RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX		BRANCH OF SERVICE: ARMY
CASE NUMBER: PD0900176		BOARD DATE: 20101109			
SEPARATION DATE: 20050519
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SUMMARY OF CASE:  This covered individual (CI) was an Army SGT/E-5 (MOS 88M, Motor Vehicle Operator) medically separated in May 2005 after more than 8 years of service.  The medical basis for separation was Low Back Pain (LBP).  The CI did not respond adequately to perform the duties of his military occupational specialty (MOS) or participate in the Army physical fitness test (APFT).  He was issued a permanent L-3 profile, and underwent a Medical Evaluation Board (MEB).  Low Back Pain and Right Ulnar Nerve Compressive Neuropathy were both addressed in the narrative summary (NARSUM) and forwarded to the Physical Evaluation Board (PEB) on DA Form 3947.  The PEB adjudicated the Low Back Pain condition as unfitting and rated it 10% using the Veterans Administration Schedule for Rating Disabilities (VASRD) and applicable Army and DoD regulations.  The PEB adjudicated the Right Ulnar Nerve Compressive Neuropathy as not unfitting and thus not ratable.  The CI accepted the findings of the PEB, and was medically separated with a 10% disability rating.  
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CI’s CONTENTION (20090205):  “I can concur that my Army rating of 10% for Lumbosacral and Cervical strain and Right Ulnar Neuropathy sustained in an ambush in Baghdad, Iraq in support of Operation Iraqi Freedom was inaccurate. Prior to my rating (30%), I was in physical therapy due to "Spinal Shock" for several months. I received several steroid shots, Ramus Blocks, Epidural injections, and plus numerous of visits to the Pain Clinic in Landstuhl, Germany, Heidelberg, Germany and VAMC West Campus in Tuskegee, Alabama. After several MRIs and X-rays my condition only got worse. My Range of Motion was very poor. My extremities had numbness, which was getting worse by the day. Finally I could not endure the pain in the legs any longer. I went to have a discectomy performed on my lower back. This surgery gave me relief, due to the fact, my L-4 and L-5 were bulging, at first. They became herniated and ruptured pressing against the sciatic nerves in my right leg, causing my legs excruciating and severe numbness.

My Cervical Spine (30%) does the same thing with my arms. I have radiating pain traveling through my arms so strong that sometimes my hands ball up involuntarily. I cannot hold items such as a pen or pencil in my hands sometimes. My hands shake as if I was standing out in cold weather. It hurts to hold my head up at times, it seems as if my neck gets fatigued. I have back spasm almost daily.

I was granted service-connected for dental treatment without a rating. My two front teeth were severely fractured exposing the nerves while Pugil stick training. I have had problem with my teeth.  When it is cold outside, my mouth hurts. I have porcelain fused to metal crowns. I am 70% disabled as a result of my injuries. I have been receiving treatments since my injuries sustained in June 2003 to the present. I am currently in pain and discomfort.”
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RATING COMPARISON:

Army PEB – 20050308	VA (5 mos. after Separation) – Effective 20050520	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Lumbar Spine Strain	5243	20%	20051021	
Right Ulnar Nerve Neuropathy	Not Unfitting	Right Arm Radiculopathy 	8518	0%	20051021	
(No Additional DA Form 3947 Entries)	Cervical Spine Strain	5237	30%	20051021	
	Right Knee Pain	5262	10%	20051021	
	PTSD	9411	30%	20060728	
	Teeth Sensitivity 		0%	20051020	
	Other x 8  /  NSC x 9				
TOTAL Combined:  10%	TOTAL Combined: 50% 20051021
   Then 70% 20060728	
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ANALYSIS SUMMARY:
Low Back Pain (LBP) – The CI was in good health until June 2003 when he was involved in a motor vehicle accident (MVA) while deployed to Iraq.  The accident occurred when his vehicle ran into vehicle in front of him, and the vehicle behind him ran into his vehicle.  The CI stated that he sustained whiplash as well as striking the steering wheel.  He was evaluated at the local Combat Support Hospital (CSH), where X-rays were read as normal and he was placed on pain medication.  His condition improved, but he continued to have LBP associated with pain in legs and reduced sensation.  The CI was sent to Doha Clinic for physical therapy (PT) and was also evaluated by Orthopedics and Neurosurgery at the CSH. The CI remained with his unit and moved to Tikrit, where he continued PT until he went to Germany in January 2004. He was then evaluated at the Troop Medical Clinic, where Magnetic Resonance Imaging (MRI) of L-spine (May 2004) showed multi-level degenerative posterior disc bulging, but no evidence of spinal canal or neuro-foraminal narrowing. The CI was then referred to the Landstuhl Pain Management Clinic.  In July 2004 he underwent a ramus nerve block and steroid injections, which provided no significant pain relief.  Repeat MRI in September 2004 again showed mild, multi-level disc bulging. The CI had been treated by PT with exercises (for muscle stretching and strengthening) and Transcutaneous Electrical Nerve Stimulation (TENS).  He had received numerous medications, including: Elavil, Pamelor, Vioxx, Tramadol, Toradol, Indocin, and Gabapentin. The CI stated that none of these treatment modalities had made a significant difference in his pain.  Due to lack of improvement and his inability to meet the physical standards of his MOS, the CI was put on permanent L3 profile and referred for a MEB.  

During the MEB exam (14 Feb 05, 3 mos. prior to separation), the CI described intermittent episodes of pain radiating into his legs associated with numbness. He also had episodes in which his legs felt heavy and numb. He described a constant back pain which was 7.5/10 in intensity. The CI stated that sometimes the pain would become as bad as 10/10, with a sensation of pins and needles, with certain aggravating factors. The aggravating factors included: walking, negotiating stairs, cold weather, sitting or standing for a long time, wearing protective gear, or lifting any significant weight.  The MEB exam revealed that his gait was non-antalgic, and on inspection there was no gross muscle atrophy or obvious difference in leg circumference.  Palpation revealed no tenderness in the sciatic notches, and no gluteal trigger points.  Manual muscle testing was 5/5 for all muscle groups.  Deep tendon reflexes were 2+ throughout.  Sensation was intact to light touch, pin prick, and cold.  Neurologic examination (including mental status, cranial nerves, motor, deep tendon reflexes, sensation, coordination and gait) was within normal limits.  Thoracolumbar range-of-motion (ROM) testing revealed active forward flexion of 35-40 degrees, and combined active thoracolumbar ROM of 135-145 degrees.  The military ROM examiner was able to obtain 65 degrees of passive forward flexion, but the CI experienced moderate pain and guarding with the passive ROM testing and measurement.  At the VA Compensation and Pension (C&P) exam completed on 21 October 2005 (5 mos. after separation), ROM testing revealed thoracolumbar forward flexion limited to 50 degrees, and combined thoracolumbar ROM of 110 degrees.  These ROM evaluations are summarized in the table below.   

Thoracolumbar	Separation Date:  20050519	
Goniometric ROM	MEB – 20050214
(active ROM)	VA C&P – 20051021	
Flexion (90⁰ normal)	35-40⁰	50⁰	
Combined (240⁰ normal)	135-145⁰	110⁰	
§4.71a Rating	20%	20%	

The Board carefully examined all of the evidentiary information available.  IAW VASRD §4.71a, when forward flexion of the thoracolumbar spine is greater than 30 degrees but not greater than 60 degrees, the rating agency should assign an evaluation of 20 percent.  Using pain as the endpoint, and resolving reasonable doubt in favor of the CI, the Board determined that the CI’s forward flexion was greater than 30 degrees but not greater than 60 degrees.  Following thoughtful deliberation, the Board recommends a disability rating of 20% for Low Back Pain.  

The Board then directed its attention to the issue of Low back (Lumbar) radiculopathy.  The CI complained of lower extremity symptoms (pain and numbness of legs) that are consistent with a diagnosis of Lumbar nerve root impingement or radiculopathy.  The Board discussed whether or not the radicular signs and symptoms were so severe, that the Radiculopathy itself should be considered an unfitting condition.  The presence or absence of functional impairment, and the impact on duty performance are crucial factors in the Board’s decision to recommend any condition as additionally unfitting.  The CI reported leg pain, and numbness.  The sensory component of a radiculopathy does not generally have fitness implications unless it is dense enough to affect proprioception and balance; which is not true in this case.  The critical decision is therefore whether or not there was significant motor weakness which would impact MOS-specific activities.  All evidence considered, the Board cannot find sufficient evidence to support recommending Lumbar radiculopathy as additionally unfitting for separation rating.  

Ulnar Nerve Compressive Neuropathy – Review of the Treatment Record shows that the CI had complained of intermittent arm numbness that he related back to the June 2003 MVA. He did not link the arm numbness to neck pain, nor was the arm numbness aggravated or worsened by neck movement.  The CI was evaluated by the Landstuhl Regional Medical Center Neurology Service for arm numbness in February 2005. During this evaluation the CI was found to have reduced sensation on the medial aspect of both forearms. He was then referred for nerve conduction testing to evaluate this further.  Nerve conduction studies revealed moderate right ulnar nerve slowing about the elbow, with demyelination only and no acute denervation. Examination of his upper extremities showed them to be symmetrical with no evidence of atrophy.  There was no winging of shoulder blades in three different positions. Manual muscle testing was 5/5 bilaterally. Deep tendon reflexes were 2+ throughout, and sensation was intact to light touch in all dermatomes tested (C4-T1).  The CI was referred to Occupational Therapy for splinting and pinch testing.  The pinch testing showed some decreased left grip strength, and a slight decrease in point sensation when compared to the right.  The diagnosis was Bilateral ulnar nerve irritation, and he was fitted with splints.  An MRI done in February 2005 was read as, “Borderline central stenosis upper cervical spine. Mild central protrusion at C2-3. No significant spinal stenosis. There was borderline central canal stenosis with the central canal measuring approximately 9-10mm at C3-4 and C4-5 levels.”

The Board deliberated concerning whether or not additional disability rating was warranted by Ulnar nerve neuropathy in this case.  Once again, it is the presence or absence of functional impairment with a direct impact on duty performance which is the most crucial factor in the Board’s decision to recommend any condition for rating as additionally unfitting.  Diminished sensation on a small area of the forearms, and subjective feelings of numbness with no significant loss of strength does not rise to that threshold.  The Board unanimously agrees that there is not sufficient evidence to support recommending Ulnar nerve neuropathy as an additionally unfitting condition for separation rating.

History of Other Conditions – Neck (Cervical spine) pain & strain, Cervical disc bulge, Bilateral arm pain, Right knee pain & swelling, Hyperlipidemia, and Teeth sensitivity were also discussed and considered by the Board.  There is no clearly documented evidence that any of these conditions caused a significant adverse effect on the performance of required military duties.  These other conditions are all judged by the Board to be not unfitting at the time of separation, and are not relevant for disability rating.  The Board therefore has no reasonable basis for recommending any additional unfitting conditions for separation rating.

History of Non-Disability Evaluation System (DES) Conditions (not documented in DES package) – Post-traumatic Stress Disorder (PTSD) was also considered by the Board.  There is no clearly documented evidence that this condition was a matter of record in the DES package.  Therefore, it is judged to be outside the scope of this Board. 
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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.  Furthermore, Army PEB reliance on the US Army Physical Disability Agency (USAPDA) pain policy (for rating the Low back pain) may have been operant in this case.  The CI’s conditions were adjudicated independently of that policy by the Board.  

In the matter of the Chronic Low Back Pain condition, the Board unanimously recommends a disability rating of 20% coded 5243, IAW VASRD §4.71a.  

In the matter of the Lumbar radiculopathy, Ulnar Nerve Compressive Neuropathy, Neck pain, Neck strain, Cervical disc bulge, Arm pain, Knee pain & swelling, Hyperlipidemia, Teeth sensitivity, or any other medical conditions eligible for Board consideration; the Board unanimously agrees that it cannot recommend any findings of unfit for additional rating at separation. 

PTSD, rated by the VA, was not a matter of record in the Disability Evaluation System (DES) package and is therefore outside the scope of the Board.  The CI retains the right to request his service Board for Correction of Military Records (BCMR) to consider adding this condition as unfitting.
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RECOMMENDATION: 
The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation.

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Low Back Pain	5243	20%	
COMBINED	20%	

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The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20090205 w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans' Affairs Treatment Record.