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AF | PDBR | CY2013 | PD-2013-02501

Original file (PD-2013-02501.rtf) Auto-classification: Denied

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX CASE: PD-2013-02501
BRANCH OF SERVICE: Army BOARD DATE: 20140807

SEPARATION DATE: 20051101

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (91G/Patient Administration Specialist) medically separated for chronic neck pain. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards. He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB). The MEB referred “C2 odontoid fracture, type II” to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB adjudicated “chronic subjective neck pain, due to C2 odontoid fracture…without neurologic abnormality or limitation of motion” as unfitting, rated 10%. The CI appealed to the Formal PEB (FPEB), which affirmed the PEB finding and rating. The CI made no further appeals and was medically separated.

CI CONTENTION: “I feel with the problem I’m having, my rating should have been more.”

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 condition is addressed below; 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.

RATING COMPARISON :

Service FPEB – Dated 20050831	VA - (~3 Mos. Post-Separation)
Condition	Code	Rating	Condition	Code	Rating	Exam
Chronic Subjective Neck Pain…without Neurologic Abnormality	5235	10%	Residuals, Odontoid Cervical Spine Fracture	5235	20%	20060118 20060208
Other x 0 (Not in Scope)	Other x 7	20060118 20060208
Combined: 10%	Combined: 40%

* Derived from VA Rating Decision (VA RD ) dated 200 60418 (most proximate to date of separation ( DOS ) )

ANALYSIS SUMMARY: The Board acknowledges the CI’s contention that suggests a higher rating should have been granted at the time of separation. 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 the VA Schedule for Rating Disabilities (VASRD) standards, based on ratable severity at the time of separation; and, to review those fitness determinations within its scope (as elaborated above) consistent with performance-based criteria in evidence at separation.

Chronic Neck Pain Condition. The CI sustained a fracture of the second cervical vertebra (C2) in a motor vehicle accident in August 2004. The fracture site was successfully surgically stabilized with screw fixation. Subsequent radiographic imaging showed a stable fibrous union of the surgical screw, but there was persistence of the fracture line due to the lack of significant formation of bony callous (new bone growth). Further surgical options were discussed, but risks were deemed unacceptable. At multiple follow-up neurosurgical evaluations through June 2005, the CI denied neck pain. At the MEB separation exam on 13 June 2005 (5 months prior to separation), the CI reported intermittent pain. The physical exam noted painful extension and rotation of the neck, but there was no tenderness. At the narrative summary (NARSUM) evaluation on 29 June 2005 (4 months prior to separation) the CI denied having neck pain or any neurologic symptoms. Physical examination noted full, but unmeasured, range-of-motion (ROM) and no neck tenderness. Although neck motion was described as being “without any limitations,” the exam was silent regarding painful motion.

The VA Compensation and Pension (C&P) exam upon which the VARD was based was performed 3 months after separation and was not in evidence. According to the VARD, the CI complained of chronic, constant sharp pain in the cervical spine area. The report was silent regarding a history of intercurrent injury since the time of separation. Turning his head reportedly caused flare-ups; and he was instructed by his physician to limit weight lifting, running, standing for more than 10-15 minutes, and driving. He did not use any assistive devices. The cited examination findings included paracervical guarding and cervical spine tenderness. Rotation was reportedly not attempted because of pain. There was no mention of the presence or absence of muscle spasm or of normal or abnormal spinal contour; no mention of gait abnormalities; and no report of the examiner’s observations of neck motions during the entirety of the clinical encounter, aside from the formal measurements recorded in the table below.

The goniometric 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)	PT ~3 Mos. Pre-Sep	VA C&P ~3 Mos. Post-Sep (from VARD)
Flex (45 Normal)	45 (45,47,45)	35
Extension (45)	40 (35,37,40)	35
R Lat Flexion (45)	40 (35,38,40)	10
L Lat Flexion (45)	35 (32,33,34)	20
R Rotation (80)	35 (33,36,37)	0
L Rotation (80)	30 (30,31,33)	0
Combined (340)	225	100
Comment	“ROM limited by pain”	+T enderness, painful motion, guarding
§4.71a Rating	10 %	20%

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 10% rating under the code 5235 (vertebral fracture or dislocation), while the VA rated the condition at 20% using the same code. Board members agreed that the PEB’s 10% rating was appropriate given the limitation of combined motion on the physical therapy (PT) exam (combined ROM greater than 170 degrees but not greater than 335 degrees); and that the VA’s 20% rating was correct, also based on combined ROM as reported by the VA rater. The probative value of these evaluations was deliberated and the entire file carefully reviewed for corroborating evidence from the period preceding separation. Board members considered that the information derived from the C&P exam lacked important details. For example, there was no history reported of intercurrent re-injury or exacerbation that would explain the complaint of “chronic, constant pain” and an exam finding of no rotational ability, in the context of recent service exams reporting “no pain” or “intermittent pain” and a clear ability on examination to perform rotation. Furthermore, dramatically reduced rotation as reported from the C&P exam would likely be due to muscle spasm, yet there was no mention of spasm or of spinal contour abnormalities as a consequence of spasm. The Board concluded that the PT ROM data was more consistent with the diagnostic and clinical pathology in evidence and was concordant with the NARSUM exam and multiple neurosurgical evaluations prior to separation; and thus was assigned preponderant probative value. It was agreed that the combined ROM data from the MEB PT exam justifies a 10% rating, and that there was no route to 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 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. In the matter of the chronic subjective 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 re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131023, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXXXX
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 , AR20150007068 (PD201302501)

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

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AF | PDBR | CY2013 | PD-2013-02501

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