RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2013-01768
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040225

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4, Personnel Services Specialist, medically separated for lumbosacral condition.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS).  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic low back pain,” “stress-related changes to the symphysis pubis,” and “degenerative joint disease, lumbosacral spine” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two other conditions (“depression” and “migraine headaches”) for PEB adjudication.  The Informal PEB adjudicated “chronic low back pain…stress reaction at the right superior symphysis” as unfitting, rated 10%.  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.  

CI CONTENTION:  “At the time my original medical board, my knees were not a problem for me.  I had more issues with my lower back.  Over the years I have had increased pain and discomfort in my knees, more so my right knee.  I’m having trouble wearing heels and flats irritate my foot.  This condition with my knees are degenerating, I know I feel that over time, it’s only going to get worse.  A lot of physical activities I used to do, I no longer can do because of the instability in my knees.  Things like climbing stairs, jogging, prolonged sitting & standing sometimes even walking is hard for me.”  

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 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 20031212	VA* - (~4 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain…Stress …Right Superior Symphysis	5237	10%	Lumbosacral Strain 	5237	10%	20031021	
Other MEB/PEB Conditions x 2 (Not In Scope)	Other x 10 (equals SC, NSC & deferred)	
RATING:  10%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20040913 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Chronic Low Back Pain…Stress Reaction at the Right Superior Symphysis Condition.  Service treatment records (STRs) indicate the CI fell from a 12-foot wall in basic training in June 2000.  She developed low back pain with morning stiffness with a pain level that ranged between 4-9/10.  Sometimes the pain interfered with sleep.  The pain persisted over 3 years while she was training for her Army physical fitness test (APFT.)  Prolonged standing or sitting made it worse.  She began to have sharp radiating pain from her low back to bilateral gluteal muscles.  X-rays were normal and magnetic resonance imaging (MRI) showed no significant lumbar spondyloarthropathy.  She was followed by physical management rehab, physical therapy, and neurology and received conservative treatments.  She received multiple profiles to restrict her physical activities and avoid exacerbations.  However, she exacerbated her condition whenever she tried to perform the duties of her MOS or prepare for her PT.  

The narrative summary (NARSUM), dated August 2003, documented a recent bone scan showed mild stress-related changes to the left more than the right superior symphysis pubis as well as stress-related changes to the L4 vertebral body.  She continued to have low back pain that limited her MOS duties and she was unable to train for a PT test.  Exam of the lumbosacral spine showed tenderness between L4-L5 with mild paravertebral spasm.  There was a full range of motion (FROM) in all directions.  She had pain with facet loading in the left lumbosacral area and had a positive FABER (a test of hip joint or sacroiliac joint pathology) and a positive Gaenslen’s test (musculoskeletal abnormalities and chronic inflammation) on the right.  Strength was 5/5 with normal tone and no atrophy.  Sensation was intact and deep tendon reflexes were 2+.  Gait was normal.  

At the VA Compensation and Pension (C&P) exam performed 4 months before separation, the CI reported pain of ingrown toenails, bilateral ankle and knee pain, and low back pain.  Exam of the low back showed no visible scars or joint deformity.  There was tenderness in the lower lumbar spine, greater over the spinous processes and over the paravertebral spinal musculature.  She had 5/5 motor strength.  She had a full range of flexion at 90 degrees, extension of 25 degrees limited by pain.  There was a FROM with bilateral bending and rotation.  
C&P neurological exam of the extremities, dated 31 October 2003, revealed no weakness, atrophy or other nerve problems.  She had normal sensation and normal gait.  

The Board directed attention to its rating recommendation based on the above evidence.  Both the PEB and the VA assigned a 10% rating, coded 5237 lumbosacral strain.  There were no periods of physician prescribed bed rest for any rating under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes (5243).  Although the NARSUM exam documented mild paravertebral spasms, there was no evidence of muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour to qualify for a 20% disability rating.  

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 low back pain condition.  

The Board also deliberated if additional disability was justified for peripheral nerve impairment.  The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting.  Pain (whether or not it radiates), stiffness, or aching is rated under the general formula for the spine and was considered in the 5243 rating above.  There was insufficient evidence in this case of functional impairment attributable to peripheral neuropathy that adversely impacted duty performance.  The Board therefore concluded that no peripheral nerve (radiculopathy) condition could be recommended for additional disability rating.  

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 low back 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 20131212, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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, AR20160000841 (PD201301768)

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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA