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AF | PDBR | CY2014 | PD-2014-00179
Original file (PD-2014-00179.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX       CASE: PD-2014-00179
BRANCH OF SERVICE: Army  BOARD DATE: 20150417
SEPARATION DATE: 20060921


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Infantryman) medically separated for neck pain. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty, but he was authorized to perform alternate physical fitness testing. He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB). The “cervicalgia secondary to cervical fractures at C2 and C6” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other condition was submitted by the MEB. The Informal PEB adjudicated “chronic neck pain…” as unfitting, rated 20% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting. Any condition 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 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.


 RATING COMPARISON :

IPEB – Dated 20060711
 VA* - based on Service Treatment Records (STR)
Condition
 Code Rating Condition Code Rating Exam
Chronic Neck Pain… 5235-5241 20% Cervical Spine Fractures C2 and C6, Residuals of Injury 5237 20% STR**
Other x 0
Other x 1
RATING: 20%
 RATING: 20%
* Derived from VA Rating Decision (VA RD ) dated 200 70501 (most proximate to date of separation [ DOS ] )
**CI did not attend C&P exam
ANALYSIS SUMMARY:

Chronic Neck Pain Condition. The CI sustained a severe neck injury in a diving accident in January 2001. Fractures of the C2 and C6 vertebrae required cervical fusion of C1-C3 and wear of a halo device for 3 months. The CI was subsequently cleared to return to un-restricted duty, but developed neck pain in 2005 that became progressively severe. There was no further surgical indication, and physical therapy (PT) and medications provided insufficient benefit.

At the MEB narrative summary (NARSUM) evaluation on 3 May 2006 (5 months prior to separation) the CI reported persistent severe neck pain rated at 8/10 in severity that was exacerbated with physical activity, or wearing a helmet or body armor. Physical examination showed a normal gait and painful neck motion. The MEB DD Form 2808, Report of Medical Exam, dated 10 May 2006, noted no neck muscle spasm or tenderness. Goniometric measurements performed by PT for the MEB NARSUM on 12 May 2006 showed flexion of 30 degrees (normal 45 degrees) and combined range-of-motion (ROM) of 175 degrees (normal 340 degrees). There was no additional limitation of motion with repetition.

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 20% rating under a combined 5235-5241 code (vertebral fracture or dislocation; spinal fusion). The VA likewise rated at 20% under the 5237 code (cervical strain). Cervical flexion measurements reflected in the MEB NARSUM PT exam supported a 20% rating (but no higher) for forward flexion greater than 15 degrees but not greater than 30 degrees. Favorable ankylosis was not present; therefore the next higher 30% rating was not warranted. 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. 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 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 20131229, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record









                          
XXXXXXXXXXXXXXX
President
DoD 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 XXXXXXXXXXXXXXXXXXXX , AR20150014354 (PD201400179)

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

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