RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2013-02010
BRANCH OF SERVICE:  Army	BOARD DATE:  20140523
SEPARATION DATE:  20051205

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (88M/Motor Transport Specialist) medically separated for chronic neck and upper back pain.  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The chronic neck and upper back pain conditions characterized as “medically unacceptable,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded three other conditions.  The Informal PEB adjudicated “chronic neck and upper back pain” as unfitting, rated 10% with likely application of the VA Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting. The CI made no appeals and was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in his application.

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 chronic neck and upper back pain conditions are addressed below and, no additional conditions are within the DoDI 6040.44 defined purview 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.

IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on ratable severity at the time of separation.

RATING COMPARISON:

Service IPEB – Dated 20051026	VA* - (12 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck and Upper Back Pain	5237	10%	Chronic Cervical Spine Strain	5237	0%	20060607	
Other x 0 (Not in Scope)	Other x 4	20060607	
Combined:  10%	Combined:  0%	
* Derived from VA Rating Decision (VARD) dated 20061011 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Chronic Neck and Upper Back Pain Condition.  A service treatment record (STR) entry reflected the CI was previously undergoing physical therapy (PT) for a gradual onset of trigger point neck and upper back pain for the previous 4 months.  His pain was “constant” and aggravated with sitting greater than 2 minutes and running.  He did not endorse upper extremity numbness, tingling, or weakness associated with his painful symptoms.  Neurophysiologic testing of the cervical spine and upper extremities were normal.  There was mild degenerative arthritis in the cervical spine.  Despite pain management therapy, PT, local injections and high level pain medication, his symptoms persisted throughout the balance of his service.  A permanent profile was issued in September 2005.  There were no periods of incapacitation.

The MEB narrative summary examination on 23 September 2005 (2.5 months prior to separation), noted an endorsement of “occasional numbness and a shooting type sensation down the left arm.”  The physical exam revealed tenderness and “tight muscles” to the upper back without painful motion.  Upper extremity sensory, motor, and strength findings were normal.  PT measured range-of-motion (ROM) revealed both the cervical spine and trunk (thoracolumbar) were normal with “tight muscle” noted on upper back muscles.  His diagnosis was chronic neck and upper back pain secondary to trigger points and degenerative arthritis in the cervical spine.

The VA Compensation and Pension exam was performed on 7 June 2006 (6 months after separation) and the source document was absent from evidence.  The VARD’s summary of that exam subjectively described a “cramping and knotting” left-sided neck pain extending into his upper back.  His physical exam revealed full non-painful cervical ROM, unchanged by repetition.  There was no gross deformity or ankylosis and no spasms or weakness palpated.  Tenderness was present from left-sided neck into the left upper back.  There were no incapacitating episodes over the previous 12 months.  Although the VA concluded that the CI’s condition was service-connected, it was non-compensable in regards to disability impairment as the Veteran had full ROM without pain.  While acknowledging some physical duty limitations, the commander’s letter was very positive in regards to the CI’s professional soldiering skills and therefore, recommended to “…do what we can for this soldier and try to work within our needs of the Army to find the best feasible option.”

The Board directs attention to its rating recommendation based on the above evidence.  Although the service and VA titled the unfitting spine condition differently, they both utilized the same code of 5237 (cervical strain) at 10% and 0%, respectively; PEB citing degenerative changes and VA citing full and non-painful ROM.  Although not specifically listed as “spasm,” the MEB and its associated PT evaluation cited “muscle tightness” in the upper back and low neck…indicative of spasticity (feelings of stiffness and a wide range of involuntary muscle spasms).  All STR encounters that presented a physical examination proximate to separation met the 10% rating criteria for localized tenderness or spasm not resulting in abnormal spinal contour.  Board members agreed that there are no available alternative or analogous coding options, which were applicable and or advantageous to the CI’s current 10% rating in accordance with the general rating formula for diseases and injuries of the spine.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB’s adjudication for the chronic neck and upper back pain 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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the chronic neck and upper back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131022, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		
XXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAMR-RB							

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXX, AR20150001818 (PD201302010)

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 and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     XXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA