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AF | PDBR | CY2012 | PD2012 01680
Original file (PD2012 01680.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: BRANCH OF SERVICE: Army
CASE NUMBER: PD1201680 SEPARATION DATE: 20030925
BOARD DATE: 20130305


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard SGT/E-5 (11B/Infantry), medically separated for chronic neck pain. The CI had a long standing history of neck pain related to a fall while on patrol in Kosovo in 1995. The symptoms worsened and failed to respond to conservative measures, and could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS). He was consequently issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded no other conditions for Physical Evaluation Board (PEB) adjudication. The PEB adjudicated the chronic neck pain as unfitting, rated 10%, citing USAPDA Pain Policy. The CI made no appeals, and was medically separated with a 10% disability rating.


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. Ratings for unfitting conditions will be reviewed in all cases. 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 Army Board for Correction of Military Records. Also 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 20030902
 VA - (*STR)
Condition
 Code Rating Condition Code Rating Exam
Chronic Neck Pain 5099-5003 10% DDD w/Disc Herniation; Cervical Spine 5295 *20% STR
No Additional MEB/PEB Entries
 Other x 2
Combined: 10%
 Combined: 20%
VARD 20031008 most proximate to Date of Separation *STR used for RD **Failed to Report for C&P 20040102


ANALYSIS SUMMARY:

Neck Condition. The CI’s history of chronic neck pain dates back to 1995. Since that time he reported stiffness, popping and headaches and numbness in right arm after activity. He was treated conservatively with unsustained improvement. Magnetic resonance imaging (MRI) dated May 2002, revealed multi-level degenerative disk disease (DDD) and disk protrusion. In July 2002, a clinic examination revealed neck with full range-of-motion (ROM), nontender to palpation, with normal motor and reflexes. 5 June 2003, 3 months prior to separation, orthopedic examination revealed steady gait, intact heel toe walk, normal motor exam and reflexes. ROM testing noted limited cervical flexion and lateral bend with normal rotation. There were no spasms or neurological deficits noted. At the MEB/narrative summary (NARSUM) evaluation, 13 June 2003, performed approximately 3 months prior to separation, the CI reported pain on motion of his neck without numbness or tingling. He stated the pain radiated into the right shoulder. On physical examination, gait was noted to be steady, and he could heel toe walk without difficulty. Sensation was intact in all extremities and motor strength was normal; reflexes were symmetrical. There was slight tenderness in neck muscles but no spasms. Cervical flexion was noted to be limited (unable to touch chin to chest,), moderate limitation of extension-lateral bend and rotation within normal limit. An addendum with recording of ROM dated 7 August 2003, 2 months prior to separation recorded flexion of “5 cm. to the sternum”, extension of 40, lateral bending to the right at 35 and left 30, rotation of 60 degrees to both sides. Neurovascular exam was noted to be intact. At the Compensation and Pension (C&P) examination, 28 December, 2004, 15 months after separation, the CI reported numbness and tingling of the upper extremities. Physical examination revealed normal strength and reflexes, decreased sensation from the shoulder to the tip of finger and ROM of 40 degree flexion, 50 on extension, and bilateral bending to 30 with bilateral rotation of 60. Pain was recorded throughout ROM testing. The examiner noted electromyogram (EMG) with nerve conduction recorded no evidence of acute radiculopathy, an examination not contained in the record in evidence. The Board directs attention to its rating recommendation based on the above evidence. 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 PEB rated the condition under the degenerative arthritis code of 5003 at 10% and applied the pain policy. The VA rated the condition VASRD 8 October 2003 using the NARSUM examination of August 2003, at 20% under the new spine rules code 5242 citing a combined ROM of 170 degrees. Sometime thereafter this coding was hand-corrected on the VARD to code 5295, an intermediate spine rules without rating change. The Board noted the close proximity of the CI’s separation date (one day) to implementation of the new, quantitative spine rules but agreed that application of the old spine rules IAW DoDI 6044.44 was required. The Board noted the NARSUM examination to record flexion of the cervical spine to within two inches of the sternum. The Board unanimously opined that this represented flexion of 35 to 40 degrees. The Board noted the report of flexion of 25 degrees on physical therapy examination of November 2002 but agreed this to be inconsistent with report of full ROM 4 months prior and findings of flexion of 44 and 48 degrees reported 2 weeks prior. The Board unanimously agreed the reduction of flexion was slight. There was no evidence of ratable peripheral nerve impairment in this case, since no motor weakness was present and sensory symptoms had no functional implication. There was no evidence of incapacitating episodes for a higher rating under 5243. Given the record of evidence the Board could not find other applicable VARSD codes for consideration. 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 adjudication for the chronic neck 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. As discussed above, PEB reliance on the USAPDA pain policy DoDI 1332.39 for rating the chronic neck pain was operant in this case and the condition was adjudicated independently of that policy/instruction by the Board. In the matter of the chronic neck 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, as follows:

UNFITTING CONDITION
 VASRD CODE RATING
Chronic Neck Pain 5099-5003 10%
COMBINED
 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120924, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




                 
                  Physical Disability Board of Review


 SFMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(TAPD-ZB),

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for AR20130007721 (PD201201680)

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                                                 
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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