RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01011
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20051205

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E5, Military Policeman, medically separated for “chronic neck pain,” “chronic low back pain” rated 10% each with a combined disability rating of 20%.  “Suspected coronary artery disease” was not rated.  

CI CONTENTION:  “Review all conditions.”  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 - 20051004	VARD - 20060620	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain	5237	10%	Degenerative Joint Disease Cervical Spine  	5242	20%	20060412	
Chronic LBP	5237	10%	Degenerative Disease Lumbar Spine  	5242	20%	20060412	
Suspected CAD 	7099-7005	Not Rated	No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Neck Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s neck pain began in June 2002 after a motor vehicle accident (MVA).  An MRI of the cervical spine showed mild to moderate degenerative changes impinging on the spinal canal.  The CI was involved in a second MVA in February 2004, which exacerbated his symptoms.  There was no surgical indication.  

The 21 December 2004 Physical Medicine (PM) MEB NARSUM examination, 11 months prior to separation, noted complaints of pain with neck movement.  Cervical range of motion (ROM) was flexion to 30 degrees (normal 45) with a combined ROM of 140 degrees (normal 340).  There was tenderness of the cervical paraspinous muscles.  At the 10 February 2005 Physical Therapy (PT) ROM study, 10 months prior to separation, forward flexion was 35 degrees and combined ROM was 255 degrees.  There was no mention of painful motion, tenderness or spasm.  

At the 12 April 2006 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported neck pain without radiation, debilitation or flare ups.  Physical examination showed flexion to 25 degrees and combined ROM of 165 degrees (normal 340) with no postural abnormalities, tenderness or spasm.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 10%, coded 5237 (cervical strain), citing forward flexion of 52 degrees.  The VA rated the neck condition 20%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination 4 months after separation, citing forward flexion to 25 degrees.  The panel agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 15 degrees but not greater than 30 degrees), as reported on the preponderance of examinations proximate to separation.  There was no evidence of intervertebral disc syndrome (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under that alternate VASRD formula.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the neck condition, coded 5242.  

Chronic Low Back Pain (LBP).  According to the STR and MEB NARSUM, the CI’s low back condition began in June 2003 after a MVA as described above.  An MRI showed multilevel degenerative disc disease without significant central canal or neuroforaminal stenosis.  The low back condition worsened after the second MVA as described above.  There was no surgical indication.  The 21 December 2004 PM MEB NARSUM examination, 11 months prior to separation, noted complaints of pain with low back movements.  Physical examination showed forward flexion to 90 degrees (normal) and combined ROM of 220 degrees (normal 240) with tenderness and painful motion.  The 10 February 2005 PT ROM study, 10 months prior to separation, was performed with inclinometers placed at T12 and L5-S1.  Forward flexion was 40 degrees and combined ROM was 135 degrees.  There was no mention of painful motion, tenderness or spasm.  An 11 March 2005 MRI showed disc space narrowing with no significant interval change.

At the 12 April 2006 C&P evaluation, 4 months after separation, the CI reported LBP without radiation.  He was able to perform daily activities and denied weakness, fatigability, decreased endurance, incoordination or flare-ups.  ROM of the lumbar (not thoracolumbar) spine showed forward flexion to 50 degrees, extension to 10 degrees (normal 30), right and left lateral flexion to 20 degrees each (normal 30) and right and left rotation 30 degrees each (normal 30).  There was no pain with motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, coded 5237 (lumbosacral strain).  The VA rated the low back condition 20%, coded 5242, based on the C&P examination 4 months after separation, citing forward flexion of 50 degrees as reported on the C&P examination.  The panel noted the PT examination prior to separation used inclinometers, which do not comply with the VASRD requirement to use a goniometer.  Additionally, the C&P examination reported lumbar, not thoracolumbar ROM as required by the VASRD.  The only examination proximate to separation that detailed a full thoracolumbar examination in compliance with the VASRD is the PM MEB NARSUM which will be cited for rating purposes.  The panel agreed that a 10% rating, but no higher, was justified for limitation of combined ROM greater than 120 degrees but not greater than 235 degrees as reported on the PM examination.  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 that there was insufficient cause to recommend a change in the PEB adjudication for the low back condition.  

Suspected Coronary Artery Disease (CAD).  According to the STR and the MEB NARSUM, the suspected CAD presented in 2003 with occasional exertional chest pain.  The CI was referred to cardiology and a stress echocardiogram was performed on 7 March 2003.  The test was terminated due to hip pain and a report of shortness of breath.  His exercise tolerance was noted to be poor and he was not able to attain the target heart rate of 85% of predicted.  The exercise EKG changes were not diagnostic but the echocardiogram images showed decreased wall motion consistent with ischemia in the inferior septum and the CI was referred for cardiac catheterization.  

At the 20 October 2004 MEB cardiology evaluation, 14 months prior to separation, the CI revealed he had run out of his medication but felt fine and had not had a return of chest pain.  He was not able to do strenuous physical activity due to back pain, but denied chest pain with low level physical activity.  Physical examination showed blood pressure of 123/73 and heart rate of 89, both normal off medication.  Heart and lung examinations were normal and there was no lower extremity swelling.  

A 22 August 2005 follow-up cardiology evaluation noted the CI had no recent chest pains even after climbing seven flights of stairs.  The cardiologist concluded the prior stress echocardiogram results likely represented a false-positive test and opined that the CI likely did not have significant CAD.  He then ordered another non-invasive test for CAD.  At the 30 August 2005 stress thallium test, 3 months prior to separation, the CI exercised nine minutes and one second on a full Bruce protocol which equates to 9 metabolic equivalents workload, attained 85% of his maximum predicted heart rate and the test was stopped due to shortness of breath and back pain.  There were no diagnostic EKG changes, nor was evidence of decreased blood flow or infarction of any of the cardiac muscle and wall motion noted to be normal.  At the 13 September 2005 cardiology follow-up, 3 months prior to separation, the cardiologist stated he believed the prior stress echocardiogram test was a false positive, he had a very low suspicion for significant CAD and that no further evaluation was required.  The CI was released without cardiac limitations, his cardiac medications were not refilled and he was encouraged to resume regular cardiovascular exercise.  

At the 12 April 2006 C&P evaluation, 4 months after separation, the suspected CAD condition was not addressed.  During the 24 July 2006 VA Cardiology evaluation, 8 months after separation, the CI reported he had not had chest pain in the preceding two years.  He informed the cardiologist he was on aspirin but no other medication.  Physical examination showed blood pressure of 130/80 and pulse 80.  Examination of the heart and lungs was normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB subsumed the MEB diagnoses of dyspnea on exertion and atypical chest pain under a single condition of suspected CAD and did not rate the condition, coded 7099-7005 (analogous to arteriosclerotic heart disease), citing AR 635-40, Appendix B, paragraph B-3c.  The VA did not address the suspected CAD condition on the initial or subsequent VA rating decisions.  There was no documented CAD to satisfy the requirements for a rating under code 7005.  There was no history of a myocardial infarction (heart attack) to justify a rating under code 7006 or hypertensive heart disease (7007).  There are no other applicable codes.  After due deliberation, considering all of the evidence and mindful of VASRD §4.104 (reasonable doubt), the panel recommends a disability rating of 0% for the suspected CAD condition, coded 7099-7005.  

BOARD FINDINGS:  In the matter of the neck condition, the panel unanimously recommends a disability rating of 20%, coded 5242 IAW VASRD §4.71a.  In the matter of the low back condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the suspected CAD condition, the panel unanimously recommends a disability rating of 0%, coded 7099-7005 IAW VASRD §4.104.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends that the CI’s prior determination be modified as follows; and, the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Neck Pain	5242	20%	
Chronic LBP	5242	10%	
Suspected CAD 	7099-7005	0%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170222, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180005735, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX  

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, XXXXXXXXXXXXXXXXXX.

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