RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXX	CASE: PD-2017-05622
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20080602

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Infantryman, medically separated for “degenerative arthritis of the cervical spine” and “degenerative arthritis of the thoracolumbar spine,” rated 10% each, with a combined disability rating of 20%.

CI CONTENTION:  No specific contention was made.  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 - 20080226	VARD - 20080728	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Degenerative Arthritis Cervical Spine	5242	10%	Osteoarthritis, Cervical Spine	5242	10%	20080528	
Degenerative Arthritis Thoracolumbar Spine	5242	10%	Arthritis, Thoracic Spine	5242	20%	20080528	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 30%	

ANALYSIS SUMMARY:

Degenerative Arthritis of the Cervical Spine. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s neck condition began in January 2004 during basic training after a ruck march, with no indications of injury or trauma. A 16 June 2006 MRI showed a small left central disc herniation/protrusion at C6-7, but was otherwise normal. Despite the neck pain he was able to successfully complete a 15-month combat deployment to Iraq from November 2006 to January 2008, although the record showed multiple visits to sick call for both upper back and neck pain.  Shortly after redeployment, he was referred for MEB.

The 23 January 2008 MEB NARSUM examination, 4 months prior to separation, was abbreviated but noted complaints of neck pain aggravated by stress, weight, and impact. Physical examination showed normal gait and stance, with both tenderness and spasm noted. The 4 February 2008 MEB range of motion (ROM) measurements were taken BY physical therapy using a dual inclinometer for flexion/extension and lateral flexion, and a goniometer for rotation. Cervical spine flexion was to 40 degrees (normal 45) and combined ROM was 280 degrees (normal 340), after repetition and not limited by pain.

At the 28 May 2008 VA Compensation and Pension (C&P) examination, 5 days before separation, the CI reported intermittent neck discomfort aggravated by jogging or weight bearing. Physical examination showed an erect posture and normal gait. Cervical spine ROM measurements revealed flexion of 40 degrees and combined ROM of 315 degrees after repetition.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the neck condition 10%, coded 5242 (degenerative arthritis of the spine), citing tenderness and spasm. The VA also rated the neck condition 10%, coded 5242, based on the C&P examination, citing cervical spine flexion not greater than 40 degrees. Panel members 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 all examinations proximate to separation. A 10% rating was also justified by the presence of tenderness and spasm; however, 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.

Degenerative Arthritis of the Thoracolumbar Spine. According to the STR and MEB NARSUM, the CI’s back condition began in 2005 or 2006 when he started experiencing lower and mid back pain. There were no records in evidence of treatment for the back condition until 2 July 2006, when a lumbar spine MRI showed normal curvature and vertebral alignment with minimal internal derangement/desiccation at L4-5 and L5-S1 and no narrowing, bulging, or disc herniation.

The MEB NARSUM examination noted the CI’s complaints were largely about neck pain, but physical examination did record both tenderness and spasm in the lower back as well as a normal gait and stance. The MEB PT ROM thoracolumbar measurements, using a dual inclinometer and goniometer as noted above, showed flexion of 90 degrees (normal), extension of 15 degrees (normal 35) and combined ROM of 225 degrees (normal 240) after repetition, with only extension limited by pain. The MEB examination (recorded on DD Forms 2807-1 and 2808) 5 days later, included a note from the examiner that the CI had reduced lordosis of the lumbar spine but did not provide any other information useful for rating purposes.

At the C&P examination, the CI reported discomfort of the upper back, especially when breathing, but indicated the condition did not usually affect his daily activities and he was not taking any pain medication. Physical examination showed a normal gait, no scoliosis or thoracic spine deformities, and an erect posture without a list. Thoracolumbar ROM was flexion of 60 degrees, extension of 30 degrees (normal), and left and right lateral flexion of 30 degrees each (normal). Painful motion was not addressed and rotation measurements were not provided. The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the back condition 10%, coded 5242, citing tenderness and spasm. The VA rated the back condition 20%, coded 5242, based on the C&P examination, citing forward flexion of 60 degrees.

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 PT examination. 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 incapacitating episodes which would provide for a higher rating under that formula. The panel noted that the MEB examination recorded reduced lordosis of the thoracic spine; however, this finding was not corroborated by any X-ray or MRI evidence, and was not consistent with other examinations proximate to separation, and there was no indication of spasm recorded on that examination. Panel members also noted that the VA examination flexion measurement of 60 degrees also supports a 20% rating, and considered that the MEB PT ROM measurements 3 months earlier showed full flexion of 90 degrees without painful motion. The CI reported at the MEB that his pain was primarily neck pain, and told the C&P examiner that his back pain did not affect his daily activities. There was no record of any worsening of the back condition after the MEB and prior to separation that would explain the significant loss of flexion between the two examinations. Therefore the panel assigned greater probative value to the MEB PT ROM measurements. 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 back condition.

BOARD FINDINGS: 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 back 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.

PD-2017-05622

AR20190009445, XXXXXXXXXXXXXXXX

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.

PD-2017-05622