RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXX CASE: PD1200767 BRANCH OF SERVICE: ARMY BOARD DATE: 20130423 SEPARATION DATE: 20030123 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an Army National Guard SGT/E-5 (91B/Combat Medic) medically separated for neck and shoulder pain which started while doing sit-ups. Despite conservative treatment, the pain condition could not be adequately rehabilitated to meet the requirements of her Military Occupational Specialty or physical fitness standards. She was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB), which forwarded the following three diagnoses to the Physical Evaluation Board (PEB): (1) degenerative cervical spondylosis, (2) undifferentiated somatoform disorder, and (3) somatic manifestations of depression. The Physical Evaluation Board (PEB) adjudicated “neck and shoulder pain with degenerative cervical spondylosis” as unfitting and rated 0% IAW the US Army Physical Disability Agency (USAPDA) pain policy. The remaining conditions were determined to be not unfitting. The CI made no appeals and she was medically separated with a 0% disability rating. CI CONTENTION: “Persistent lower back pain/while sitting, walking, turning and laying. Increase[d] weakness in left leg. Early morning stiffness/aching in right arm. Severe pain in both knees.” SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The rating for the unfitting neck and shoulder pain is addressed below. All other conditions contended by the CI (low back pain [LBP], left leg weakness, right arm stiffness/aching, and bilateral knee pain) are not in the scope of the Board. Any conditions or contention not requested in this application or otherwise outside the Board’s defined scope of review remain eligible for future consideration by the Board for Correction of Military Records. RATING COMPARISON: Service PEB – Dated 20011220 VA – (11 Mos. Pre-Separation) Condition Code Rating Condition Code Rating Exam Neck and Shoulder Pain with Degenerative Cervical Spondylosis 5099-5003 0% Degenerative Disk Disease/ Cervical Spondylosis 5010- 5290 10% 20020228 Undifferentiated Somatoform Disorder Not Unfitting No VA entry 20020228 Somatic Manifestations of Depression Not Unfitting Headaches 8100 NSC 20020228 Memory Loss 8999 NSC 20020228 No Additional MEB/PEB Entries Other x 4 Combined: 0% Combined: 10% Derived from VA Rating Decision (VARD) dated 20020415. ANALYSIS SUMMARY: The Board’s authority as defined in DoDI 6040.44, resides in evaluating the fairness of Disability Evaluation System (DES) fitness determinations and rating decisions for disability at the time of separation. The Board utilizes service and VA evidence proximal to separation in arriving at its recommendations and DoDI 6040.44 defines a 12-month interval for special consideration of post-separation evidence. Post-separation evidence is probative only to the extent that it reasonably reflects the disability and fitness implications at the time of separation. Neck and Shoulder Pain with Degenerative Cervical Spondylosis. The goniometric range-of- motion (ROM) evaluations in evidence, which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below. Cervical ROM (Degrees) MEB ~16 Mo. Pre-Sep VA C&P ~11 Mo. Pre-Sep Flex (45 Normal) Not Measured 45 (55) Extension (45) 45 R Lat Bending (45) 25 L Lat bending (45) 20 R Rotation (80) 60 L Rotation (80) 55 Combined (340) -- 250 Comment Pain in neck and arm with ROM and reflex testing; tenderness over cervical spine, throughout trapezius, and extending into the deltoid; spasm in trapezius muscle; positive Spurling’s sign with pain radiating to her right shoulder upon cervical extension and rotation; negative compression test; motor 5/5 bilaterally; sensory normal bilaterally; reflexes 2+ and symmetric Increased cervical lordosis and thoracic kyphosis; midline and paraspinous muscle tenderness; no spasm neuro exam normal in bilateral upper extremities §4.71a Rating 5290 10% 10% 5293 20% 10% The CI first reported symptoms of neck pain after a motor vehicle accident (MVA) while on active duty in the Army in 1983, when she was found to have trapezius muscle spasm. When she was a civilian in 1988, she was again evaluated for neck pain and LBP. At that time, neck X- rays noted “straightened cervical lordosis” and lumbar X-rays noted “mild DJD.” A Line of Duty (LOD) investigation documents that the CI was a Texas Army National Guard soldier, who experienced the onset of neck pain and back pain while doing sit-ups during an Army Physical Fitness Test (APFT) on 21 August 1999. Clinic notes document trapezius muscle trigger point tenderness. The shoulder examinations were always normal, and the shoulder pain was attributed to radiation of pain from the trapezius muscles. Prior to the MEB, no specific ROM measurements were documented, but decreased cervical flexion and extension were noted, due to tender trigger points in the upper lateral left neck and left upper trapezius. Outpatient orthopedic notes from March and April 2000 note continued neck pain and right upper extremity radicular symptoms. The MEB narrative summary (NARSUM) completed approximately 16 months prior to separation noted that, although she mentioned a MVA in 1982, the CI denied “specific injuries or trauma,” adding that her pain has been present for “2-3 years off and on.” At the MEB exam, the CI reported neck pain radiating into her head, into her right shoulder, and down her back. It was aggravated by movement, lifting heavy objects, or wearing Kevlar. She also reported right hand paresthesias and tingling, and the pain woke her up at night. The pain did not moderate with conservative therapy and was present approximately 50% of the time. The NARSUM recorded her pain as “slight and occasional.” The NARSUM also documented cervical spine X-ray findings of osteophyte formation and disc space narrowing at C5 through C7 levels with intact alignment consistent with degenerative changes and spondylosis. A cervical magnetic resonance imaging (MRI) demonstrated degenerative spondylosis, worse at C5-6 and C6-7, with significant neuroforaminal narrowing on the right at C5-6 and C6-7 and with left paracentral disc, osteophyte complex, and indention of the cord at C5-6. The physical examination findings are noted in the chart above. At the VA Compensation and Pension (C&P) exam approximately 11 months prior to separation, the CI reported neck pain upon arising in the morning, improving with motion but worsening with rest and head turning. The VA examination reported that she described occasional “right greater than left upper extremity radicular symptoms.” No objective evidence of upper extremity radiculopathy was noted. The VA examiner added that the “shoulder pain” was actually not in the shoulder joint itself, but was a combination of cervical radicular and myofascial symptoms. At the time of the VA examination, the CI had not yet separated from the Army National Guard pending a medical separation and was working as a substitute teacher and as a telemarketer. The physical examination findings are noted in the chart above. The 2002 Veterans Administration Schedule for Rating Disabilities (VASRD) coding and rating standards for the spine, which were in effect at the time of separation, were changed to the current §4.71a rating standards on 26 September 2003. The 2002 standards for rating based on ROM impairment were subject to the rater’s opinion regarding degree of severity, whereas the current standards specify rating thresholds in degrees of ROM impairment. When older cases have goniometric measurements in evidence, the Board reconciles (to the extent possible) its opinion regarding degree of severity for the older spine codes and ratings with the objective thresholds specified in the current VASRD §4.71a general rating formula for the spine. This promotes uniformity of its recommendations for different cases from the same period and more conformity across dates of separation, without sacrificing compliance with the DoDI 6040.44 requirement for rating IAW the VASRD in effect at the time of separation. Board precedent is that a functional impairment tied to fitness is required to support a recommendation for addition of a peripheral nerve rating at separation. Although upper extremity radicular symptoms were noted in the service treatment records and both the MEB NARSUM and C&P examinations, no abnormal neurologic findings were ever noted and there was no evidence of any functional impairment. Since no evidence of functional impairment exists in this case, the Board cannot support a recommendation for additional rating based on peripheral nerve impairment. The Board directs attention to its rating recommendation based on the above evidence. The PEB concluded that the degenerative cervical spondylosis, rated as “slight and occasional” was unfitting, and rated this condition, IAW the USAPDA pain policy, at 0% analogous to 5003. The VA rated the condition using code 5010 arthritis, due to trauma, substantiated by X-ray findings with 5290 spine, limitation of motion of at 10% based on the X-ray findings and slight decreased ROM of the cervical spine. Both the MEB NARSUM and the C&P examinations support a 10% disability rating with VASRD code 5290, the NARSUM exam for painful motion and the VA exam for slightly decreased ROM. The Board also considered VASRD code 5293 intervertebral disc syndrome. However, while both examinations noted radicular symptoms and the NARSUM exam noted frequency of the presence of pain, neither of the examinations noted the frequency or severity of intervertebral disc syndrome symptoms. The Board concluded there was not enough information available to determine an appropriate rating using 5293. After due deliberation, considering the totality of the evidence and mindful of VASRD §4.3 Reasonable doubt, the Board recommends a disability rating of 10% for the neck and shoulder pain with degenerative cervical spondylosis condition. BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. As discussed above, PEB reliance on the USAPDA pain policy was operant in this case and the condition was adjudicated independently of that policy by this Board. In the matter of the neck and shoulder pain with degenerative cervical spondylosis condition, the Board unanimously recommends a disability rating of 10%, coded 5290 IAW VASRD §4.71a. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation: UNFITTING CONDITION VASRD CODE RATING Neck and Shoulder Pain with Degenerative Cervical Spondylosis 5290 10% COMBINED 10% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120618, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxx, DAF Director of Operations Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxxx, AR20130009073 (PD201200767) 1. I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation to modify the individual’s disability rating to 10% without recharacterization of the individual’s separation. This decision is final. 2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum. 3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures. BY ORDER OF THE SECRETARY OF THE ARMY: Encl xxxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)