RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX		CASE: PD-2019-00228 BRANCH OF SERVICE: MARINE CORPS	SEPARATION DATE: 20040515

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

CI CONTENTION: Review requested of the neck condition as well as additional conditions not identified by the Medical Evaluation Board (MEB) and/or 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 – 20040317	VARD - 20040621	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain	5242	10%	Residual Cervical Spine Strain	
5237	
30%	
20040401	
C6-7 Segmental Dysfunction and Myofasciitis	Cat II					
Mild Cervical Spondylosis…Posterior Disc Bulge	Cat II					
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 70%	

ANALYSIS SUMMARY:

Chronic Neck Pain. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s neck pain began in early 2003 after a fall during boot camp training. An MRI on 24 September 2003 showed mild spondylosis from C3-C6 and posterior disc bulges at C4-C6 without cord involvement. Evaluation by neurosurgery on 23 October 2003 revealed moderate tenderness and mild spasms with cervical spine flexion to 45 degrees (normal), and conservative treatment was recommended instead of surgery. During the 12 November 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, there was mild tenderness along the C3-C5 spinous processes and paraspinal regions, but no visible deformity. At a physical therapy (PT) visit, 6 days, later, cervical spine motion was within normal limits. The 1 December 2003 MEB NARSUM examination noted CI complaints of continued symptoms, and physical examination showed mild tenderness over the C3-C5 paraspinal muscles and trapezius. Cervical spine flexion was to 20 degrees (normal 45) and combined ROM was 285 degrees (normal 340). Cervical spine ROM measurements performed by PT on 29 March 2004, 2

months before separation, showed flexion to 10 degrees and combined ROM of 225 degrees. The CI reported good results after initial PT, but had increased symptoms after undergoing PT by a different provider.

At the 1 April 2004 VA Compensation and Pension (C&P) examination, 2 months before separation, the CI reported constant pain, rated at 10/10, but denied any incapacitation. Physical findings showed normal posture and no muscle spasm or tenderness. Cervical spine flexion was to 10 degrees and combined ROM was 265 degrees, with painful motion. However, the examiner opined that “after having observed him functioning in the non-clinical situation his neck and back symptoms were GROSSLY over exaggerated.” Cervical spine X-rays were normal.

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), and listed “C6-C7 segmental dysfunction and myofasciitis” and “mild cervical spondylosis and posterior disc bulge” as Category II conditions contributing to the disability in this case. The panel concluded that these related diagnoses could not be reasonably justified as separately unfitting; nor would separate ratings be achievable without violation of VASRD §4.14 (avoidance of pyramiding). The VA rated the cervical spine condition 30%, coded 5237 (cervical spine strain), based on the C&P examination, citing flexion to 15 degrees or less. Panel members agreed that a 20% rating, but no higher, was justified for limitation of flexion as reported on the MEB NARSUM examination, which was corroborated by other pre-separation examinations and consistent with the diagnostic and clinical pathology in evidence. There was no documentation of intervertebral disc syndrome which resulted in incapacitating episodes requiring physician-prescribed bed to warrant consideration 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 20% for the cervical spine condition, coded 5242.

BOARD FINDINGS: In the matter of the cervical spine condition, the panel recommends a disability rating of 20%, coded 5242 IAW VASRD §4.71a. 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 Neck Pain	5242	20%	

2	PD-2019-00228

DEPARTMENT OF THE NAVY
SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309
WASHINGTON NAVY YARD, DC 20374-5023

IN REPLY REFER TO,
1850
CORB:003 12 Oct 20

From: To:

Subj:

Ref:

Director, Secretary of the Navy Council of Review Boards 

PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)
(a) DoDI 6040.44
(b)	PDBR ltr of 16 Jun 20
(b)	

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation to the Department of the Navy for appropriate action.

2.	On 7 October 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) took action in your case by accepting the recommendation of the PDBR. Accordingly, your records will be corrected to reflect an increase in the disability rating awarded by the Department of the Navy Physical Evaluation Board (PEB) from 10% to 20% without re-characterization of your discharge.

3.	For your information, since all disability ratings from 0% to 20% qualify for disability severance pay, the above stated increase will not result in your entitlement to additional compensation.

4.	The Assistant Secretary's determination, which represents final action in your case by the Department of the Navy, has been forwarded to the office of the Deputy Commandant, Manpower and Reserve Affairs, for appropriate changes to your personnel records and notification to you upon completion.