARSUM, the CI’s eye condition was reported on 1 June 2007 as a 2-day history of photopsia (flashes of light) and marked photophobia, which she treated with sunglasses.  There was no history of trauma or surgery.  She was evaluated by optometry, had a normal eye examination, and was diagnosed as having eye sensitivity to light.  She was seen again by optometry with a normal finding, but her mood was frustrated, unhappy, and anxious.  A mental health evaluation was considered.  On 18 July 2007 she was evaluated by ophthalmology and noted burning pain when in the light and no pain when in the dark.  She was likewise diagnosed with eye sensitivity to light, or photophobia, with no abnormalities detected on routine eye examination except myopia (near sightedness);  there were no uveitis, corneal, or retinal abnormalities.  At a neurology clinic visit on 26 June 2007, she complained of headaches that were precipitated by light exposure.  Neurology assessed them as headache syndrome, mild and non-incapacitating.  The MEB NARSUM examination noted the complaint of excessive eye sensitivity to light. The CI required sun shades at all times to prevent headaches.   Physical examination noted only a refractive error and referred to DD Form 2808 where distant vision was 20/50 on the right and 20/40 on the left, both of which were corrected to 20/20. 

At the 29 May 2008 VA C&P examination, 9 months after separation, the CI reported headaches occurred when light was around her head.  Physical examination showed no icterus (yellow eyes).  Extraocular muscle movements were intact. Pupils were round and reactive to light.  Fundoscopic examination revealed no retinal hemorrhages or exudates.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the eye condition 0%, analogously coded as 5003 (degenerative arthritis), citing no identifiable etiology and pain was minimal/constant IAW U.S. Army Physical Disability pain policy.  The VA rated the eye condition as not service connected (NSC), analogously coded 6099-6009 (unhealed eye injury) based on the C&P examination, citing no clinical diagnosis to account for the complaints of light sensitivity.  

The panel noted the CI had photophobia marked by burning eye pain that was mitigated by sun glasses.  However, the etiology was not determined, although she reported the photophobia caused headaches, but a more specific diagnosis such as dry eyes, anterior segment disease, uveitis or retinal dystrophies associated with photophobia and/or eye pain was not raised.  Furthermore, she did not have prescribed bed rest by a physician or other healthcare provider for an incapacitating episode, although she did lie down when having a bad headache.  Since the CI did not undergo a corneal transplant (code 6036), which does provide a rating if there is pain, photophobia, and glare sensitivity, the panel is unable offer a higher rating than 0% in the absence of a more precise diagnosis.  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 bilateral eye pain condition.  

Contended PEB Condition:  Headache Syndrome.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The contended condition was not profiled, implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that the condition 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 the contended condition, so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the cervicalgia condition, the panel recommends a disability rating of 10%, coded 5237 IAW VASRD §4.71a.  In the matter of the bilateral eye pain condition and IAW VASRD §4.79, the panel recommends no change in the PEB adjudication.  In the matter of the contended headache syndrome condition, the panel recommends no change from the PEB determination as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Cervicalgia	5237	10%	
Bilateral Eye Pain	5099-5003	0%	
COMBINED	10%	

AR20190008807,  

Dear XXXXXXXXXXXX:

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.