RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2021-00028
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030814

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve  E6, Radiology Specialist, medically separated for “chronic back pain…” and “chronic neck pain…,” rated 10% each, with a combined disability rating of 20%.   

CI CONTENTION:  All the MEB conditions should have been rated by the PEB as he was given a higher rating by the VA when the unfitting conditions were taken into account.    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 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 - 20030701	VARD - 20031120	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain…	5299-5295	10%	Lumbar Degenerative Disc Disease Status Post Fusion L4-5
and L5-S1	5243	10%	20031010	
Chronic Neck Pain…	5293
5099-5003	10%	Cervical Degenerative Disc Disease Status Post C5-6 and C6-7	5290	10%	20031010	
Right Shoulder Impingement	Not Unfitting	Right Shoulder Impingement	5299-5203	10%	20031010	
Mild Left Elbow Ulnar Neuropathy	Not Unfitting	Left Elbow Ulnar Neuropathy	8516	10%	20031010	
Adjustment Disorder with Depressed Mood 	Not Unfitting	Depressive Disorder	9434	30%	20031009	
Gastroesophageal Disease	Not Unfitting	Gastroesophageal Reflux Disease	7346	0%	20031010	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Back Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI underwent back surgery with fusion in November 2002 for degenerative disc disease (DDD).  

The 10 March 2003 MEB NARSUM examination, 5 months prior to separation, noted complaints of sleep disturbance and the inability to participate in fitness testing.  Physical examination showed range of motion (ROM) with flexion of 90 degrees (normal 90) and extension of 15 degrees (normal 30).  There were no other measurements recorded.  Tenderness was present.  

At the 10 October 2003 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported pain occurring 2 times per month with each time lasting for days. The pain was localized and aching in nature. From 1 to 10 (10 being worst pain) the pain level was at 4. He reported it did not cause incapacitation or loss of time from work.  Physical examination showed a normal gait.  (ROM) measurements showed flexion of 90 degrees (normal 90) and combined ROM of 240 degrees (normal 240).  ROM was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination. There was no ankylosis of the spine. There were no signs of intervertebral disc syndrome present.  There were no complaints of radiating pain on movement.  There was no muscle spasm or tenderness.  A straight leg raising test was negative.   

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, analogously coded as 5299-5295 (lumbosacral strain), citing pain on motion with no neurologic abnormality or muscle spasms.  The VA also rated the back condition 10%, coded 5243 (intervertebral disc syndrome), based on the C&P examination.

In accordance with DoDI 6040.44, the panel is required to recommend a rating IAW the VASRD in effect at the time of separation, and the CI separated prior to current 26 September 2003 VASRD spine rule amendments.  The panel agreed that a 10% rating, but no higher, was justified for characteristic pain on motion.  At the time of separation, the record demonstrated full flexion of the spine, therefore, a higher rating under the limitation of motion spine code 5292 was not warranted.  There were no additional codes that would provide for a higher rating.  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 pain condition.  

Chronic Neck Pain.  According to the STR and the MEB NARSUM, the CI underwent neck surgery with fusion and discectomy in March 2003 for herniation of the nucleus pulposus.  The 10 March 2003 MEB NARSUM examination, 5 months prior to separation, noted complaints of neck pain, sleep disturbance and the inability to participate in high impact activities.  Physical examination showed tenderness was present.  The recorded ROM was identical to the lumbar spine ROM.

At the 10 October 2003 VA C&P examination, 2 months after separation, the CI reported the condition did not cause incapacitation, and did not result in any time lost from work.  Physical examination showed no evidence of radiating pain on movement with no evidence of muscle spasm.  ROM showed flexion of 45 degrees (normal 45) and combined ROM of 240 degrees (normal 340) with painful motion.  There was no ankylosis of the spine. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 10%, coded 5293 and analogously coded 5099-5003 (intervertebral disc syndrome and degenerative arthritis respectively).  The VA also rated the neck condition 10%, coded 5290 (limitation of motion of cervical spine and intervertebral disc syndrome), based on the C&P examination.

In accordance with DoDI 6040.44, the panel is required to recommend a rating IAW the VASRD in effect at the time of separation, and the CI separated prior to current 26 September 2003 VASRD spine rule amendments.  The NARSUM documented tenderness, and the ROM did not appear to be correct since it was identical to the lumbar spine ROM.  Panel noted the VA also used the interim spine rules to provide its 10% rating based on limitation of motion, slight, coded 5292.  Panel members agreed, a 10% rating was also achievable under the 5292 code based on the C&P examination, most proximate to separation.  The panel concluded, at the time of separation, a rating higher than that granted by the PEB was not warranted under any applicable code.  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 pain condition.  

Contended PEB Conditions:  Right Shoulder Impingement; Mild Left Elbow Ulnar Neuropathy; Adjustment Disorder with Depressed Mood; and Gastroesophageal Disease.  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 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 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.  In the matter of the contended right shoulder impingement, mild left elbow ulnar neuropathy, adjustment disorder with depressed mood, and gastroesophageal disease 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.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20200507, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20210013423, XXXXXXXXXXXXXX

Dear XXXXXXXXXXX:

	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.

Sincerely,