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AF | PDBR | CY2013 | PD-2013-02693
Original file (PD-2013-02693.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD - 20 13 - 0 2693
BRANCH OF SERVICE: Army   BOARD DATE: 201 5 0513
Separation Date: 20060915


SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) was an Active Guard Reserve W-1 (Military Personnel Tech nician ) medically separated for chronic neck pain. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent U3L3S2 profile and referred for a Medical Evaluation Board (MEB). The “cervical spondylosis C3-4 and C5-6” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded one additional condition as medically unacceptable (bilateral plantar fasciitis ) and five other medically acceptable conditions (sleep apnea, posttraumatic stress disorder (PTSD), vertigo, tinea versicolor , and bilateral knee pain) for PEB adjudication. The I nformal PEB adjudicated “chronic neck pain secondary to hypertrophic degenerative changes” as unfitting, rated 10%. The remaining bilateral plantar fasciitis condition was determined to be not separately unfitting. The other five conditions were determined to be not unfitting and therefore not ratable. The CI made no appeals and was medically separated.


CI CONTENTION : His PTSD and bilateral feet conditions, along with other conditions rated by the VA, continued to worsen and/or received higher ratings from the VA. His complete submission is at Exhibit A.


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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting. Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records. Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate. The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions. That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws. The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.








RATING COMPARISON :
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Service IPEB – Dated 20060825
 VA – 3 Mos. Pre -Separation
Condition
 Code Rating Condition Code Rating Exam
Chronic Neck Pain 5299-5242 10% Degenerative Joint Disease (DJD) – Cervical Spine 5299-5242 30% 20060621
Bilateral Plantar Fasciitis Not Separately Unfit Bilateral Plantar Fasciitis with Pes Planus 5299-5276 0% 20060621
Sleep Apnea Not Unfitting Sleep Apnea with History (Hx) Sinusitis 6847 50% 20060621
PTSD Not Unfitting PTSD 9411 30% 20060621
Vertigo Not Unfitting Idiopathic Vertigo 6299-6204 30% 20060621
Tinea Versicolor Not Unfitting Tinea Versicolor 7899-7806 0% 20060621
Bilateral Knee Pain Not Unfitting Stress Induced Reaction, Left Knee 5099-5010 10% 20060621
Stress Induced Reaction, Right Knee 5099-5010 10% 20060621
Other x 0
 Other x 3
Rating: 10%
 Combined: 90%
Derived from VA Rating Decision (VARD) dated 20070316 (most proximate to date of separation [DOS]) .


ANALYSIS SUMMARY :

Chronic Neck Pain . The CI developed neck pain in 2000 and was told there was no thing wrong. A cervical spine X -ray showed a proximate unciate process (bony prominence) of C4, C5 and C6 with minimal encroachment of the neural foramina (the openings that the nerve roots pass through) of C4-5 and C5-6 on the right side. A cervical spine magnetic resonance image ( MRI ) in November showed degenerative spondylosis and disc disease at C3-4 and C4-5. A repeat cervical spine MRI showe d the same find ings as the November MRI. The o rthopedist noted a 4- year history of neck pain mostly in the lower neck. The c hiropractor noted that constant sharp neck pain was greater on the right than the left and radiated to the right shoulder. The pain was present on a daily basis, increased throughout the day and was aggravated by sit-ups and push-ups. There were physical exam findings of pain with all range - of - motion (ROM) evaluations , with pain localized at the right mid - cervical level and paravertebral muscle hyper- tonicity bilaterally about the lower cervical and upper thoracic paraspinal muscles. The CI followed with the c hiropractor and o rthopedics from 2005 and throughout 2006. The physical medicine and rehabilitation (PM&R) examiner noted a 3 - year history of chronic radicular neck pain with physical exam findings of tenderness to palpation ( TTP ) and painful motion. The CI was evaluated by physical therapy (PT) with physical exam findings of TTP in the bilateral upper trapezius muscles and with the right anterior cervical spine more tender than the left side and 25% limited in ROM. A cervical spine CT (computed tomography) scan was done for a neck mass but not to evaluate the discs. A cervical spine MRI showed degenerative hypertrophic joint changes at multiple levels, worse at C3-4 with narrowing of the central canal at this level. The PM&R examiner noted that the CI underwent an electromyogram (EMG) which was normal . The CI reported that he had lightheadedness, dizziness, numbness , and tingling. There were physical exam findings of tenderness, and pain on motion.

The commander’s statement documented that the CI was unable to carry a ruck sack, unable to take his fitness test, unable to wear individual body arm or or Kevlar, unable to do any lifting or combatives , and unable to stand for periods longer than 10 minutes. He further stated that the CI’s physical impairments prevented him from completing his MOS duties. The n eurosurgeon noted that the CI’s symptom of neck pain w as p resent all of the time. There were physical exam findings of restricted, painful neck movements ; however , motor and sensory were intact. The MEB narrative summary (NARSUM) exam approximately 3 months prior to separation documented that the CI had daily neck pain and an inability to fully raise his neck without discomfort which limited him in doing his day - to - day job. He used a TENs unit (transcutaneous electrical nerve stimulation) at home which helped in the acute setting but did not change his overall symptoms. The examiner rated the pain according to the American Medical Association (AMA) pain scale at moderate and daily. The MEB NARSUM physical exam findings are summarized in the chart below.

The VA Compensation and Pension (C&P) exam approximately 3 months prior to separation documented that the CI had daily neck pain and numbness which was aggravated by exercise, prolonged standing, prolonged sitting, running, and changes in weather. The VA C&P physical exam findings are summarized in the chart below along with the PT exam approximately 2 months prior to separation which provided ROM measurements for the MEB. I n arriving at its rating recommendation , the Board weighed th e ROM evaluations in evidence, with documentation of additional ratable criteria , as summarized in the chart below.
Cervical ROM (Degrees) PT 2 Mos. Pre-Sep MEB 3 Mos. Pre-Sep VA C&P 3 Mos. Pre-Sep
Flex (45 Normal) 15 No ROM s 45
Combined (340) 155 270
Comment Pos. painful motion Pos. TTP & painful motion No tenderness or spasm; Normal reflexes & strength
§4.71a Rating 30% (PEB 10%) 10% 10% (VA 30%)
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The Board direct ed attenti on to its rating recommendation based on the above evidence . The PEB coded the chronic neck pain condition as 5299 analogous to 5242 (d egenerative arthritis of the spine ) and rated at 10%. The VA coded the cervical spine DJD condition as 5299 analogous to 5242 and rated at 30% citing a cervical spine forward flexion of “10 degrees.” The Board reviewed the C&P exam and all data present for review and members agree d that the 10 degree s forward flexion ROM measurement was one of three ROM measurements on the PT exam 2 months prior to separation. T he Board reviewed the entire combined file for evidence that would support either the 45 - degree ROM measurement contained in the C&P exam or the 15 - degree measurement documented in the PT exam a month earlie r , as b oth exams were before separation. After review of the service treatment record within 6 months of separation, the Board identified six service treatment entries that documented, normal, full , or “less limited” cervical spine motion. Board members agree d that the C&P ROM measurement of 45 degrees most closely represented the CI’s cervical spine ROM at the time of separation. As noted above, the C&P exam contained a forward flexion of 45 degrees which is consistent with a 10% rating. After due deliberation , and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic neck pain condition.

Contended PEB Conditions. The contended conditions adjudicated as not unfitting by the PEB were sleep apnea, PTSD, bilateral plantar fasciitis, vertigo, bilateral knee pain , and tinea versicolor . The Board’s first charge with respect to these 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 and requires a preponderance of the evidence.

The vertigo, bilateral knee pain and tinea versicolor conditions were not profiled, nor were they implicated by t he commander’s statement. These conditions were not judged to fail retention standards. These conditions were reviewed and considered by the Board. There was no indication from the record that any of these conditions significantly interfered with satisfactory duty performance.

The sleep apnea, PTSD and bilateral plantar fasciitis conditions were profiled upon entry into the disability evaluation system. The sleep apnea condition was diagnosed in 2005 after the CI underwent a polyso m nogram on 31  O ctober 2005. The examiner diagnosed mild to moderate obstructive sleep apnea, fragmented sleep architecture and possible limb movement disorder . The examiner recommended CPAP (continuous positive airway pressure) titration. The CI underwent a second polyso m nogram on 3 November and the examiner diagnosed mild sleep apnea fairly well corrected with CPAP of 13cm water, heated humidity and mask of choice. Although the CI was profiled for a sleep apnea condition, there were no special additional restrictions related to use of a CPAP machine. The commander’s statement made no mention that the sleep apnea interfered with the CI performing h is MOS duties . The MEB examiner mentioned that the sleep apnea condition was controlled with use of a CPAP machine. There was no mention of fatigue or daytime somnolence. The VA C&P examiner noted sleepiness and fatigue which occurred daily ; however , there were no limitations noted.

The CI was first treated by p odiatry in 1999 for right foot plantar fasciitis and pes planus. The examiner ordered custom shoe inserts. In 2005 , the primary c are provider documented physical exam findings of TTP at the plantar medial arch and mild discoloration. The examiner advised night splints, ice, massage and a 30- day profile. The MEB NARSUM examiner documented that the CI had a history of plantar fasciitis for 3 years that “prevents him from ruck marching, running or conducting physical training with his soldiers. He has undergone podiatry evaluations without improvement.” There were physical exam findings of moderate pes planus with positive TTP on the plantar surface. The CI was able to toe walk with pain but unable to heel walk due to discomfort. The examiner rated the pain according to the AMA pain scale at slight and frequent. The MEB examiner diagnosed “bilateral plantar fasciitis, which interferes with his ability to run and ruck and is medically unacceptable in accordance with Army Regulation 40-501.” The commander’s statement documented that the CI was unable to stand for periods longer than 10 minutes. On 16 June 2006, t he VA C&P examiner documented daily bilateral foot pain aggravated by running as well as prolonged standing and sitting. The Board noted that the PEB p roceedings document contained the following statement:

“ Plantar Fasciitis is not separately unfitting. It is long-standing and has not interfered with the performance of his duties.”

 The available treatment record documented an initial psy chiatric assessment in June 2006 where the CI received th e diagnosis of PTSD. He had two additional visits prior to the psychiatric NARSUM . The post-d eployment h ealth a ssessment (PDHA) screen , dated 3 January 2005 , recorded the CI’s denial of witnessing anyone wounded, killed or dead during the deployment . He also noted that he had not engaged in direct combat whe n he discharged his weapon, and he responded “No” to having felt that his life was in danger or had fear of being killed. The CI responded “No ” to all symptoms su ggestive of PTSD or depression. The CI underwent a MEB exam for the PTSD condition on 22 August 2006 which was 25 days prior to separation . The examiner documented that there was no evidence of psychotic symptoms to include hallucinations or delusions. The CI did not express suicidal or homicidal ideations, nor was there any emergency room visit for psychiatric care or psychiatric hospitalization . He had brief trials of medication to treat insomnia and anxiety. Although the CI reported that he had some significant intrusive experiences, the examiner concluded that these stress symptoms needed to be understood in the context of the tendency to mildly over - endorse atypical symptoms. The mental status exam was normal. The examiner diagnosed a mild impairment for military duty and social and industrial adaptability. There was no Axis I diagnosis rendered. The Global Assessment of Functioning was 70 (s ome difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships ) . The commander’s statement made no mention that the PTSD interfered with the CI performing h is MOS duties . Although the CI was profiled for the PTSD condition, it was an “S2” profile and there were no special additional restrictions related to the PTSD condition.
After due deliberation , and 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 PTSD, sleep apnea, bilateral plantar fasciitis, vertigo, bilateral knee pain , and tinea versicolor conditions; and, therefore, no additional disability ratings can be recommended.


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 pain , the Board unanimously recommends no change in the PEB adjudication for the chronic neck pain condition. In the matter of the contended sleep apnea, PTSD, bilateral plantar fasciitis, vertigo, bilateral knee pain , and tinea versicolor 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 re-characterization of the CI’s disability and separation determination.


The following documentary evidence was considered:
Exhibit A. DD Form 294, dated 20 131218 , w/atchs
Exhib it B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record







XXXXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review
invalid font number 31502


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 XXXXXXXXXXXXXXX , AR20150014170 (PD201302693)

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

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