Search Decisions

Decision Text

AF | PDBR | CY2014 | PD-2014-01525
Original file (PD-2014-01525.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD -20 1 4 - 0 1525
BRANCH OF SERVICE: Army   BOARD DATE: 201 5 0121
Separation Date: 20091004


SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-1 (M1 Armor Crewman) medically separated for thoracolumbar and cervical spine pain. The conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS). Alternate bike, swim and walk fitness tests were authorized. He was issued a permanent U3/L3 profile and referred for a Medical Evaluation Board (MEB). The neck and back condition, characterized as “lumbar degenerative disc disease” and “cervical degenerative disc disease,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded five other conditions (occipital neuralgia, cluster headaches, nightmare disorder, panic disorder and enthesopathy) for PEB adjudication. The Informal PEB adjudicated the thoracolumbar and neck pain conditions as unfitting, rated 10% and 10%, referencing the VA Schedule for Rating Disabilities (VASRD). The remaining conditions were determined to be not unfit . The CI made no appeals and was medically separated.


CI CONTENTION : “All conditions sleep apnea, PTSD, neck and back degeneration”


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.

invalid font number 31502


RATING COMPARISON :
invalid font number 31502
Service IPEB – Dated 20090608
 VA - (1.5 Mos. Pre -Separation)
Condition
 Code Rating Condition Code Rating Exam
Thoracolumbar Spine Pain 5299-5243 10% Degenerative Disc Disease (DDD) – Lumbar Spine 5242 10% 20090813
Chronic Neck Pain 5299-5243 10% DDD – C-Spine 5242 10% 20090813
Occipital Neuralgia Meets Retention Stds No VA Entry
Cluster Headaches Meets Retention Stds Recurrent Cluster Headaches 8199-8100 0% 20090813
Nightmare Disorder Meets Retention Stds Nightmare Disorder 9412 NSC 20090813
Panic Disorder Meets Retention Stds PTSD w/ Anxiety Disorder & NOS Panic Attacks & Depressive Dis 9411 30% 20090813
Enthesopathy Meets Retention Stds No VA Entry
Other x0
 Other x4
Combined: 20%
 Combined: 80%
Derived from VA Rating Decision (VARD) dated 20091216 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY :

Thoracolumbar Spine Pain Condition . While on deployment in January 2007, the CI developed lower back pain which radiated to the left lower extremity after heavy load work. He was evaluated and diagnosed with low back strain. The examiner ordered a non-steroidal anti-inflammatory drug and pu t the CI on a profile for 4 days with restrictions of no lifting or running. The lumbar spine X -ray and thoracic spine X -ray were both normal. The CI had an episode of acute low back pain (LBP) and was evaluated in the emergency room on 11   September 2008. A lumbar spine magnetic resonance imaging ( MRI ) demonstrated L4-5 and L5-S1 DDD ; L4-5 mild left paracent ral disc protrusion and mild left foraminal narrowing and L5-S1 mild right paracentral disc protrusions with a posterior annular tear. T he CI was referred to p hysical t herapy (PT) for LBP rated 4/10 in intensity, which would awaken him frequently and was worse in the mornings. The physical exam findings were limited flexion with symptoms that radiated to the left lower extremity; however there was normal motor, sensory and reflex testing. The CI underwent 6 weeks of intense PT without complete back pain resolution. The o rthopedist documented low back complaints that were consistent with DDD. The Physical Medicine examiner documented that the CI reported a constant ache in his lower back, rated at 4/10 and worsened to 8/10 with all movements along with pain that radiated down his right leg. There wer e physical exam findings of pain limited flexion to 60 degrees and all range - of - motion (ROM) l imited by pain, although the motor , sensory and reflexes were normal. The c ommander’s s tatement indicated that the CI’s profile prevented him from performing his MOS and rendered him non-deployable. The MEB Addendum exam approximately 10 months prior to separation documented that the CI had r are occasional episodes of back pain that radiated to his posterior thigh and calf. There was no physical exam done at this exam. The MEB na rrative s ummary (NARSUM) exam approximately 9 months prior to separation documented that almost any type of physical activity could significantly aggravate his LBP which was described as a dull ache type sensation and ranged in intensity from 4/10 to 8/10 . The CI reported that there was an improvement in the sciatica pain. The MEB NARSUM physical exam findings are summarized in the chart below. The CI was given a permanent L3 profile for LBP (DDD) and another medical condition, with a Code C and specific restrictions noted on the profile. The pain management provider noted that the CI reported constant lower back soreness and was agreeable to a series of three epidural steroid injections ( ESI’s) . The CI received one ESI’s under fluoroscopy on 23 February 2009, 9 April 2009 and 3 June 2009. The Pain Management provider documented that the CI had a minimal back pain relief from the ESI’s and the examiner was considering further injections or other medical treatment. The VA Compensation and Pension (C&P) exam approximately 2 months prior to separation documented that the CI reported that damp , c old weather aggravated hi s back and the pain would radiate to his bilateral hips in the form of sciatic pain. The VA C&P physical exam findings are summarized in the chart below.
There were two ROM evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.
Thoracolumbar ROM (Degrees)
 MEB ~9 Mo s . Pre-Sep VA C&P ~2 Mo s . Pre-Sep
Flexion (90 Normal)
 80 80
Combined (240)
 220 220
Comment
 Pos. painful motion; N o spasm ; Normal strength, sensation & reflexes; Pos. tenderness to palpation Pos. painful motion; N o spasm ; No Deluca criteria; Normal strength, sens ation & reflexes
§4.71a Rating
 10 % 10 %
invalid font number 31502
The Board direct ed attenti on to its rating recommendation based on the above evidence . The PEB coded the t horacolumbar s pine p ain condition as 5299 analogous to 5243 ( Intervertebral disc syndrome ) and rated at 10%. The VA coded the DDD- l umbar s pine condition as 5242 ( d egenerative arthritis of the spine ) and rated at 10%. The General Rating Formula for Diseases and Injuries of the Spine considers the CI’s pain symptoms “with or without symptoms such as pain (whether or not it radiates), stiffness or aching in the area of the spine affected by residuals of injury or disease . ” The CI met the 10% rating criteria for “Forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees” and “combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees . ” 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 t horacolumbar s pine p ain condition.

Chronic Neck Pain Condition. The CI injured his neck during combative training. During his deployment he began to develop more neck pain. The cervical spine MRI demonstrated mild dessication and disc space narrowing at C3-4 and C5-6 and DDD. The p rimary c are p rovider ( PCP) documented that the CI reported tenderness to palpation ( TTP) at C3-4. There were physical exam findings of TTP of the spinous processes, C3 spinous process TTP; C4 spinous process TTP which radiated from the left side of the neck to the left temple of the face. The PCP documented muscle stiffness and pain on the right side of the shoulder to the back of the neck. The physical exam findings were numbness, TTP from the right shoulder bade to the right side of the neck with muscle tightness. The pain clinic specialist noted that the CI reported sharp, shooting neck pain that started behind the ear on the left side and it stayed on the left side of the head and to the eyeball which caused nausea. The examiner scheduled a left occipital nerve block. The c ommander’s s tatement indicated that the CI’s profile prevented him from performing his MOS and rendered him non-deployable. The MEB Addendum exam completed approximately 10 half months prior to separation documented that the CI had pain in the posterior scalp with paresthesia that covered the occipital nerve on the left. The CI also had significant pain in the left upper and mid trapezius region. There was no physical exam performed at this exam. The MEB NARSUM exam approximately 9 months prior to separation documented that the neck pain was primarily on the left upper and mid trapezius region. The dull burning sensation neck pain ranged from 3/10 to 8/10 and was aggravated with any type of vigorous activity. The cervical spine MRI demonstrated a small posterior protrusion at C6-7 indenting the ventral surface of the spinal cord and mild multilevel degenerative changes with associated foraminal narrowing. The CI was given a permanent U3 profile for cervical degenerative disease (neck pain) and another medical condition, with a Code C and specific restrictions noted on the profile. The VA C&P exam approximately 2 months prior to separation documented that the CI reported that flare-ups include cold, damp weather caused the pain to radiate down to the back of the arms particularly the left side. The CI underwent trigger point injections which gave him pain relief for 2 weeks. The VA C&P physical exam findings are summarized in the chart below.

There were two ROM evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.
Cervical ROM (Degrees)
 MEB ~ 9 Mo s . Pre-Sep VA C&P ~2 Mo s . Pre-Sep
Flex (45 Normal)
 45 55 (45)
Combined (340)
 250 210
Comments
 Pos. painful motion; N ormal motor, sensory & reflexes ; Pos. tenderness to palpation Pos. painful motion & spasm ; No Deluca criteria; Normal neurological exam
§4.71a Rating
 10% 10%

The Board direct ed attention to its rating recommendation based on the above evidence. The PEB coded the c hronic n eck p ain condition as 5299 analogous to 5243 (i ntervertebral disc syndrome ) and rated at 10%. The VA coded the DDD-Cervical Spine condition as 5242 (d egenerative arthritis of the spine ) and rated at 10%. The General Rating Formula for Diseases and Injuries of the Spine considers the CI’s pain symptoms “with or without symptoms such as pain (whether or not it radiates), stiffness or aching in the area of the spine affected by residuals of injury or disease. ” The CI met the 10% rating criteria for “combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees. ” 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 c hronic n eck p ain condition.

 Contended PEB Conditions. The contended conditions adjudicated as not unfitting by the PEB were o ccipital n euralgia, c luster h eadaches, n ightmare d isorder, p anic d isorder (CI contended PTSD) and e nthesopathy . T he 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, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. None of these conditions (and no mental health condition regardless of diagnosis) was profiled; the CI was only profiled for the neck and low back conditions. N one of these conditions were implicated in the c ommander’s s tatement; and, none were judged to fail retention standards. All were reviewed by the a ction o fficer and considered by the Board. There was no indication from the record that any of these conditions significantly interfered with satisfactory duty performance. 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 o ccipital n euralgia, c luster h eadaches, n ightmare d isorder, p anic d isorder (contended PTSD by the CI) and e nthesopathy contended 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 t horacolumbar s pine p ain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the c hronic n eck p ain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the contended o ccipital n euralgia, c luster h eadaches, n ightmare d isorder, p anic d isorder /PTSD and e nthesopathy 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 140429 , w/atchs
Exhib it 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 XXXXXXXXXXXXXXX, AR20150013462 (PD201401525)


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)
                                                     

Similar Decisions

  • AF | PDBR | CY2013 | PD-2013-02524

    Original file (PD-2013-02524.rtf) Auto-classification: Approved

    The VA Compensation and Pension (C&P) exam approximately 6.5 months after separation documented that the CI had constant daily neck pain rated at 7/10, neck stiffness occurred with turning the neck to any side with radiation down both upper extremities with feelings of hand weakness during an acute exacerbation. invalid font number 31502 RECOMMENDATION : The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be...

  • AF | PDBR | CY2013 | PD2013 00161

    Original file (PD2013 00161.rtf) Auto-classification: Approved

    The ratings for the unfitting neck and back conditions are addressed below. The PT note on 16March 2007, 3 months prior to separation recorded bubble inclinometer ROM without specification of the method used, or normal values, at flexion 21 degrees, and extension 9 degrees with pain.The MEB NARSUM exam on 23 April 2007, approximately2 months prior to separation, documented that the CI’s LBP symptoms had slowly worsened and that he had undergone rest, activity modification, anti-inflammatory...

  • AF | PDBR | CY2014 | PD-2014-01977

    Original file (PD-2014-01977.rtf) Auto-classification: Approved

    The Informal PEB (IPEB) adjudicated “chronic neck pain” and “chronic low back pain” as unfitting, rated 10% and 0%, respectively, for a combined 10% disability, with likely reliance on AR 635-40 for rating. Disk protrusions were noted to decrease from 2005 through 2007 and the mild dilatation of the central thoracolumbar spinal canal (Syrinx) was stable.At the MEB exam, the CI reported back pain exacerbated by activity and rare left leg pain. In the matter of the back condition, the Board...

  • AF | PDBR | CY2012 | PD2012 00114

    Original file (PD2012 00114.rtf) Auto-classification: Approved

    The MEB forwarded bilateral ulnar neuropathy at the elbow, chronic neck pain, chronic LBP, and mood disorder with depressive features due to ulnar neuropathy and post-surgical pain unresolved conditions to the Physical Evaluation Board (PEB) IAW AR 40-501. The Board first considered if both the chronic neck pain and chronic LBP conditions, having been de-coupled from the combined PEB adjudication, were each reasonably justified as independently unfitting. Physical Disability Board of Review

  • AF | PDBR | CY2013 | PD-2013-00696

    Original file (PD-2013-00696.rtf) Auto-classification: Denied

    The chronic neck and lumbar pain conditions, characterized as “cervical spine pain and lumbar spine pain” and “mild degenerative disk disease (DDD), cervical spine,” were the only conditions forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.The Informal PEB adjudicated “chronic neck pain,” and “chronic lumbar pain”as unfitting, rated 10% and 10% respectively, with likely application ofthe Veterans Affairs Schedule for Rating Disabilities (VASRD).The CI made no appeals and was...

  • AF | PDBR | CY2014 | PD2014 00906

    Original file (PD2014 00906.rtf) Auto-classification: Approved

    The VARD also noted the absence of radicular findings and no recording of ROM (the CI refused testing).The Board directs attention to its rating recommendation based on the above evidence.The PEB rated the condition for ROM limited by pain, coded 5237, and assigned a rating of 0%.The VA rated the condition under code 5242, 10% for muscle spasm.Under the applicable spine rules, a rating of 10% requires cervical spine flexion of greater than 30 degrees but less than 40 degrees or a combined...

  • AF | PDBR | CY2011 | PD2011-00989

    Original file (PD2011-00989.docx) Auto-classification: Denied

    The Physical Evaluation Board (PEB) adjudicated the low back condition as unfitting, rated 10%, with application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD) and likely application of the US Army Physical Disability Agency (USAPDA) pain policy. At the VA Compensation and Pension (C&P) exam a month after separation, the CI reported up to 10/10 in LBP with radiation of pain, use of narcotic pain medication and no episodes of incapacitation. The contended condition...

  • AF | PDBR | CY2013 | PD2013 00409

    Original file (PD2013 00409.rtf) Auto-classification: Approved

    The chronic back pain and chronic neck pain conditions, characterized as “chronic neck pain and chronic back pain, with degenerative disc disease” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. In addition, the CI was notified by the Army that his case may be eligible for review of the military disability evaluation of his MH condition in accordance with Secretary of Defense directive for a comprehensive review of Service members who were referred to a disability...

  • AF | PDBR | CY2012 | PD-2012-01569

    Original file (PD-2012-01569.txt) Auto-classification: Approved

    The CI was given several profiles for his neck. The CI did have minimal tenderness at the prior to separation neurological consultation and had slight tightness of the neck muscles at the MEB examination in addition to the positive MRI findings. A neurosurgical consult to the MEB on 26 March 2002 (10 months prior to separation) noted normal gait, normal ROM of the lumbar spine, and normal sensation, strength, and reflexes.

  • AF | PDBR | CY2012 | PD2012 01622

    Original file (PD2012 01622.rtf) Auto-classification: Denied

    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 back, neck and bilateral foot pain conditions are addressed below;no additional conditions are within the DoDI 6040.44 defined purview of the Board. In the matter of the bilateral foot pain condition and IAW VASRD §4.71a, the Board unanimously...