RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2018-00119
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070204

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve  E7, Administrative Specialist, medically separated for “chronic low back pain” and “chronic neck pain,” rated 10% and 0%, respectively, with a combined  disability rating of 10%.   

CI CONTENTION:  Review requested of the back, neck, bilateral knee, tinnitus, depression, and migraine conditions as well as additional conditions (traumatic brain injury, PTSD, chronic upper respiratory issues) not identified by the Medical Evaluation Board (MEB) and/or the 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 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 - 20070123	VARD - 20070829	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	10%	Low Back Degenerative Disc Disease (DDD)/Degenerative Joint Disease (DJD)	5243	20%	20070305	
Chronic Neck Pain	5299-5237	0%	DDD/DJD Cervical Spine 	5243	10%	20070305	
Bilateral DJD, Shoulders	Not Unfitting	Right Shoulder Strain	5024	10% 	20070305	
		Left Shoulder Strain	5024	10% 	20070305	
Bilateral Retropatellar Pain Syndrome	
Not Unfitting 
	DJD, Right Knee	5010-5260	10%	20070305	
		DJD, Left Knee	5260	10%	20070305	
Chronic Migraine	Not Unfitting	Migraine Headache	8100	30%	20070305	
Tinnitus	Not Unfitting	Tinnitus	6260	10%	20070305	
Depressive Disorder	Not Unfitting	Post-Traumatic Stress Disorder (PTSD)	9411	NSC	20070305	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain (LBP).  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s LBP began in 1998 while taking a physical fitness test during a drill period with her Army Reserve unit.  A lumbar spine MRI on 26 July 2006 showed degenerative changes at L4-5 and L5-S1, and neuroforaminal narrowing primarily at L5-S1; surgery was not indicated.  During the 28 August 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, physical examination showed full active thoracolumbar ROM, with tenderness, but no muscle spasm.  Electrodiagnostic tests from 11 September 2006 suggested a remote L5-S1 left radiculopathy, and the examiner noted ongoing symptoms down both legs suggested irritation of nerve roots without acute radiculopathy.  At the 13 September 2006 MEB orthopedic consultation, the CI complained of a long history of LBP exacerbated during a recent deployment.  She reported a “clunking sensation” and pain radiating down her bilateral lower extremities (LEs) to the feet, greater on the left.  She also endorsed weakness, numbness, and tingling into the bilateral LEs at different times and with different activities.  The provider noted reactions to maneuvers not expected to elicit pain based on the pathology.  The CI walked with a non-antalgic gait and could heel and toe walk without difficulty.  

The 2 October 2006 MEB NARSUM examination, 4 months before separation, noted complaints of chronic LBP with long standing right and left LE sciatica and worsening piriformis spasm.  The CI also reported left LE weakness to the point of collapse, and most recently, right LE weakness with occasional collapse as well.  She also had increased difficulty with navigating stairs and standing or sitting for any period of time.  The MEB examination was cited for physical findings.  

At the 5 March 2007 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported constant LBP which travelled to her feet, and was often elicited by physical activity and stress, but relieved by rest.  Physical examination revealed normal posture and gait, with no spasm or tenderness.  Thoracolumbar ROM measurements showed flexion to 60 degrees (normal 90) and combined ROM of 175 degrees (normal 240).  Joint function of the spine was additionally limited by pain, fatigue and weakness with repetition, with pain as the major functional impact. There was evidence of radiating pain on movement with flexion, but no signs of intervertebral disc syndrome (IVDS) with chronic or permanent nerve root involvement.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10%, analogously coded 5299-5237 (lumbar spine strain), citing tenderness to palpation.  The VA rated the low back condition 20%, coded 5243 (IVDS), based on the C&P examination, citing thoracolumbar forward flexion to 60 degrees.  Panel members   noted that thoracolumbar ROM measurements varied at serial examinations in the record between levels supporting a 20% rating or a 10% rating, with a majority of the examinations, both prior to and after separation, supporting a 10% rating.  Although there was no thoracolumbar ROM recorded in degrees prior to separation, the panel agreed ROM described as “full” was clear and did not require any speculation for rating assignment.  There was no evidence of 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 evidence of IVDS which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of a rating under that alternate 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.  

Chronic Neck Pain.  According to the STR and MEB NARSUM, the CI’s neck pain began in 1998 when she had to wear a Kevlar helmet for extended periods of time while on active status.  She denied any specific injury or trauma.  A cervical spine MRI on 13 February 2006 revealed degenerative changes, neuroforaminal narrowing, and severe central canal stenosis at C5-6 and moderate stenosis at C6-7.  On 21 February 2006, X-rays showed normal, stable cervical spine alignment in flexion and extension, and degenerative changes at C5-6 and C6-7. 

During the MEB examination, physical findings showed decreased cervical ROM, without tenderness or muscle spasm.  At the MEB orthopedic consult, the CI reported neck pain that radiated to both arms, and that she could not lift anything more than 15 pounds without symptom exacerbation.  Wearing a Kevlar helmet increased her pain and caused neck and upper back spasms.  She was also unable to wear a protective vest, fire a weapon, or construct a fighting position.  Physical examination revealed no tenderness or bony abnormalities along the cervical spine, with full ROM and pain at extremes of motion.  Strength was 4/5 in the biceps, and with wrist flexion and grip.  Sensation was decreased to light touch over the left thumb in the C6 distribution, but otherwise intact.  Biceps and triceps reflexes were 2+ bilaterally and testing for myelopathy was negative.  The MEB NARSUM examination noted complaints of continued neck stiffness and pain, which traveled into the arms and hands.  Physical findings from the MEB orthopedic examination were referenced.  Goniometric ROM measurements by PT on 28 August 2006, showed cervical spine flexion to 40 degrees (normal 45), and combined ROM of 225 degrees (normal 340), with pain present in all planes.  

At the C&P examination, the CI reported constant neck pain which traveled to her hands and was exacerbated by physical activity and stress, and alleviated by rest and medication.  The neck pain did not cause any incapacitation, but restricted her from running, martial arts or high impact sports.  The examiner documented normal posture and gait, but noted use of a cane for ambulation.  There was no evidence of radiating pain on movement, muscle spasm, or tenderness. Measured ROM was painful and showed flexion to 40 degrees and combined ROM of 270 degrees.  After repetition, pain limited extension by an additional 15 degrees for a combined ROM of 255 degrees.  Joint function was further limited by fatigue, weakness and lack of endurance.   

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 0%, analogously coded 5299-5237 (cervical spine strain), citing “no loss of motion.”  The VA rated the neck condition 10%, coded 5243 (IVDS), based on the C&P examination, citing cervical spine flexion greater than 30 degrees but not greater than 40 degrees.  Panel members agreed that a 10% rating, but no higher, was justified for limitation of flexion and/or combined ROM greater than 170 degrees but not greater than 335 degrees, as reported on both the MEB 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 evidence of IVDS which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of a rating under that alternate formula.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the cervical spine condition, coded5243.  

Contended PEB Conditions:  Bilateral Shoulder DJD, Bilateral Retropatellar Pain Syndrome, Chronic Migraine, Depressive Disorder, Not Otherwise Specified (NOS), and Tinnitus.  The panel’s main charge is to assess the fairness of the PEB determinations that the contended conditions were not unfitting.  The contended conditions were not profiled or implicated in the commander’s statement, and 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 determinations for any of the contended conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  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 cervical spine condition, the panel recommends a disability rating of 10%, coded 5299-5237 IAW VASRD §4.71a.  In the matter of the contended shoulder and knee conditions, migraines, depressive disorder and tinnitus, the panel recommends no change from the PEB determination as not unfitting.  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, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Low Back Pain	5299-5237	10%	
Chronic Neck Pain	5299-5237	10%	
COMBINED	20%	

The following documentary evidence was considered:

AR20200004671

Dear XXXXXXXXXXXXXXXXXXXXXX:

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.