RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02093
BRANCH OF SERVICE:  army	SEPARATION DATE:  20090813

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E6, Recruiter, medically separated for “chronic neck pain” and “chronic low back pain,” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  PTSD was not adjudicated correctly.  The VA rated him higher for his back condition.  He also requested review of an additional condition not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 - 20090317	VARD - 20100309	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain	5241	10%	C5-C6 Degenerative Disc Disease…	5242	20%	20091001	
Chronic Low Back Pain	5237	10%	Lumbar Spine Degenerative Disc Disease	5242	10%	20090908	
PTSD	Not Unfitting	PTSD	9411	50%	20090911	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:

Chronic Neck Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s neck pain began in 2004 when he stumbled and twisted his neck while carrying heavy weight.  His condition improved but was re-aggravated in 2007 when he also began to have radiating right elbow pain.  He underwent a C5-C6 spinal fusion and laminectomy in June 2008.  The 17 December 2008 MEB NARSUM examination, 8 months prior to separation, noted complaints of constant-daily neck pain.  Physical examination showed a normal gait and stance.  Range of motion (ROM) was performed during the MEB physical therapy examination on 11 July 2008, 13 months before separation.  Repetitive-goniometric cervical spine flexion was 35 degrees (normal 45) and combined ROM was 205 degrees (normal 340); painful motion was present.  At the 1 October 2009 VA Compensation and Pension (C&P) spine examination, 2 months post-separation, the CI reported constant-daily neck pain that radiated down the right arm and occasionally the left.  Physical examination showed cervical spine flexion to 30 degrees and combined ROM was 205 degrees; painful motion was present.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 10%, coded 5241 (spinal fusion), citing limitation of flexion.  The VA rated the neck condition 20%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination, citing limitation of flexion.  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 MEB 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 intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula.  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 neck condition.  

Chronic Low Back Pain.  According to the STR and MEB NARSUM, the CI’s low back condition began in 1991 when he fell off a truck and landed on his back.  A lumbar spine MRI in May 2007 revealed mild bilateral L4 foraminal narrowing.  The MEB NARSUM examination noted complaints of low back pain 3 to 4 times weekly.  Physical examination showed a normal gait and stance, and spinal tenderness.  MEB physical therapy ROM measurements, 13 months before separation, showed repetitive-goniometric lumbar spine flexion was 75 degrees (normal 90) and combined ROM was 205 degrees (normal 240); painful motion was present.  

At the 8 September 2009 C&P general examination, 1 month after separation, the CI reported pain all day every day.  Medications brought relief and he used a brace, which helped.  Physical examination showed a normal gait without spinal tenderness or muscle spasm.  Curvature and posture were normal.  Lumbar spine ROM was flexion to 90 degrees and combined ROM was 185 degrees; painful motion was present.  ROM was not reduced by repetitive 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), citing limitation of flexion or combined ROM.  The VA rated the back condition 10%, coded 5242, based on the C&P general examination, citing painful motion.  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 NARSUM 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 documentation of IVDS with incapacitating episodes which would provide for a higher rating under that formula.  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 low back condition.  

Contended PEB Condition:  PTSD.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The CI was referred to the MEB due to orthopedic conditions.  He was diagnosed and treated for PTSD but GAF scores were predominantly in the range of mild symptoms and impairment, and the most recent scores prior to separation were in the mild bordering on transient range.  Mental status examinations were essentially unremarkable, with occasional references to anxiety.  There were no specific references to symptoms that were traumatic in focus (e.g. nightmares).  The commander’s statement, 8 months prior to separation, did not implicate the CI’s PTSD, and the contended condition was permanently S3 profiled 5 months prior to separation.  The MEB report did not judge the CI’s PTSD to fail retention standards.  The CI’s treating psychiatrist’s last follow-up, 2 months prior to separation, noted a diagnosis of PTSD with a GAF score of 70.  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 neck condition and IAW VASRD §4.71a, the panel majority recommends no change in the PEB adjudication.  The single voter for dissent recommends modification to 20% and did not elect to submit a minority opinion.  In the matter of the low back condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended PTSD, the panel agrees it cannot recommend it for additional disability rating.  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 20170225, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR, 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