RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01879
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051015

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E5, Unit Supply Specialist, medically separated for “low back pain” and “cervical pain,” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  The Physical Evaluation Board (PEB) did not fully review several conditions identified by the Medical Evaluation Board (MEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20050913	VARD – 20060524 and 20061114	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Low Back Pain	5299-5237	10%	Low Back	5235	10%	20060906	
Cervical Pain	5237	10%	Cervical Spine	5242	10%	20060408	
Bilateral Elbow Pain	Not Unfitting 	Left Elbow	5299-5024	10%	20060408	
		Right Elbow	5299-5024	10%		
Major Depressive Disorder	Not Unfitting	Major Depressive Disorder	9434	10%	20060830	
Coronary Artery Disease	Not Unfitting	Coronary Artery Disease	7005	10%	20060415	
Obstructive Sleep Apnea	Not Unfitting	Obstructive Sleep Apnea	6847	30%	20060824	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Low Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI saw a neurologist in 2001 with complaints of back pain.  An MRI showed degenerative disk disease (DDD) at L4-5 with a broad central disk protrusion and a posterior annular tear.  The CI reported a motor vehicle accident in September 2004 aggravated his back condition.  

The 6 March 2005 MEB NARSUM examination, 7 months prior to separation, noted complaints of back pain.  Physical examination showed tenderness.  Straight leg raising (to determine nerve root irritation) was negative.  He was able to toe and heel walk.  Range of motion (ROM) measurements showed flexion of 80 degrees (normal 90) and combined ROM of 205 degrees (normal 240) with painful motion.  

At the 6 September 2006 VA Compensation and Pension (C&P) evaluation, 11 months after separation, the CI reported a history of pre-existing degenerative and spinal stenosis.  Physical examination showed a normal gait and heel-to-toe walk.  Straight leg testing was negative.  Muscle strength and reflexes of the lower extremities were normal.  There was palpable pain and percussion pain in the low lumbar area midline.  ROM measurements showed flexion of 60 degrees and combined ROM of 160 degrees with painful motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, analogously coded 5299-5237 (lumbar spine strain), citing DDD with ROM near full, limited by pain with tenderness and no objective neurological signs distally.  The VA rated the back condition 20%, coded 5235 (vertebral fracture or dislocation), based on the C&P examination.  The VA deducted 10% for a pre-service disability of the back.   

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 a combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the NARSUM examination proximate to separation.  Members noted the VA examination, 11 months after separation, had a flexion measurement of 60 degrees, which would warrant a 20% rating; however, the pre-separation NARSUM examination was more proximate to separation and had a higher probative value due to its proximity to separation.  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 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.  

Cervical Pain.  According to the STR and the MEB NARSUM, the CI’s neck condition began in January 2004 (mobilized 23 January 2004) after a physical fitness test and was further aggravated after a motor vehicle accident in September 2004.  The CI was referred to neurology for persistent neck and bilateral arm pain with numbness.  He reported having a negative EMG (electromyogram).  An MRI dated 2 February 2005 showed mild bony spurring and generalized disc protrusion at C6-7. 

The MEB NARSUM examination noted complaints of neck pain and bilateral arm pain with numbness.  Physical examination showed tenderness, but strength, sensation and reflexes were normal.  The cervical spine ROM measurements showed flexion of 40 degrees (normal 45) and combined ROM of 215 degrees (normal 340) with painful motion.  

At the C&P examination, 6 months after separation, the CI reported neck pain with numbness between the shoulder blades.  The CI denied any incapacitating episodes within the prior year.  Physical examination showed tenderness.  The cervical spine ROM measurements showed flexion of 60 degrees (normal 45) and a combined ROM of 255 degrees (normal 340); painful motion was not reported.  Strength testing was unreliable and the examiner stated “this is almost pathognomonic for malingering.”  Sensation was intact. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 10%, coded 5237 (cervical spine strain), citing ROM mildly limited with 40 degrees forward flexion and 210 degrees combined ROM.  The VA rated the cervical spine condition 10%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination, citing painful motion with arthritis.   

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 combined ROM (greater than 170 degrees but not greater than 335 degrees) reported on the NARSUM examination proximate to separation.  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.  

Contended PEB Conditions:  Bilateral Elbow Pain, Major Depressive Disorder (MDD), Coronary Artery Disease and Obstructive Sleep Apnea (OSA).  The panel’s main charge is to assess the fairness of the PEB’s determination that the bilateral elbow pain, MDD, coronary artery disease and OSA were not unfitting.  The bilateral elbow pain was profiled U3; the MDD was profiled S3; and the coronary artery disease was profiled P3.  The OSA met retention standards and was not profiled.  All the contended conditions were implicated in the commander’s statement as preventing him from performing the physical duties involved with his MOS.  
	
Bilateral Elbow Pain.  His elbow symptoms started a day after a fitness test in April 2004.  The left-handed CI felt that pushups contributed to his symptoms.  His elbows “hurt, ache.”  The Semmes Weinstein’s light touch test was 2.44 (normal) in all digits of both hands.  The Tinel’s test (to determine nerve irritation) was positive in both cubital tunnels.  There was a positive elbow flexion test (to determine cubital tunnel syndrome) bilaterally and tenderness over the lateral epicondyle bilaterally.  Grip strength on the right was 110 pounds with pain at the lateral epicondyle and grip strength on the left was 100 pounds with pain.  Intrinsic strength was normal for both hands.  A Froment test (to determine palsy of the ulnar nerve which results in decreased pinch strength) was negative bilaterally.  The examiner’s assessment was bilateral lateral epicondylitis and bilateral cubital tunnel syndrome with minimal functional deficits with routine tasks.  An electrodiagnostic study dated 8 February 2005 of the bilateral median and ulnar motor and sensory and bilateral radial sensory responses were normal.  Symptoms of the bilateral epicondylitis were noted to have improved on 9 February 2005, although no subjective improvement of symptoms was noted on 23 February 2005 when the CI’s grip strength increased to 120 pounds on the right and 130 pounds on the left with pain.    

The MEB NARSUM examination noted complaints of bilateral elbow pain.  Physical examination showed full active ROM of the elbows and wrists.  He had normal strength of the bilateral upper extremities and light touch was intact.  He had a negative Tinel’s at the elbow and the wrist.  He had pain at his lateral epicondyle with resisted extension.  He had tenderness over the lateral as well as the medial epicondyle.  On 11 March 2005, grip strength on the right was 140 pounds and 160 pounds on the left with pain.  On 5 April 2005, grip strength on the right was 120 pounds with no pain and 140 pounds on the left with pain.  There was tenderness over the left lateral epicondyle, but no tenderness over the right.  

At the C&P examination, the CI reported elbow pain exacerbated by a lot of mechanical work with arms and elbows.  Physical examination revealed palpable tenderness over the extensor tendon on the lateral humeral epicondyle.  Flexion was to 135 degrees (normal 145) and extension was 0 degrees (normal).  Pain could be accentuated by forceful extension against resistance.  Supination, pronation, wrist extension and wrist flexion all had normal ROMs.  There was no motor weakness in either hand and no signs of atrophy.  X-rays of the elbow were normal.  

The PEB bundled the bilateral elbow pain and found it not unfitting.  However, based on the CI’s MOS where lifting and carrying loads of varying sizes and weights were essential components, the panel determined each elbow was separately unfitting and each warranted a separate rating.  Panel members noted the CI had satisfactory grip strength in both hands and had full ROM of the elbows.  At the conclusion of occupational therapy the CI still had tenderness of the left epicondyle, while at the VA examination there was no motor weakness in either hand, although pain could be accentuated by forceful extension against resistance.  There was no applicable VASRD elbow code; however, code 5024-5003 (tenosynovitis-arthritis, degenerative) is applicable for each elbow with a 0% rating for each elbow.  Members noted that painful motion during ROM measurements would warrant a 10% rating, but pain was only apparent with resisted extension and not with active extension. 

After due deliberation, the panel agreed the preponderance of evidence with regard to the potential for functional impairment of the bilateral elbow condition favors its recommendation as an additionally unfitting condition for disability rating.  The right and left elbows are each appropriately coded 5024-5003 and meet the VASRD §4.71a criteria for a 0% rating for each elbow.  

MDD.  The 27 April 2005 MEB addendum, 6 months prior to separation, indicated the CI had no documented psychiatric history.  On mental status examination, he was appropriately dressed, well-nourished, cooperative, and made good eye contact.  His speech was normal in rate and volume.  He was alert and oriented to person, place, time and situation.  Mood was “okay,” with concordant affect initially.  However, during the interview his affect ranged from tearful to angry.  Affect remained concordant with topics discussed.  He admitted having a depressed mood often as of late.  Thought processing was linear, logical and goal directed.  His thought content was lucid and completely within normal limits.  Language was articulate and coherent.  There was no evidence of current suicidal/homicidal ideation, perceptual disturbance or psychosis.  There was no noted psychomotor agitation or retardation.  His insight and judgment were good.  The CI requested treatment and was placed on Celexa (citalopram, an antidepressant).  The examiner opined the CI’s depression was sufficient enough to cause moderate impairment in his occupation and social functioning and slight impairment for social and industrial adaptability.  His prognosis was good, if compliant with an appropriate treatment plan.  There was no performance-based evidence from the record that the MDD 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 of the MDD, so no additional disability rating is recommended.  

Coronary Artery Disease.  The CI was admitted to the hospital on 2 June 2005 for a severe episode of sub-sternal chest pain compared to diffuse chest fullness that occurred 8 days earlier.  On the way to the hospital, he received aspirin and nitroglycerin and his pain resolved; however, a subsequent EKG and cardiac enzymes were abnormal.  He received Lovenox (anticoagulant), Integrilin (blood thinner) and a beta blocker.  He then underwent cardiac catheterization that showed single vessel atherosclerotic coronary artery disease with a high-grade ruptured plaque with a midcircumflex of 80% (eccentric narrowing), approximately 12 mm in length.  Normal left ventricular function was obtained through a successful stent deployment without complication.  The CI was treated with Plavix (an anticoagulant), which was recommended for 9 months, aspirin, Toprol XL (beta blocker), Zocor (for high cholesterol), and nitroglycerin.  The CI underwent a stress test on 22 July 2005 and a cardiac SPECT scan on 22 August 2005.  He achieved 12.20 METS with high exercise tolerance, a normal hemodynamic response to exercise, a non-ischemic EKG response, but there was a small fixed basal inferior wall perfusion abnormality in the distribution of the left circumflex or right coronary artery and an ejection fraction of 60%.  The examiner noted the CI’s condition was stable.  The CI underwent cardiac rehabilitation.  The 15 April 2006 VA C&P evaluation indicated the CI had done well after stent placement without any recurrent angina.  He continued taking Plavix, aspirin, Toprol XL and Zocor, and was back at work.  

After due deliberation, the panel agreed the preponderance of evidence with regard to the functional impairment of coronary artery disease with a continuing need for the use of anticoagulant medication favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 7005 (arteriosclerotic heart disease) and meets the VASRD §4.104 criteria for a 10% rating based on requirement for continuous medication.  

OSA.  During the MEB evaluation process it was suspected the CI may have sleep apnea due to symptoms of snoring and breathing cessation at night according to his wife, excessive tiredness during the day, and falling asleep while at work.  A sleep study performed on 28 February 2005 demonstrated evidence of moderately severe OSA with hypoxemia and sleep fragmentation.  Treatment with CPAP (continuous positive airway pressure) and weight loss were recommended.  A multiple sleep latency test performed on 1 March 2005 was moderately abnormal with the differential diagnosis to include sleep apnea, narcolepsy, idiopathic CNS (central nervous system) hypersomnolence, severely fragmented or disruptive sleep due to either psychosocial or medical condition, or insufficient sleep.  The MEB neurology addendum dated 19 April 2005 noted the CI’s height of 70 inches and weight of 303 pounds.  The examiner noted the CI would require use of a positive pressure airway device and should not drive or operate heavy machinery if excessively tired.  He required a source of electrical power to operate the CPAP machine and maintain it in working and hygienic order.  The CI met retention standards and was to be reevaluated in 12 months.  On 28 April 2005, the breathing disordered abnormality demonstrated improvement in breathing on a final CPAP of 16 cm of water.  At the 24 August 2006 VA C&P examination the CI’s weight was 297.  He still had some daytime hyper somnolence, but denied any other kind of respiratory problems.  The CI underwent cardiac rehabilitation and was doing well.  There was no performance-based evidence from the record that OSA 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 of the OSA, so no additional disability rating is recommended.  

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.  In the matter of the contended bilateral elbow pain condition, the panel agrees it was unfitting and recommends a disability rating of 0% for the right elbow and 0% for the left elbow, each coded 5024-5003 IAW VASRD §4.71a.  In the matter of the contended coronary artery disease, the panel agrees it was unfitting and recommends a disability rating of 10%, coded 7005 IAW VASRD §4.104.  In the matter of the contended MDD and OSA, 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.  

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

CONDITION	VASRD CODE	PERMANENT RATING	
Low Back Pain	5299-5237	10%	
Cervical Pain	5237	10%	
Coronary Artery Disease	7005	10%	
Right Elbow Pain	5024-5003	0%	
Left Elbow Pain	5024-5003	0%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170307, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

	

AR20180008184, 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, (AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

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

Sincerely,					      
Enclosure