RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00678
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20060217

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Administrative Specialist, medically separated for “chronic subjective neck pain” and “chronic back pain,” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  The VA gave him a higher rating.  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 - 20051025	VARD - 20060803	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5238	10%	Chronic Low Back Strain 	5242-5237	10%	20060511	
Chronic Subjective Neck Pain, 	5238	10%	Chronic Neck Pain 	5238	10%	20060511	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s low back pain (LBP) began in 2001 after falling while carrying some equipment.  Magnetic resonance imaging (MRI) studies showed mild diffuse spondylosis with moderate degenerative facet disease at L3-4, L4-5 and L5-S1 but no significant degenerative disc disease at any level.  At the 19 February 2005 chiropractic clinic appointment, the CI’s range of motion (ROM) measurements were flexion of 70 degrees (normal 90) and combined ROM of 215 (normal 240) with painful motion noted.  Surgical intervention was not recommended.  

ROM measurements were obtained at a physical therapy (PT) appointment on 22 September 2005 recording flexion of 80 degrees and combined ROM of 195 degrees, with painful motion.  During the 26 September 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported intermittent back pain with episodic back spasms, aggravated by prolonged sitting and standing, rotational movements, jumping, running, bending and lifting heavy equipment.  The examiner noted limitation of movement of the lumbosacral spine, identifying decreased flexion but not providing measurements.  He noted that pain was elicited by ROM but was silent regarding gait, spinal contour, spasm or tenderness.  The 4 October 2005 MEB NARSUM examination, 4 months prior to separation, noted complaints of LBP that was severe at times with certain motions.  Physical examination showed a symmetric and non-antalgic gait with an erect, symmetric, and relaxed posture.  Muscles spasm was noted.  The examiner stated “no significant abnormality for functional ROM.”  

At the 11 May 2006 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI reported LBP at a severity of 6/10, flaring to 9/10 once or twice a week for about half-a-day elicited by prolonged sitting and standing, walking, running or lifting.  Physical examination showed tenderness in the left lower lumbar musculature with spasm present but a normal gait and spinal contour.  The CI had full thoracolumbar ROM with painful motion noted.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5238 (spinal stenosis), citing thoracolumbar ROM limited by pain with muscle spasm.  The VA also rated the back condition 10%, dual coded 5242-5237, (lumbosacral strain with degenerative arthritis of the spine), based on the C&P examination, citing localized tenderness and muscle spasm not resulting in abnormal gait or spinal contour.  

The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and/or combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported at the  PT clinic appointment 5 months prior to separation.  A 10% rating was also supported by muscle spasm reported on the NARSUM and VA C&P examinations.  Although there was muscle spasm, it was not severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no documentation of intervertebral disc syndrome (IVDS) 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 there was insufficient cause to recommend a change in the PEB adjudication for the back condition.  

Chronic Subjective Neck Pain.  According to the STR and MEB NARSUM, the CI’s neck condition was diagnosed in 2005 with no history of injury or trauma.  MRI studies showed straightening of the usual lordosis with mild degenerative disc disease and mild central canal stenosis at C4-5 and C5-6; and foraminal stenosis on the right at C3-4, bilaterally at C4-5, and on the left at C5-6.  

During the 26 September 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the examiner listed “spinal stenosis - mild neck pain – intermittent” as a diagnosis, indicating it was aggravated by strenuous exercise or overhead lifting and stating it did not affect daily activities.  The 4 October 2005 MEB NARSUM examination, 4 months prior to separation, included a diagnosis of cervical stenosis and referred to an earlier MRI, but provided no further information regarding the neck condition.  

At the 11 May 2006 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI reported 5/10 cervical pain on an irregular basis that appeared every 2-3 days and lasted 2-3 hours.  The pain did not affect his activities of daily living.  Physical examination showed a normal gait and spinal contour with full cervical ROM.  Tenderness was noted in the upper trapezius muscles but spasm was not mentioned.  The examiner also stated that multiple cervical X-rays had been taken and showed no fracture, dislocation, or joint narrowing; and no significant bone or joint abnormalities.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 10%, coded 5238 (spinal stenosis), citing cervical ROM limited by pain.  The VA also rated the neck condition 10%, coded 5238, based on the C&P examination, citing localized tenderness.  Although there was insufficient limitation of motion to support a 10% rating, the panel agreed a 10% rating was justified for the presence of tenderness.  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.  There was no documentation of IVDS 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 there was insufficient cause to recommend a change in the PEB adjudication for the neck condition.  

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the neck condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  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 20170212, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180004733, 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