RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXX	CASE:  PD-2017-04459
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20081007

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

CI CONTENTION:  His conditions continue to worsen and negatively affect his life.  The CI 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 - 20080702	VARD - 20090319	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	10%	Lumbar Degenerative Disc Disease	5242	40%	20081104	
Chronic Neck Pain	5299-5237	10%	Cervical Spinal Stenosis	5238	20%	20081104	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began in 2002 after a fall.  Over the course of the next few years, the CI was treated with medications, duty limitations, and injections without resolution of his pain.  A lumbar spine MRI on 14 April 2005 showed disc herniation at L5-S1 without nerve compression.  In family practice on 11 June 2007, the CI was noted to have normal range of motion (ROM) of the neck and back.  The neurological examination and gait were normal.  A repeat MRI on 18 September 2007 showed resolution of the herniation, but there was still persistent foraminal narrowing of the lumbar spine at L5-S1 and new minimal central stenosis at L3-4.  Surgery was not recommended.  The next day in the chiropractic clinic, the lumbar (not thoracolumbar) flexion was limited to 45 degrees (normal 60) with 10 degrees of extension (normal 30).  The neurological examination including the gait was normal.  

The 9 April 2008 MEB NARSUM examination, 6 months prior to separation, noted ongoing pain.  Physical examination showed normal gait, motor strength and sensation and straight leg raise testing was negative.  There was no tenderness.  The CI was observed to move easily without apparent discomfort prior to formal ROM testing.  Goniometric ROM testing showed normal flexion, rotation and lateral flexion, but extension was limited to 15 degrees by pain.  There was no change in ROM with repetition due to fatigue.  During the 21 May 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported moderate to severe back pain.  The spine and neurological examinations were checked normal.  

At the 4 November 2008 VA Compensation and Pension (C&P) examination, 1 month before separation, the CI reported moderate pain with prolonged sitting, standing or grocery shopping.  Physical examination showed spasm, tenderness and painful motion; the gait and spinal contour were normal.  Atrophy and weakness were absent.  The neurologic evaluation was normal.  The ROM showed flexion of 35 degrees and combined ROM of 140 degrees.  There was painful motion noted with flexion, extension and left lateral flexion, but no additional limitation after repetition.  X-rays were unremarkable.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, analogously coded 5299-5237 (lumbosacral strain), citing painful motion.  The VA rated the back condition 40%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination, citing forward flexion limited to 35 degrees with pain starting at 25 degrees.  The panel considered the conflicting ROM measurements presented in the MEB NARSUM and VA examinations.  Although the VA examination was more proximate to separation, the record contained no evidence of an intervening event that would have caused the CI’s ROM to go from “normal,” or 90 degrees, to 35 degrees.  In addition, the prior clinical examinations had noted either normal or minimally reduced flexion when the ROM was recorded.  Therefore, panel members agreed the MEB NARSUM examination held more probative rating value than the VA examination and was used for rating purposes.  The panel agreed that a 10% rating, but no higher, was justified for limitation of combined ROM greater than 120 degrees but not greater than 235 degrees, as reported on the MEB NARSUM examination.  The muscle spasm 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.  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.  

Chronic Neck Pain.  According to the STR and MEB NARSUM, the CI’s neck condition began in 2002 after a fall as noted above.  A cervical spine MRI on 13 June 2005 showed mild disc bulging at C2-3 and C4-5 without nerve impingement and mild narrowing of the central canal at C4-5.  In family practice on 11 June 2007, the CI was noted to have normal range of motion (ROM) of the neck and back.  In the chiropractic clinic on 19 September 2007, the CI was noted to touch his chin to his chest (normal flexion, 45 degrees or better) and extend to 20 degrees (normal 45).  The 18 December 2007 cervical spine MRI showed posterior disc osteophytes with the cervical spinal cord being contacted and mildly compressed at several levels.  

The MEB NARSUM examination showed a normal gait and the CI appeared comfortable and moved easily without any apparent discomfort until ROM testing, which showed discomfort with extension.  Motor strength and sensation were normal and there was no tenderness.  Goniometric range of motion (ROM) testing showed normal flexion (45 degrees), rotation (80 degrees) and lateral flexion (45 degrees), but extension was limited to 15 degrees by pain.  There was no change in ROM with repetition due to fatigue.  During the MEB examination, the CI reported moderate to severe neck pain with numbness and tingling in the arms at night.  Physical examination of the spine and neurological evaluation were normal. 

At the VA C&P examination, the CI reported moderate constant neck pain worse with extension.  Severe flare-ups occurred with sudden neck jerking or postural changes every 2-3 weeks lasting for hours.  Physical examination showed spasm, guarding, tenderness and painful motion, but gait and spinal contour were normal.  The neurologic evaluation showed normal motor strength, sensation and reflexes.  The ROM study showed flexion of 45 degrees and combined ROM of 255 degrees.  There was painful motion noted with extension and left and right lateral flexion and left and right rotation, but no additional limitation after repetition.  X-rays were unremarkable.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 10%, analogously coded 5299-5237 (cervical strain), citing painful motion.  The VA rated the neck condition 20%, coded 5238 (spinal stenosis), based on the C&P examination, citing combined ROM limited to 165 degrees.  The panel observed that this combined ROM is for the onset of pain rather than the limit in motion.  The correct combined ROM is actually 255 degrees which supported a 10% rating.  The panel agreed that a 10% rating, but no higher, was justified for limitation of combined ROM (greater than 170 degrees but not greater than 335 degrees), as reported on the MEB NARSUM and VA examinations.  Although there was muscle spasm and guarding, 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.  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.  

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.  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:

[AR Number], XXXXXXXXXX

Dear XXXXXXXXX:

	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.