RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03180
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080409

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Automated Logistical Specialist, medically separated for “cervical strain…associated with radiation of pain into [the] left hand” with a disability rating of 10%.  

CI CONTENTION:  Neck and wrist conditions continue to worsen and the rating for the current state of conditions is not accurate.  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 - 20080426	VARD - 20080529	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cervical Strain…Associated with Radiation of Pain… 	5237	10%	Cervical Spine Degenerative Disc Disease with Osteophyte Complex	5243	10%	20080204	
			Cervical Spine Radiculopathy and Radial Nerve Palsy	8510	20%	20080204	
Left Superficial Radial Nerve Injury, Incomplete	Not Unfitting					
Left Wrist Pain Status Post Scaphoid Fracture and Open Reduction Internal Fixation [ORIF]	Not Unfitting	Left Wrist Status Post Scaphoid Fracture with ORIF	5215	10%	20080204	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Cervical Strain…Associated with Left Hand Radiation Pain.  According to the service treatment record and MEB narrative summary (NARSUM), in July 2005, the left-handed CI had gradual onset of neck pain with numbness in the left arm not associated with a specific injury.  In August 2006, X-rays and a subsequent MRI documented:  multilevel degenerative disc disease (DDD) of the cervical spine with a C3-C4 disc osteophyte complex slightly effacing the spinal cord and producing subtle cord edema or gliosis; and a C6-C7 disc osteophyte complex and facet hypertrophy producing mild spinal canal narrowing, and at least moderate bilateral neural foraminal narrowing.  Surgical intervention was not recommend.  

During the 6 November 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI complained of left neck pain down to the upper back and left arm, with occasional dizziness and headaches from the neck pain and frequent left hand aching.  The 20 November 2007 MEB NARSUM examination noted complaints of neck and upper back pain not relieved by electrical stimulation or injections.  The pain was rated at 7-9/10, and interfered with sleep, and the CI had numbness that radiated across the left shoulder and down the back of the arm associated with movements that lasted from seconds to a few hours.  He was restricted from lifting over 20 pounds.  The examiner noted cervical tenderness without spasms and range of motion (ROM) was recorded as “good.”  Strength during supination and pronation was mildly decreased (4/5), with mildly decreased grip strength that was still 5/5.  Reflexes were 1+ in the upper extremities and bilaterally symmetric.  There was described numbness over the dorsum of the left hand, but there was hypersensitivity to pinprick.  Formal cervical ROM measurements with an inclinometer, and after repetition, showed flexion over 45 degrees (normal) and pain-limited rotations for a combined ROM of 310 degrees (normal 340).  

The 4 December 2007 neurology evaluation and electrodiagnostic study (EMG/NCS) noted CI complaints of neck pain with numbness/tingling that started in the left side of the neck and went down the shoulder/back to the triceps, volar forearm, and was maximal in digits 2 and 3.  However, he denied muscle weakness in the left arm.  Physical examination showed normal left arm strength and reflexes, with sensation decreased to pinprick on palmar digits 3 and 1 on the left, and increased dysesthesias on radial aspect volar hand.  The abnormal EMG/NCS supported diagnoses of “left chronic C7 radiculopathy and left superficial radial nerve injury, incomplete.”  

At the 4 February 2008 VA Compensation and Pension (C&P) examination, 2 months before separation, the CI reported neck and left arm pain and tingling that interfered with sleep.  Physical examination revealed cervical tenderness and flexion over 45 degrees with a combined ROM of 335 degrees, limited by pain.  Left arm reflexes and grasp were normal, but there was hypesthesia (diminished sensitivity to tactile stimuli) over the entire dorsum of the left hand and wrist, with light touch and proprioception otherwise normal.  The diagnosis was cervical spine DDD with osteophyte complex, and the physician noted “slight loss of muscle function on the left found with nerve conduction testing and EMG; he also has nerve conduction loss (neuropathy).”  

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 tenderness and ROM limited by pain.  The VA also rated the neck condition 10%, but coded 5243 (intervertebral disc syndrome (IVDS), based on the C&P examination, citing combined ROM of 335 degrees, painful motion, and joint function limited after repetitive motion.  Panel members agreed that a 10% rating was justified for tenderness reported on all examinations; or alternatively for painful motion or combined ROM (greater than 170 degrees but not greater than 335 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.  

The panel noted that the PEB considered radiculopathy in its adjudication, explicitly addressing the MEB’s submission of radiculopathy, and rendered a de facto “unfitting, but not ratable” determination by stating within the unfitting cervical spine disability description, that “radiculopathy is not separately ratable as the Soldier has intact reflexes and strength.”  The VA rated the cervical radiculopathy with the radial nerve palsy 20%, coded 8510 (upper radicular group (fifth and sixth cervicals)), citing loss of muscle function and paresthesias, based on the pre-separation VA examination.  The CI contended this condition, and radiculopathy is therefore in the panel’s scope of review and will be addressed.  

The CI had cervical osteophyte complexes impacting the spinal cord and narrowing the neural foramina with left upper extremity radicular pain and paresthesias, and electro-diagnostic studies showed evidence of radiculopathy and neuropathy.  The cervical radiculopathy was profiled, implicated in the commander’s statement and NARSUM, and failed retention standards.  All panel members agreed that the cervical radiculopathy was unfitting.  

Complicating the rating of the cervical radiculopathy, the CI also had a left superficial radial nerve injury following a left wrist scaphoid fracture in April 2005 with surgical repair.  Given the overlap of the left upper extremity peripheral nerve deficits and combined interference with dominant arm function, the panel considered the disability of the left upper extremity.  According to VASRD §4.124a, ratings are by comparison with the mild, moderate, severe, or complete paralysis of peripheral nerves.  All panel members agreed that the CI’s disability was no greater than equivalent to mild incomplete paralysis (20%).  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 pain-limited neck ROM.  However, the panel agreed the preponderance of the evidence with regard to the functional impairment of the cervical radiculopathy (left upper extremity peripheral nerves) favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 5243-8510 and meets the VASRD §4.124a criteria for a 20% rating.  

Contended PEB Conditions:  Left Wrist Pain Status Post Scaphoid Fracture and ORIF; and Left Superficial Radial Nerve Injury, Incomplete.  The panel’s main charge is to assess the fairness of the PEB’s determination that left wrist pain and left radial nerve injury were not unfitting.  The profile included left wrist pain and cervical radiculopathy, and the commander’s statement implicated the pinched nerve in the neck, degenerative arthritis, wearing combat gear, and pain interfering with sleep.  The NARSUM implicated the cervical radiculopathy and lifting restrictions, but the MEB separated the cervical radiculopathy as not medically acceptable from the wrist and wrist nerve conditions as meeting standards.  There was no performance-based evidence from the record that the left wrist joint limitations were separately and significantly interfering with satisfactory duty performance at separation.  The left upper extremity cervical radiculopathy was intertwined with the left radial nerve injury and were considered in the analysis above under the left upper extremity peripheral nerve rating.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the separately contended wrist condition, so no additional joint disability rating is recommended.  

BOARD FINDINGS:  In the matter of the neck condition and IAW VASRD §4.71a, the panel recommends no change in the PEB’s 10% adjudication for pain-limited ROM.  However, the panel finds the left upper extremity cervical radiculopathy additionally ratable (in combination with the in left radial nerve injury) at 20%, coded 5243-8510, IAW VASRD §4.124a.  In the matter of the contended left wrist joint condition, 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.  

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	
Cervical Strain	5237	10%	
Cervical Radiculopathy and Left Radial Nerve Palsy	5243-8510	20%	
COMBINED	30%	

The following documentary evidence was considered:

AR20190008431, 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.  Inquiries 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.

Enclosure