RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01036
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20060825

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E4, Carpentry/Masonry Specialist, medically separated for “chronic neck pain” and “chronic low back pain,” rated 10% and 0%, respectively, with a combined disability rating of 10%.   

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 - 20060714	VARD - 20070501	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain	5299-5242	10%	Multilevel Cervical Disc Disease	5243	10%	20061102	
Chronic Low Back Pain	5243	0%	Multilevel Lumbar Disc Disease	5243	10%	20061102	
Anxiety Disorder	Not Unfitting	Anxiety Disorder	9413	10%	20061020	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30% 	

ANALYSIS SUMMARY:  

Chronic Neck Pain.  According to the service treatment record (STR) and the MEB narrative summary (NARSUM), the CI’s neck condition began in September 2004 with insidious onset.  At a 14 December 2004 neurosurgery evaluation the CI reported neck pain with bilateral hand numbness, without weakness.  The neurological examination showed no sensory or motor deficits and normal reflexes.  Cervical MRI on 16 December 2004 showed degenerative disc disease (DDD) with mild to moderate posterior disc protrusion at C5-C6 with anterior contact to the spinal cord and probable impingement of the exiting nerve.  A 17 February 2005 physical medicine and rehabilitation examination noted hyperreflexia and clonus, noted on intermittent examinations previously, but indicated there were no other signs of upper motor neuron disease and electrodiagnostic studies for radiculopathy were recommended.  Repeat cervical MRI on 20 July 2005 was unchanged.  Electrodiagnostic studies of the upper extremities on 2 August 2005 were abnormal and were suggestive of a sensory demyelinating peripheral neuropathy.  There was no evidence of cervical radiculopathy or neurogenic thoracic outlet syndrome.  The 8 August 2005 neurosurgery evaluation noted the MRI showed no significant evidence of nerve root or cord compression and provided a diagnosis of cervical spondylosis with pain.  Non-surgical treatment was recommended.  

During the 17 August 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 12 months prior to separation, neck flexion was 35 degree (normal 45) and combined cervical range of motion (ROM) of 265 degrees (normal 340) and combined ROM of 265 degrees (normal 340).  The 8 December 2005 MEB NARSUM examination, 9 months prior to separation, noted complaints of neck pain that was exacerbated with breathing and neck movements.  Physical examination performed on 17 November 2005 showed cervical muscle tenderness.  Neurological examination was normal with normal motor strength in all extremities.  Cervical ROM was flexion of 35 degrees and total combined ROM of 265 degrees.  

At the 13 December 2005 physical therapy (PT) appointment, 8 months prior to separation, the CI reported neck pain.  Physical examination showed a normal spinal contour.  Neck ROM was flexion of 35 degrees and total combined cervical ROM of 225 degrees, with painful motion.  There was tenderness to palpation and there were trigger points in the cervical region.  Examination maneuvers to elicit radicular symptoms were negative.  The CI was right-hand dominant and grip strength was equal in both hands.  

An MRI dated 8 March 2006 noted complaint of neck pain and showed cervical spondylosis (degenerative changes of the spine) and spinal canal stenosis at multiple levels in the thoracic spine.  A follow-up electrodiagnostic study on 15 March 2006 noted chronic neck pain and was compatible with mixed sensory-motor peripheral neuropathy of the upper and lower extremities.  The DD Form 2808 was updated by the examiner on 20 April 2006, 4 months prior to separation, and noted no significant changes since the last examination 

At the 2 November 2006 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported neck pain that occurred approximately three to four times per week and was worsened when his neck was in the forward flexed position.  Physical examination showed a steady gait and good erect posture without abnormal spinal curvatures.  There was no muscle spasm.  Neck ROM was flexion of 45 degrees and combined cervical ROM of 310 degrees with pain on right-side rotation.  There was no additional limitation due to pain, lack of endurance, weakness, incoordination or fatigue with repetitive movements.  Sensation was intact and reflexes were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 10%, coded 5299-5242 (analogous to degenerative arthritis of the spine), citing ROM limited by pain and tenderness without neurological abnormality.  The VA also rated the neck condition 10% coded 5243 (intervertebral disc syndrome), based on the C&P examination 2 months after separation, citing “forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees or combined ROM  of the cervical spine greater than 170 degrees but not greater than 335 degrees.”

The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion greater than 30 degrees but not greater than 40 degrees and/or combined ROM greater than 170 degrees but not greater than 335 degrees, as reported on the NARSUM, MEB and VA examinations.  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 evidence of intervertebral disc syndrome (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula for that condition.  Although upper extremity EMG/NCV studies were abnormal, the working diagnosis was a peripheral neuropathy and not a radiculopathy related to the neck condition.  There was no nerve related condition involving the upper extremities addressed by the MEB or adjudicated by the PEB.  Therefore, the panel could not recommend additional rating on this basis.  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.

Chronic Low Back Pain.  According to the STR and the MEB NARSUM, the CI’s back condition began in September 2004 after climbing in and out of and riding in a large vehicle.  Lumbar spine MRI in November 2004 showed DDD with disc herniation at L4-5 narrowing the neuroforamina (space through which the spinal nerve root passes) bilaterally.  Electrodiagnostic studies of lower extremities on 12 April 2005 demonstrated evidence compatible with a right L5 radiculopathy.  A repeat MRI on 20 July 2005 showed DDD and facet arthropathy of the lumbar spine with mild to moderate central canal stenosis and bilateral neuroforaminal narrowing.  At the 8 August 2005 neurosurgery evaluation, the CI reported back pain with burning pain that radiated to the left buttocks and down the left lower extremity at times.  The neurosurgeon noted the MRI showed no significant evidence of nerve root or cord compression and provided a diagnosis of lumbar spondylosis with pain and recommended non-surgical treatment.  

During the MEB examination ROM of the thoracolumbar spine showed flexion of 55 degrees (normal 90) and combined ROM of 150 degrees (normal 240).  At the 19 September 2005 physical medicine clinic visit the CI reported that his referred pain decreased after physical therapy (PT), but he still had mild pain in the left gluteal area.  Physical examination showed tenderness of the left sciatic notch.  Back ROM was 80 to 90 degrees of flexion.  Straight leg raise testing to elicit radicular symptoms was negative.  The assessment was that the CI had obtained good results in terms of pain and ROM with physical therapy. 

The 8 December 2005 MEB NARSUM examination (performed by the same examiner as the MEB DD Form 2808 examination) noted complaints of back pain that was exacerbated with prolonged standing, sitting, driving and climbing.  The CI denied bowel or bladder incontinence.  Physical examination performed on 17 November 2005 showed normal gait.  Tenderness of the lumbosacral muscles was noted.  Neurological examination was normal with normal motor strength in all extremities.  Back ROM was flexion of 55 degrees and total combined ROM of 150 degrees.  

At the 13 December 2005 PT clinic appointment, 8 months prior to separation, the CI reported 4/10 back pain with repetitive activities.  Physical examination showed a normal gait and spinal contour.  There was tenderness and moderate lumbar spasm noted.  Back ROM was flexion of 55 degrees and total combined thoracolumbar ROM 165 degrees.  Straight leg testing was positive.  An MRI dated 8 March 2006, 6 months before separation, showed lumbar spondylosis causing neural foramina narrowing at multiple levels.  A follow-up electrodiagnostic study on 15 March 2006 showed bilateral peripheral neuropathies of the upper and lower extremities.  On 20 April 2006 4 months prior to separation, the examiner noted no significant changes since the last examination.

At the C&P examination the CI reported low back pain radiating to both legs.  Pain worsened with straightening from a bending or sitting position and with going up stairs or hills.  Physical examination showed a steady gait and good posture without lordosis or scoliosis.  There was no muscle spasm and tenderness was not addressed.  The ROM study showed flexion of 75 degrees and total combined thoracolumbar ROM of 225 with pain at the end range of right rotation.  There was no additional limitation due to pain, lack of endurance, weakness, incoordination or fatigue with repetitive movements.  Sensation was intact and reflexes were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 0%, coded 5243, citing ROM limited by pain without significant neurological abnormality.  The VA rated the back condition 10%, coded 5243, based on the C&P examination 2 months after separation, citing forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees or combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees. 

The panel noted that the MEB DD Form 2808, MEB NARSUM, and PT ROM evaluation for the MEB supported a 20% rating whereas, the VA examination supported a 10% rating.  The panel considered the probative values of the disparate examinations and agreed that the VA examination, because it was the most proximate examination to separation (and closer to separation than the nearest service examination by 6 months) best reflected the CI’s level of disability at separation.  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 on the VA examination proximate to separation.  The PT examination noted muscle spasm, however, it was not severe enough to result in an abnormal gait or spinal contour and none of the other examinations noted spasm, thus the next higher 20% rating was not justified on this basis.  The CI did have IVDS related to the low back condition, however there was no evidence of 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 10% for the back condition, coded 5243.  

The panel next considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The CI initially reported radiating pain to the lower extremities and numbness of the right lower extremity and the electrodiagnostic study in April 2004 was interpreted as compatible with right L5 radiculopathy.  However, more proximate to separation the CI reported LBP and pain that radiated to the left buttocks.  Repeat electrodiagnostic studies noted changes consistent with a “mixed sensory-motor peripheral neuropathy” of both the upper and lower extremities and did not mention a lumbar radiculopathy.  In any case, there was no neurologic abnormality noted on the MEB NARSUM or VA physical examinations.  Therefore, there was no evidence in this case that motor or sensory deficit existed to any degree that could be described as functionally impairing.  The panel concluded that an additional disability rating was not justified for radiculopathy related to the unfitting low back condition.  

Contended PEB Condition:  Anxiety Disorder with Dysthymia.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  Although the contended condition was profiled and judged to fail retention standards, the commander’s statement indicated that the CI’s duty performance was satisfactory and that he worked from 0800-1600 performing customer service, administrative and light maintenance tasks.  The commander noted the CI had been found non-deployable and also indicated “there is some doubt as [to the CI’s] physical ability to perform in his PMOS at any time, any place, or under any conditions.”  The CI had experienced an exacerbation of his mental health (MH) symptoms while deployed, but completed his deployment with his unit.  There was no evidence in the STR that the CI was unable to go to work, had to leave work, or was ineffective at work due to MH symptoms.  The 4 January 2006 MH NARSUM indicated that the CI’s symptoms were improved on medication.  He remained depressed, but panic symptoms were “fairly well under control” with medications and the CI reported sleeping well.  The panel considered that the CI was on multiple psychotropic medications for control of his MH symptoms and he was non-deployable.  However, according to DoDI 1332.38 (E3.P3.4.1.3) “inability to perform the duties of his or her office, grade, rank, or rating in every geographic location and under every conceivable circumstance will not be the sole basis for a finding of unfitness.”  Therefore, the panel could find no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  The panel agreed that the profile and the fact that the MH condition was found to fall below retention standards did not constitute a preponderance of evidence to overcome the PEB’s fitness determination.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the neck condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the back condition, the panel unanimously recommends a disability rating of 10% coded 5243 IAW VASRD §4.71a.  In the matter of the contended anxiety disorder with dysthymia, the panel unanimously 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 that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Neck Pain	5299-5242	10%	
Chronic Back Pain	5243	10%	
COMBINED	20%	

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 

AR20180004923, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

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.

Sincerely,					      
Enclosure