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AF | PDBR | CY2013 | PD-2013-02800

Original file (PD-2013-02800.rtf) Auto-classification: Denied

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX CASE: PD-2013-02800
BRANCH OF SERVICE: AIR FORCE BOARD DATE: 20150415

DATE OF PLACEMENT ONTO TDRL: 20020207
DATE OF REMOVAL FROM TDRL: 20030811

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Health Services Management) medically separated for neck and upper back pain. These conditions could not be adequately rehabilitated to meet the requirements of her Air Force Specialty or physical fitness standards, so she was referred to a Medical Evaluation Board (MEB). The “right cervical, shoulder & paraspinal musculoskeletal pain” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123. The MEB also identified and forwarded three other conditions (stress disorder, migraine headaches, and intermittent bowel problems) for PEB adjudication. The Informal PEB (IPEB) adjudicated “chronic cervical neck pain…” and “chronic upper back pain” as unfitting, rated 20% and 10%, respectively. The remaining conditions were not addressed by the PEB, and presumed to be not unfitting by omission. The PEB also found the conditions had not yet stabilized and recommended placing her on the Temporary Disability Retired List (TDRL). The CI made no appeals and was placed on the TDRL. Approximately 18 months later, the IPEB adjudicated “chronic cervical neck pain” and “chronic back pain” as unfitting, each rated 10%, citing application of DoD guidelines and the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.

CI CONTENTION: “I am currently still being seen by a pain manager for the injuries to my C5 C6 vertebrae.”

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 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. In addition, the Secretary of Defense Mental Health Review Terms of Reference directed a comprehensive review of Service members with certain mental health (MH) conditions referred to a disability evaluation process between 11 September 2001 and 30 April 2012 that were changed or eliminated during that process. The MH condition was reviewed regarding diagnosis change, fitness determination and rating in accordance with VASRD §4.129 and §4.130.

RATING COMPARISON :

Final PEB – 20030707	VA Rating Decision*
TDRL Placement – 20020207	Code	Rating	Condition	Code	Rating Proximate
Condition		TDRL Placement	TDRL Removal			TDRL Placement	TDRL Removal
Chronic Cervical Neck Pain	5290	20%	10%	Not Applicable	-	-	-
Chronic Back Pain…	5295	10%	10%	Not Applicable	-	-	-
Other x 0 (Not in Scope)	Other x0
RATING: 30% → 20%	RATING: -%

* No VA claim submitted, no VARD or C&P applicable

ANALYSIS SUMMARY: A majority of the CI’s service treatment records (STRs) were not available in evidence before the Board and could not be located after appropriate inquiries. Further attempts at obtaining the relevant documentation would likely be futile and introduce additional delay in processing the case. Additionally, no VA data was present due to the CI not applying for VA disability compensation. Members deliberated if this negatively impacted their ability to render a fair assessment and agreed that the available evidence was not sufficiently probative; evidence presumed missing could materially affect the Board’s final recommendation.

Neck Pain. The CI had two motor vehicle accidents (MVA) that resulted in her complaints for chronic neck pain. The first MVA was in May 2000 and she was treated with muscle relaxers and narcotic pain medication. A magnetic resonance imaging study in December 2000 revealed mild degenerative changes C3-4 bilaterally, right greater than left, and a mild broad base disc bulge at C5-6. She was evaluated by a neurologist who diagnosed “likely whiplash syndrome with muscle spasm after 2 MVAs.” The NARSUM prepared 10 months prior to TDRL placement noted a history consistent with that outlined above. The physical exam stated, “No significant muscle spasm” and “There may be slightly diminished grip strength on the right, but circulation, muscle strength and sensation are all otherwise normal.” A month prior to TDRL placement, her pain management provider submitted a note that contained the following statements:

“We have tried several treatment modalities including Cervical epidural steroid injection, TENS, MATRIX treatment, physical therapy, Trigger point injection and Botox injections. None of these treatments have been helpful in alleviating her pain. She has been evaluated by Neurosurgery for consideration of surgical options; I have no record of their assessment and recommendations, as far as I know there is no current plan for surgery. In summary, this patient has chronic neck and shoulder pain of unclear etiology. The pain appears to have a myofascial component. She is currently being managed on opioid therapy.”

Additionally, a NARSUM update completed a month prior to TDRL placement contained the following statement:

“Since the dictation of the narrative summary on 4/26/01, the patient complains of persistent daily neck pain, intermittent bilateral upper back pain, and right shoulder pain radiating to right elbow. She denies numbness or weakness in upper or lower extremities. She does complain of periodic tingling in her right middle finger. Patient states she is able to function in her daily activities. Her pain is no worse than previously. However, even with the current treatment regimen, she still has daily pain.”

In reference to her physical exam, the update simply stated that her physical exam was unchanged. An orthopedic consult 2 weeks prior to TDRL placement contained the following physical exam findings. Her neck had mildly tender paraspinal muscles and no obvious trigger points. She had a decreased range-of-motion (ROM) of her neck. She could flex to within 3 cm of her sternum. She extended to 45 degrees (normal). She laterally bends 45 degrees (normal) to both sides with slight pain on going to the right. She rotates 80 degrees (normal) to the left and 70 degrees to the right. She had normal strength, sensation and reflexes with no evidence of numbness or tingling.

The Board directed attention to its rating recommendation based on the above evidence in regards to TDRL placement. The PEB adjudicated the chronic cervical neck pain with slightly decreased grip strength by applying VASRD code 5290 (limitation of cervical spine motion) and rated it 20% consistent with “moderate.” There is no VA data for this condition. The 2002 VASRD coding and rating standards for the spine, which must be applied to the Board’s recommendation IAW DoDI 6040.44, differ significantly from the current §4.71a (General Rating Formula for the Spine). The earlier criteria were subject to the rater’s opinion regarding degree of severity, as opposed to the more objective current standards with quantifiable rating thresholds grounded in ROM measurements. The 2002 criteria relevant for consideration in the Board’s recommendation are cited in context below.

5290 Spine, limitation of motion of, cervical:
Severe ............................ 30
Moderate ....................... 20
Slight .............................. 10

The Board assigned exclusive probative value on the orthopedic exam performed 2 weeks prior to TDRL placement as it was the most proximate to TDRL placement and contained the best data on which to base a rating recommendation. The Board considered that the majority of the cervical motion was normal with some pain on movement present. There was no additional data that would support a rating higher than the 20% applied by the PEB. 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 adjudication for the chronic cervical neck pain condition at TDRL placement.

Almost 2 months prior to TDRL removal, the CI underwent an orthopedic evaluation for her neck pain. That evaluation documented that the CI’s symptoms have been stable with occasional exacerbations, usually a 6/10 in severity with occasional increases. The right side is affected more than the left, as she described the pain along the medial border of her right scapula as being the worst. She also described intermittent radiation of pain into her right upper extremity with numbness and tingling in the index, middle and ring fingers. This pain resolved spontaneously and only occurred on a very irregular basis. The physical exam related to her neck pain revealed a good ROM without pain. She did have some tenderness to palpation (TTP) in the lower cervical spine, as well as in the right shoulder region. There was no evidence of radicular pain. There was normal strength, sensation and reflexes of her upper extremities. Plain film X-rays of her neck were essentially normal. A neurologic exam was also performed almost 2 weeks prior to TDRL removal and it documented a normal neurologic exam.

The Board directed its attention to its rating recommendation based on the above evidence regarding TDRL removal. At TDRL removal, The PEB adjudicated the chronic cervical neck pain condition by applying VASRD code 5290 and rated it 10% consistent with “slight.” There is no VA data for this condition. The Board reviewed the orthopedic evaluation performed 2 months prior to TDRL removal and members agreed that there was improvement in the CI’s neck condition in that the exam revealed “…a good range of motion without pain.” Additionally, the Board considered whether an additional service rating could be recommended under a peripheral nerve code for a potential upper extremity radiculopathy; but, there was no ratable deficit in evidence and no functional link to fitness. 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 adjudication for the chronic cervical neck pain condition at removal from TDRL.

Chronic Upper Back Pain. The same two MVAs that caused her neck pain also were identified as causing her back pain. There was no evidence of any radiographic studies performed to evaluate her back pain. The NARSUM prepared 10 months prior to TDRL placement noted a history consistent with that outlined above. The physical exam of her back revealed “…no significant muscle spasm palpable and explained that this was because of a multiple injection treatment at trigger-points which she had done yesterday, no note found in the chart to reflect this though.” An orthopedic consult 2 weeks prior to TDRL placement contained the following physical exam findings, back with full ROM, negative straight leg raise, and normal strength of her legs. There were no STRs concerning her back pain present for review by the Board.

The Board directed its attention to its rating recommendation based on the above evidence for TDRL placement. At TDRL placement, the PEB adjudicated the chronic upper back pain condition by applying VASRD code 5295 (Lumbosacral strain) and rated it 10% for “With characteristic pain on motion.” There is no VA data related to this condition. The 2002 VASRD coding and rating standards for the spine, which must be applied to the Board’s recommendation IAW DoDI 6040.44, differ significantly from the current §4.71a general rating formula for the spine. The earlier criteria were subject to the rater’s opinion regarding degree of severity, as opposed to the more objective current standards with quantifiable rating thresholds grounded in ROM measurements. The 2002 criteria relevant for consideration in the Board’s recommendation are cited in context below.

5295 Lumbosacral strain:
-Severe; with listing of whole spine to opposite side, positive Goldthwaite’s sign, marked limitation of forward bending in standing position, loss of lateral motion with osteo-arthritic changes, or narrowing or irregularity of joint space, or some of the above with abnormal mobility on forced motion .............................................. 40
-With muscle spasm on extreme forward bending, loss of lateral spine motion, unilateral, in standing position ............................................... 20
-With characteristic pain on motion ..................... 10
-With slight subjective symptoms only .................. 0

The orthopedic evaluation 2 week prior to TDRL placement noted that the CI’s back had full ROM. There was no evidence of painful motion and no STR data to review; therefore, IAW DoDI 6040.44 the Board may not recommend a lower combined rating than that conferred by PEB. 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 adjudication for the chronic back pain condition at TDRL placement.

Almost 2 months prior to TDRL removal, the CI underwent an orthopedic evaluation for her upper back pain as noted in the neck pain section above. The pertinent physical exam findings related to her upper back pain revealed her spine to be non-tender to palpation, but she did have moderate TTP along the medial border of her right scapula. A neurologic exam was also performed almost 2 weeks prior to TDRL removal and it documented a normal gait and neurologic exam.

The Board directed attention to its rating recommendation based on the above evidence for TDRL removal. At TDRL removal, the PEB adjudicated the chronic back pain condition by applying VASRD code 5295 and maintained the 10% rating. There is no VA data for this condition. The data present for review supports that the CI’s back pain condition remained stable during the TDRL period, and no evidence to the contrary is present. Additionally, IAW DoDI 6040.44 the Board may not recommend a lower combined rating than that conferred by PEB. 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 adjudication for the chronic back pain condition at TDRL removal.

Mental Health Condition. The evidence present for review contained two entries related to a MH condition. The Board noted that the initial narrative summary (NARSUM) prepared 10 months prior to TDRL placement contained the following statement in the past medical history section, “History of reactive depression, post-traumatic stress disorder since rape in 1997.” The Board noted that the CI enlisted into the US Air Force on 18 April 1996. Also, a neurology note dated 4 September 2001 noted “post-traumatic stress d/o” in the past medical history section. The evidence present for review did not contain any profiles that noted a MH condition. The commander’s statement did not note the presence of a MH condition and contained the following recommendation, “I recommend retention and return to duty with physical limitations of SSgt Hurst.” The MEB report did document a MH condition of “stress disorder” and referred it to the PEB for adjudication. The PEB document did not address the “stress disorder” condition. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient evidence to recommend that an unfitting MH condition was present at the time of TDRL placement and so no additional disability rating is 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 cervical neck pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the chronic back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of a MH condition, there was no evidence to support that an unfitting MH condition existed. 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 20130906, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

invalid font number 31506

SAF/MRB

1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762

XXXXXXXXXXXXXXXXX

Dear XXXXXXX:


Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2013-02800 .

         After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate. Accordingly, the Board recommended no re-characterization or modification of your separation.

         I have carefully reviewed the evidence of record and the recommendation of the Board. I concur with that finding and their conclusion that re-characterization of your separation is not warranted. Accordingly, I accept their recommendation that your application be denied.

Sincerely,

XXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

cc:
SAF/MRBR

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AF | PDBR | CY2013 | PD-2013-02800

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