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AF | PDBR | CY2012 | PD2012 01732
Original file (PD2012 01732.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:   BRANCH OF SERVICE: Army
CASE NUMBER: PD1201732   SEPARATION DATE: 20060822
BOARD DATE: 20130730


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSG/E-6 (79S, Career Counselor) medically separated for cervical and lumbar spine conditions. He experienced an onset of radiating back pain in 1999, and similar cervical symptoms in 2005; both associated with degenerative spine and disc disease (non-surgical). The CI did not improve adequately with treatment to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards. He was issued a permanent P3/U3/L3 profile and referred for a Medical Evaluation Board (MEB). The spine conditions “cervical spondylosis” and “lumbar spondylosis,” along with associated diagnoses “myofascial pain” and “polyneuropathy,” were forwarded to the Physical Evaluation Board (PEB) as medically unacceptable IAW AR 40-501. The MEB also identified and forwarded a knee condition, “iliotibial band syndrome,” which was judged to meet retention standards. The PEB found the CI fit for duty and he appealed the decision. Upon Informal Reconsideration following the appeal, the PEB adjudicated the cervical spine (subsuming myofascial pain) and lumbar spine conditions as unfitting, rated 10% each, citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The polyneuropathy and knee conditions were determined to be not unfitting. The CI made no further appeals, and was medically separated with a combined 20% disability rating.


CI CONTENTION: “I believe the rating was too low, and judging by the VA findings, I should have had a higher rating.”


SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings for the unfitting cervical and lumbar spine conditions are addressed below. Since the PEB adjudicated polyneuropathy and iliotibial band syndrome were integral to the VA “findings” cited in the application, members agreed that those conditions were appropriately included in the Board's scope of review; and, are accordingly addressed below. 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 the Correction of Military Records.



RATING COMPARISON:

Service Recon PEB – Dated 20060614
 VA (1 Mo. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Cervical Spondylosis
 5299-5237 10% Cervical Disc Disease 5242 10% 20060728
Lumbar Spondylosis
 5299-5237 10% Lumbar Spondylosis 5242 20% 20060728
Polyneuropathy
 Not Unfitting Neuropathy, L Upper Extremity 8710 20% 20060728
Neuropathy, R Lower Extremity 8720 10% 20060728
Neuropathy, L Lower Extremity 8720 10% 20060728
Iliotibial Band Syndrome
 Not Unfitting Retropatellar Pain, R Knee 5024-5260 0% 20060728
Retropatellar Pain, R Knee 5024-5260 0% 20060728
No Additional MEB/PEB Entries
 0% X 9 / Not Service Connected x 2 20060728
Combined: 20%
 Combined: 60%
Derived from VA Rating Decision (VARD) dated 20061212 ( most proximate to date of separation [DOS]).


ANALYSIS SUMMARY: The goniometric range-of-motion (ROM) evaluations in evidence which the Board weighed in arriving at its rating recommendations for the cervical and lumbar spine conditions (discussions follow) are summarized in the chart below.

Cervical & Lumbar ROM
 MEB PT ~4 Mo. Pre-Sep VA C&P ~1 Mo. Pre-Sep
Cervical Lumbar Cervical Lumbar
Flexion (Normal: C 45⁰ / L 90⁰)
 50⁰ 90⁰ 35⁰ 60⁰
Combined (Normal: C 340⁰ / L 240⁰)
 290⁰ 240⁰ 245⁰ 160⁰
§4.71a Rating
 10% 10%* 10% 20%
* Conceding painful motion.
Cervical Spine Condition. The CI first complained of radiating neck pain in June 2005, attributing onset during an Iraq deployment (2003-04). This was associated with bilateral upper radicular symptoms (addressed below); and, magnetic resonance imaging (MRI) revealed spondylosis (degenerative facet disease) and C5/6 disc disease with left nerve root compression. He was treated conservatively with analgesics, physical therapy (PT), chiropractic care, and temporary profiles without success. In January 2006 a provisional diagnosis of recalcitrant myofascial pain was made and surgery was discussed, but deferred by the CI. With continued pain and intolerance of Kevlar, MEB referral was made. Multiple outpatient entries in the service treatment record (STR) document no or minimal, ROM impairment. The commander’s statement forthrightly opined that the impairment (encompassing all conditions) “does not interfere with his current duty performance,” and recommended retention on active duty. The narrative summary (NARSUM) characterized the pain only as “constant, minimal” and referred to profile restrictions (body armor, Kevlar, load bearing) as the only limitations. The physical exam documented “multiple areas of tenderness” and “no functional limitation” of ROM. Goniometric ROM measurements by PT are charted above. At the VA Compensation and Pension (C&P) evaluation (1 month before separation), the examiner noted neck pain radiating to both shoulders; exacerbated by turning, lifting, prolonged driving, and overhead activity. The VA physical exam did not comment on cervical spasm or tenderness; and recorded the ROM measurements charted above, annotating the absence of painful motion.

The Board directs attention to its rating recommendation based on the above evidence. The PEB's DA Form 199 referenced cervical ROM "limited by pain with localized tenderness" for its 10% rating under code 5299-5237 (analogously to cervical strain). The VA's 10% rating under code 5242 (degenerative arthritis of spine) cited loss of motion. The service and VA ROM evidence meet the 10% criteria of the VASRD §4.71a general rating formula for the spine, and there is no evidence of contour abnormality or other features which would achieve a higher rating. 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 cervical spondylosis condition.

Lumbar Spondylosis. The CI developed low back pain (LBP) after a motor vehicle accident in 1999. The STR documents periodic visits for back pain over the ensuing years, and the condition was subject to temporary profiles dating to 2000. Bilateral radicular symptoms were present (addressed below). Serial MRI results are in evidence with confirmation of spondylosis, diffuse degenerative changes, and minor disc bulges at L3/4 and L4/5 without neural encroachment. There were no surgical indications, and multiple conservative modalities were pursued with no lasting improvement. Multiple STR entries document normal gait and grossly normal ROM, with no STR entry to the contrary. The NARSUM description of pain and limitations was incorporated with those for the cervical spine as above. The physical exam was likewise equivalent, and documented a normal gait and posture. Goniometric ROM measurements by PT are charted above. The VA C&P before separation noted radiating pain exacerbated by prolonged sitting and driving; and documented the absence of “prostrating episodes.” The VA physical exam documented normal gait and posture, and the absence of spasm. VA ROM measurements are charted above, and specified the absence of painful motion.

The Board directs attention to its rating recommendation based on the above evidence. The PEB's DA Form 199 referenced "full ROM with localized tenderness" for its 10% rating under code 5299-5237 (analogous to lumbar strain). The VA's rating under code 5242 (degenerative arthritis of spine) cited flexion of 60⁰, which is the lower threshold for a 20% IAW the §4.71a spine formula. The disparity between the service and VA ROM evidence has obvious implications for the Board's rating recommendation. Members deliberated the probative value of these conflicting evaluations, and considered that: the MEB ROM measurements were corroborated by multiple gross observations in the STR over the year preceding separation; there was no documentation of interim injury or aggravation in explanation of the singular ROM limitations documented in the VA rating exam; and, the lack of spasm or painful motion as documented by the VA examiner was incongruent with the measured ROM limitations. Members concluded, therefore, that the single VA measurement of flexion to 60⁰ was not sufficiently probative to justify a 20% recommendation based on ROM criteria. There was no evidence of abnormal gait or contour, and no evidence for incapacitating episodes, that would otherwise achieve a rating higher than 20%. After due deliberation, considering all of the evidence with deference to reasonable doubt, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication of the lumbar spine condition.

Contended Polyneuropathy Condition. As noted above, both the cervical and lumbar spine conditions were associated with disc involvement and extremity neuropathies. Peripheral nerve conduction impairments were confirmed electrodiagnostically for the left upper and both lower extremities. Symptoms were confined to radicular pain and intermittent paresthesias, with no motor weakness or impairment of coordination. Multiple neurological examinations in the STR, the NARSUM, and the VA C&P examination documented normal strength, reflexes, and gross sensory findings. No references to specific MOS impediments from the neuropathies are found other than the CI’s statement in the MEB physical examination that “If I type too long, my arms go numb.” This is overshadowed significantly by the commander’s statement, however, as previously elaborated. The Board’s first charge with respect to the conditions is an assessment of the appropriateness of the PEB’s fitness adjudications. The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. Firm Board precedence requires a functional impairment linked to fitness to support a recommendation for addition of a peripheral nerve rating. The pain component of a radiculopathy is subsumed under the general spine rating as specified in §4.71a. The sensory component in this case has no functional implications, and no motor weakness was in evidence. There is thus no evidence of a separately ratable functional impairment (with fitness implications) from the radiculopathies. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the polyneuropathy condition.

Contended Illiotibial Band Syndrome. The CI had a history of bilateral knee pain that was diagnosed as iliotibial band syndrome in the NARSUM, but was not significantly documented in the STR. It was never profiled; was considered to meet retention standards; was not implicated by the commander; and, was not subject to compensable rating by the VA. There was no performance based evidence from the record that the condition significantly interfered with satisfactory duty performance; and all members agreed that there was insufficient cause to recommend a change in the PEB fitness determination for the iliotibial band syndrome.


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 cervical spine condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the lumbar spine condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the contended polyneuropathy and iliotibial band syndrome conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting. 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
Cervical Spondylosis with Myofascial Pain
 5299-5237 10%
Lumbar Spondylosis
5299-5237 10%
Polyneuropathy
 Not Unfitting
Illiotibial Band Syndrome
 Not Unfitting
COMBINED
 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120807, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record





 SFMR-RB                                                                         


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


 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for AR20130019545 (PD201201732)

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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