RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX		CASE: PD-2017-03845 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20081002

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Air Defense Artillery Specialist, medically separated for “chronic cervical spine pain” with a disability rating of 10%.

CI CONTENTION: Her condition was significantly worse and not diagnosed properly. She contends she “also had several other conditions but my rating did not seem to reflect that.” 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 - 20080827	VARD - 20090210	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cervical Spine Pain	5299 5243	10%	DDD of the Cervical Spine with Muscle Spasm and Cervicalgia	5243	10%	
20081002	
Left Shoulder Pain	Not Unfitting	Mild Left Shoulder Strain	5299-5203	10%		
Left Heel/Ankle Pain	Not Unfitting	Left Heel/Ankle Condition	5299-5271	NSC		
Right Great Toe Bunion	Not Unfitting	Bunion, Right Great Toe	5280	0%		
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 30%	

ANALYSIS SUMMARY:

Cervical Spine Pain. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s cervical spine condition began in January 2008 after she suffered an injury while lifting a container during a field exercise. She was taken to the emergency room during the initial injury and was placed on anti-inflammatory medications and muscle relaxants.  She  later

underwent physical therapy (PT). A MRI, performed because her symptoms were refractory to conservative management, showed multilevel degenerative disc disease (DDD) of the cervical spine.  Lumbar and thoracic diagnostic imaging was normal.

The 13 May 2008 MEB NARSUM examination, 5 months prior to separation, noted complaints of chronic neck and upper back pain rated 6/10. Physical examination revealed tenderness over the cervical spine and associated paraspinal muscles, and there was limited cervical spine range of motion (ROM) due to pain. Waddell's testing (for non-physiologic findings) was negative. The examiner referred to the PT note for ROM.

The 1 August 2008 PT examination, 2 months prior to separation, recorded active cervical spine ROM with flexion to 40 degrees (normal 45), and combined ROM of 245 degrees (normal 340), with painful motion with no additional ROM limitation or functional loss following repetition. There was no tenderness, spasm or guarding, and spinal contour was normal.

At the 2 October 2008 VA Compensation and Pension (C&P) examination on the day of separation, the CI reported a cervical spine condition. Physical examination revealed cervical ROM flexion of 45 degrees and combined ROM of 215 degrees with pain and stiffness. There was no evidence of cervical abnormal curvature nor spasm.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the cervical spine condition 10%, analogously coded 5299-5243 (intervertebral disc syndrome [IVDS]), citing spasm and limited flexion IAW the VASRD General Rating Formula for Diseases and Injuries of the Spine. The VA also rated the cervical spine condition 10%, analogously coded 5243, based on the C&P examination, citing painful motion.

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) or combined ROM (greater than 170 degrees but not greater than 335 degrees), as reported on the PT, MEB, NARSUM, and VA examinations. Although there was muscle spasm, it was not 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 sufficient 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 cervical spine condition.

Contended PEB Conditions: Left Shoulder Pain, Left Heel/Ankle Pain and Right Great Toe. The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting. None of the conditions were profiled or implicated in the commander’s statement and they did not fail retention standards. There was no performance- based evidence from the record that any of the conditions 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 any of the contended conditions, so no additional disability ratings are recommended.

BOARD FINDINGS: In the matter of the cervical spine condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. In the matter of the contended left shoulder pain, left heel/ankle pain and right great toe conditions, 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. Therefore, the panel recommends no modification or re- characterization of the CI’s disability and separation determination.

AR20190011848, XXXXXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXXXXXX

	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.