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AF | PDBR | CY2014 | PD-2014-02065
Original file (PD-2014-02065.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2014-02065
BRANCH OF SERVICE: Army  BOARD DATE: 20150210
SEPARATION DATE: 20090127


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Abrams Tank System Maintenance) medically separated for cervical strain and intervertebral disc syndrome of the lumbar spine. 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 L3/U3 profile and referred for a Medical Evaluation Board (MEB). The “cervicalgia,” “low back pain w/ S1 radiculopathy,” and “neuritis lumbar” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded anxiety and mood symptoms for PEB adjudication. The Informal PEB adjudicated “cervical strain” and “intervertebral disc syndrome of the lumbar spine” as unfitting, rated 10% and 10%, with likely application Veterans Affairs Schedule for Rating Disabilities (VASRD ). T he remaining condition was determined to be not unfitting . The CI made no appeals and was medically separated.


CI CONTENTION: “Please consider all conditions found unfitting and not unfitting by the physical evaluation board.”


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 :

IPEB – Dated 20081104
 VA* - (~5 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Cervical Strain 5237 10% Kyphosis, Cervical Spine (Also Claimed As Cervical Spine Condition, Cervicalgia, Intervertebral Disc Degeneration, Cervical, And Cervical Spondylosis) 5299-5239 Not Service connected (NSC) 20090629
Intervertebral Disc Syndrome of the Lumbar Spine 5243 10% Degenerative Disc And Joint Disease, Mild, Lumbar Spine (Also Claimed As Lower Lumbar Condition, Lumbago, Intervertebral Disc Degeneration, Lumbar, And Lumbar Spondylosis) 5242 10% 20090629
Anxiety and Mood Symptoms Not Unfitting Anxiety Disorder (Also Claimed As Generalized Anxiety Disorder) 9400 NSC 20090629
Other x0
 Other x7
RATING: 20%
 RATING: 40%
* Derived from VA Rating Decision (VA RD ) dated 200 90803 (most proximate to date of separation ( DOS ) )


ANALYSIS SUMMARY:

Cervical Strain Condition. The CI suffered an injury to his neck in March 2006 when a drum fell onto the side of his head. He was evaluated in the emergency room with a computed automated tomography scan of the head and neck which was normal. Although he continued to have neck pain, he was deployed to Iraq from October 2006 until January 2008 where his neck pain worsened due to wearing combat gear on a daily basis and another injury suffered in June 2007. The CI was treated by physical therapy (PT) and after evaluation by orthopedics he declined any surgical intervention. He had a magnetic resonance imaging (MRI) scan 7 months prior to separation with the following impression:

1. Abnormal kyphotic curvature to the upper cervical spine causes apparent moderate central canal stenosis at the C3-4 level. This curvature may be secondary to positioning. However, this is not significantly changed compared with the CT scan of March 2006.
2. Otherwise, no significant central canal stenosis or neuroforaminal narrowing.

The MEB physical exam performed 7 months prior to separation noted tender posterior cervical muscles, pain limited range-of-motion (ROM) and normal strength both upper extremities. The narrative summary (NARSUM) prepared 5 months prior to separation noted flare-ups of his neck pain on a daily basis with essentially constant 8/10 neck pain. He denied any exacerbating or palliative factors. The pertinent physical exam findings are summarized in the chart below. At the VA Compensation and Pension (C&P) exam performed 5 months after separation, the CI reported constant sharp neck pain at 2/10. He took no pain medication of any kind. The CI denied any radiation of the pain but he did experience some neck stiffness with flare-ups if he gets too active and occasional numbness and tingling in his hands. He was employed in a landscaping job, but he was unable to do the lifting, pushing, and pulling required and he quit.

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 exam ~7 Mo. Pre-Sep VA C&P ~5 Mo. Post-Sep
Flex (45 Normal)
 45 40
Combined (340)
 305 330
Comment
 Pos. painful motion; No spasm or tenderness No painful motion or spasm
§4.71a Rating
 10 % * (PEB 10%) 1 0% (VA NSC)
*IAW VASRD §4.59, Painful motion
The Board directed its attention to its rating recommendation based on the above evidence. The PEB applied VASRD code 5237 (lumbosacral or cervical strain), and rated it 10% using verbiage consistent with application of VASRD standards. The VA applied the analogous code 5299-5239 (spondylolisthesis or segmental instability), and did not grant service-connection. The PT exam and the C&P exam document either painful motion (IAW §4.59) or ROM measurements that are consistent with a 10% rating. There is no evidence based alternative coding/rating scheme that would result in a rating greater than 10%. Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that a disability rating of 10% for the cervical strain condition was appropriately recommended in this case.

Intervertebral Disc Syndrome of the Lumbar Spine Condition. The CI’s low back pain (LBP) began with the same injury in March 2006 that caused his neck pain. Again, he reported that the daily use of combat gear exacerbated his low back pain. Eight months prior to separation, an MRI scan revealed mild broad-based disc protrusions at the L4-L5 and L5-S1 levels with mild central canal stenosis and mild to moderate foraminal narrowing at the L5-Sl level. He was evaluated by orthopedics where tenderness to palpation of the lumbar paravertebral musculature was noted. There was evidence of painful motion without any radicular signs. His leg strength and reflexes were normal; however, he had diminished sensation in the lateral right thigh and lower leg. His gait was normal. Electromyography (EMG) 5 months prior to separation revealed findings consistent with a radiculopathy (pinched nerve) at S1 on the left greater than the right. The MEB physical exam noted normal gait, strength, reflexes and no evidence of radicular signs. There was decreased ROM with pain and tender paraspinal lumbar muscles. The NARSUM noted daily flare-ups of his constant LBP. The pertinent physical exam findings are summarized below. At the C&P exam, the CI reported occasional weakness in his legs. He denied bowel or bladder complaints and erectile dysfunction. The CI was independent in his activities of daily living and he could drive. His back pain increased if he stood for more than 5 minutes or walked for more than 20 minutes. He was unable to run and was unemployed but was looking for work. There was no mention of incapacitating episodes. The C&P examiner diagnosed mild lumbar spine degenerative disc disease and added the following remarks:

“Veteran was no show for EMG. There is no objective evidence of radiculopathy. Slight kyphotic cervical of spine curvature is most likely congenital and not related to military service.”

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.

Thoracolumbar ROM (Degrees)
 PT Exam ~7 Mo. Pre-Sep VA C&P ~5 Mo. Post-Sep
Flexion (90 Normal)
 85 90
Combined (240)
 235 240
Comment
 Normal gait; No spasm or a bnormal spinal curvature No Deluca criteria; Normal gait; Pos. spasm with abnormal spinal contour; No weakness
§4.71a Rating
 10 % (PEB 10%) 10% (VA 10%)

The Board directed its attention to its rating recommendation based on the above evidence. The PEB applied VASRD code 5243, (Intervertebral disc syndrome [IDS]), and rated the lumbar spine condition at 10% citing ROM measurements. The VA applied code 5242 (degenerative arthritis of the spine), and also rated it 10% based on the ROM measurements contained in the C&P exam. The General Rating Formula for Diseases and Injuries of the Spine also covers “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 PT and C&P exam both documented thoracolumbar ROM measurements that are consistent with the 10% rating using the general rating formula. Although the evidence is sparse for the diagnosis of IDS as adjudicated by the PEB, the Board considered the alternate rating method contained in the VASRD for rating IDS with is based on documentation of incapacitating episodes caused by the IDS. The Board reviewed the data for evidence of incapacitating episodes and none were found. There are no data based coding/rating schemes that would allow for a rating greater than 10% for the CI’s low back condition. Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that a disability rating of 10% for the intervertebral disc syndrome of the lumbar spine condition was appropriately recommended in this case.

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that the anxiety and mood symptoms were not unfitting. The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. The anxiety and mood symptoms were not profiled and were not judged to fail retention standards. There was no commander’s statement available in the evidence present for Board review. All entries were reviewed and considered by the Board. There was no performance based evidence 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 anxiety and mood symptoms contended conditions and so no additional disability ratings are 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 cervical strain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the intervertebral disc syndrome of the lumbar spine condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the contended anxiety and mood symptoms conditions, the Board unanimously recommends no change from the PEB determination 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 20140509, 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 XXXXXXXXXXXXXXX, AR20150013711 (PD201402065)


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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