RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2013-01969
BRANCH OF SERVICE:  Army	BOARD DATE:  20150217
SEPARATION DATE:  20080812

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Wheeled Vehicle Mechanic) medically separated for chronic low back pain (LBP).  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty; however, his physical profile authorized him to perform an alternate aerobic physical fitness test event.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The condition characterized as “low back pain” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded four other conditions (“right shoulder pain”, “right wrist pain”, “hypertriglyceridemia” and “acute stress reaction”) for PEB adjudication.  The Informal PEB adjudicated “chronic low back pain” as unfitting, rated 20% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI attached a one page statement to his application which was reviewed by the Board and considered in its recommendations.

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.

RATING COMPARISON:

 IPEB – Dated 20080522	VA* - (~1 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	20%	Lumbosacral Spine Degenerative Disc Disease with
Radiculopathy	5242	20%	20080715	
Right Shoulder Pain	Not Unfitting	Status Post Right Shoulder Dislocation with
Impingement Syndrome	5203	0%	20080715	
Right Wrist Pain	Not Unfitting	Right Wrist Strain	5215	0%	20080715	
Acute Stress Reaction	Not Unfitting	No VA Placement	
Other x 0 (Not In Scope)	Other x 0 (equals SC, NSC & deferred)	
RATING:  20%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20080904 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Chronic Low Back Pain Condition.  The narrative summary (NARSUM) notes in May 2004 during deployment the CI fell down a flight of stairs and injured his back.  After a period of light duty he returned to his convoy duties and completed the deployment.  At a subsequent pre-deployment evaluation in late 2005 the CI reported a constant, steady increase in LBP and he was found not deployable.  However, despite the back pain the CI voluntarily deployed in December 2005 and returned with his unit in December 2006.  While deployed, the CI reported that there were limitations on his activities and he was treated with physical therapy (PT).  The CI’s back pain was stable during deployment, but was aggravated after his return when he fell and struck his back on a rock while playing football in January 2007.  Lumbar spine X-rays on 18 January 2007 noted a narrow L5-S1 disc space, without other abnormality and magnetic resonance imaging (MRI) on 13 February 2007 showed, mild spinal arthritis and degenerative disc disease (DDD), with a focal disc protrusion causing mild impingement of the left L5 nerve root.  PT was tried, but stopped due to lack of benefit.  A neurosurgical evaluation performed on 26 March 2007 noted LBP with radiation into the left leg and exam noted tenderness of the lower lumbar area with normal strength, sensation and reflexes of the lower extremities (LE) and negative straight leg raise (SLR) bilaterally.  Surgery was not recommended.  The CI was referred for epidural steroid injection, which increased his pain and caused a reaction, and no further injections were given.  The CI was also treated with osteopathic manipulation and deep tissue massage, neither of which provided relief, in fact his left LE pain was reportedly increasing.  The CI aggravated his back when he fell down stairs at home at the end of September 2007 and a second MRI was performed on 6 October 2007, which noted DDD and a disc bulge at L5-S1, possibly contacting the S1 nerve roots bilaterally.  Frequent muscle spasm was noted in the service treatment record (STR) and many visits documented range-of-motion (ROM).  Five PT ROM evaluations between 8 months prior to separation and the MEB noted thoracolumbar (TL) flexion as follows: 15 degrees, a day later 30 degrees, a week later 48 degrees, 50 degrees, and 55 degrees for the MEB.

At the MEB examination on 17 April 2008, 4 months prior to separation, the CI reported constant LBP with flares three times per week with muscle spasms.  The MEB physical exam noted an antalgic gait and use of a cane to ambulate.  There was tenderness to palpation (TTP) of the TL spine and muscle spasm present.  ROM was flexion of 55 degrees, 55 degrees, 55 degrees (normal 90 degrees) and combined ROM of 175 degrees (normal 240 degrees), with pain with all ROM.  Lower extremity sensation and reflexes were normal and the CI was able to toe and heel walk, but was unable to stand on one foot on the left or squat due to left leg pain.

At the VA Compensation and Pension (C&P) examination on 15 July 2008, a month prior to separation, the CI reported LBP that radiated intermittently to the left or right LE, without other neurological problems.  He denied flares-ups or any incapacitating episode since the original fall and had not missed work in the past 12 months.  The exam noted ROM of flexion of 45 degrees with pain, and combined ROM of 195 degrees.  Reflexes were normal and SLR was positive bilaterally.  Five repetitions did not cause any fatigue, weakness, lack of endurance or incoordination or increased loss of ROM.  A post separation VA treatment note dated 30 September 2008 noted low back tenderness with “full ROM.”

At the C&P examination on 18 May 2009, 9 months after separation, the CI reported back pain with radiation to both LE.  On exam he was able to rise up on heels and toes.  There was TTP of the lumbar area with muscle spasm present with normal strength, sensation, and reflexes, and positive SLR bilaterally.  ROM was described as “he can flex forward and reach the knees” and reported in degrees as flexion of 28 degrees and combined ROM of 55 degrees.  An outpatient treatment visit dated 24 June 2009 noted mild lumbar tenderness, with normal LE strength, sensation, and reflexes and 6 August 2009 a visit for wrist pain indicated the CI was working out daily on exercise machines and a visit for back pain on 12 August 2009 noted a “steady gait.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 20%, coded 5299-5237 and initially the VA rated it 20%, coded 5242 (spinal arthritis).  The VA increased the rating to 40%, based on the 2009 C&P examination noted above.  The Board agreed that the evidence supports the 20% rating according to the VASRD spine rating rules in effect at the time of separation for flexion greater than 30 degrees and not greater than 60 degrees and also for muscle spasm associated with an abnormal gait.  The Board deliberated if a higher evaluation was supported by the ROM evidence with consideration of the C&P examination 9 months after separation.  Members noted that the after separation C&P may have reflected worsening of the back condition or a flare-up with muscle spasm, but service exams were stable for several months prior to separation and VA outpatient visits more proximate to the DOS noted mild tenderness, steady gait and full ROM.  Additionally the C&P examiner noted that the CI could “flex forward and reach to the knees,” which was inconsistent with the ROM reported in degrees.  Members agreed that the totality of the evidence in record supports the 20% rating, and reviewed to see if coding as 5243 and rating based on incapacitating episodes provided a higher evaluation.  However, there was no documentation of physician prescribed bed rest in the 12 months prior to separation and at the C&P exam, the most proximate exam to separation, the examiner noted the CI had no incapacitating episodes since the original injury, and denied flare-ups or missed work in the last 12 months.  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 low back condition.

The Board also considered if there was evidence in the record to support recommending the LE radiculopathy as separately unfitting and eligible for an additional disability rating.  Board precedent is that a functional impairment tied to fitness is required to support a recommendation for addition of a peripheral nerve rating at separation.  Proximate to separation the CI had reported LE radicular pain, but strength, sensation, and reflexes were normal throughout the record.  The pain component of a radiculopathy is subsumed under the general spine rating as specified in §4.71a and since no evidence of a motor or sensory deficit associated with functional impairment exists in this case, the Board cannot support a recommendation for additional rating based on peripheral nerve impairment.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the right shoulder, right wrist, and acute stress reaction conditions 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.

Right shoulder.  According to the NARSUM the CI dislocated his right shoulder in the fall down stairs while deployed as noted above.  At the MEB examination the CI reported right shoulder pain.  Right shoulder X-rays on 5 March 2008 were unremarkable.  The NARSUM noted the right shoulder pain meets retention standards.  At an evaluation for right wrist and hand symptoms on 4 February 2008 shoulder examination was performed and noted tenderness over the acromioclavicular joint (ACJ) with normal right upper extremity (RUE) strength and diagnosed ACJ arthritis.  The CI was offered injection of the ACJ.  PT measured ROM of the right shoulder on 3 March 2008 noted flexion of 155 degrees, 155 degrees, 160 degrees and abduction of 160 degrees times three with painful motion noted.

Right wrist.  According to the NARSUM the CI lacerated the right forearm in the fall down stairs while deployed as noted above.  At the MEB examination the CI reported right wrist pain.  The exam noted pain with percussion over the scar, with normal strength, no evidence of instability, and ROM of flexion 45 degrees (normal 80 degrees) and extension 65 degrees (normal 70 degrees).  The CI was right hand dominant and grip strength was decreased on the right compared to the left.  Right wrist X-rays on 20 December 2007 were normal.  Notes in the STR indicated that an MRI of the wrist on 4 November 2005 was unremarkable.  The CI reported that initial evaluation for chronic forearm wrist pain after the laceration included electrodiagnostic (EMG) studies, which were normal.  He reported difficulty with grasping and wrist rotation.  He reported pain into the top of his hand and some tingling of the thumb, index and middle fingers and weakness of his hand and wrist that impaired his ability to work as a mechanic.  Exam noted pressure over the radial nerve and pronation of the forearm caused pain.  Strength was normal except mildly decreased with wrist dorsiflexion.  Repeat EMG performed on 21 November 2007 and wrist X-rays on 7 December 2007 were normal.  Evaluation by an orthopedic hand specialist on 28 January 2008 noted that the CI reported vague forearm pain with tingling, with no numbness following repair of a laceration without any bone, tendon or vascular involvement.  The exam noted no evidence of nerve compression at the elbow or wrist, or vascular or sensory abnormalities.  The examiner comments are excerpted below:

Counseled on excellent outcome no functional deficits noted nothing to offer for pain meets retention standards per AR-40-501 no profile.

At the physical medicine MEB NARSUM on 14 February 2008 evaluation the CI reported pain of the wrist that became much worse with use.  The consult request noted activity related nerve pain which “comes on with pronation/supination.”  The examiner noted the laceration of the volar (underside) of the ulnar aspect of the forearm was well healed and wrist MRI, X-rays and EMG were normal.  The exam was as noted in the MEB exam and the examiner agreed with orthopedics that the right arm pain met retention standards.  A consult was made to neurology to evaluate the CI for chronic regional pain syndrome (CRPS) and the evaluation on 10 March 2008 noted that the CI’s pain was reproduced with pressure over flexor tendons with normal strength, sensation, and reflexes.  The diagnosis was chronic flexor tendonitis and noted that the CI seemed to have intermittent median nerve irritation from the tendonitis, but did not have CRPS.  The CI was given a brace for the wrist.  The neurologist commented that given the chronic nature of the wrist pain and “impact on current duty” the arm condition failed medical retention standards.  The NARSUM examiner noted that two of three specialist opinions determined the wrist condition met retention standards and one did not.  The examiner indicated that following further discussion with the CI it was decided that the wrist condition met retention standards.

The final permanent profile on 17 April 2008 noted U2 profile for shoulder, right wrist pain.  A prior permanent profile dated 28 January 2008 was U1.  The Board noted that a U2 profile indicates a condition which may require some activity limitations, but is not in all cases disqualifying for continued military service.  The permanent profile limitations pertinent to the RUE noted “may wear right wrist splint as needed” and indicated the CI could carry and fire a weapon and could participate in upper body weight training, with the remainder of physical limitations applicable to the back condition.  The right shoulder and wrist conditions were not implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed and considered by the Board.  There was no performance based evidence from the record that either 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 right shoulder and wrist conditions and so no additional disability ratings are recommended.

Acute Stress Reaction.  A psychiatry consult for the MEB on 3 April 2008 noted the CI had a history of acute stress reactions to combat experiences, especially following return from the first of two deployments.  The CI reported that there was much more combat action during his first deployment and that he experienced relationship difficulties and social withdrawal after his return.  The second deployment was less eventful and he reported his anxiety was reduced after the second deployment.  The examiner noted that the CI’s biggest stressor was his loss of capabilities due to his physical injuries, but that he had a positive outlook and was optimistic about the future.  The mental status evaluation was normal and the examiner’s assessment was a resolving acute stress reaction with a Global Assessment of Functioning of 71-80 (mild to minimal impairment range).  The examiner further commented that “this soldier does not have a psychiatric disability.”  The CI’s psychiatric condition was judged to have no impact on duty performance and the CI was determined fit for full unrestricted military from a psychiatric perspective.  Notes in the STR indicated that at a wellness assessment on 12 February 2007 the CI presented with concern for his marriage after two deployments and reported no psychological symptoms related to deployment or combat stress.  The CI was treated for insomnia but denied depression or increased stress, and there was no report of nightmares.  At a 22 February 2008 the CI reported feeling depressed about his medical condition, declined anti-depressant medication and reported concern that he may have posttraumatic stress disorder (PTSD).  A screening social work evaluation on 4 March 2008 noted symptoms of poor sleep, anger concerns and moderate anxiety, but a negative screen for PTSD.  The CI was going to enroll in an anxiety group and was involved in marriage counseling.

Performance evaluation reports from October 2005 to 31 October 2007 indicated the CI’s overall performance was “successful” and “superior” and he was rated “among the best” consistently.  The commander’s statement noted that the CI’s physical limitation due to the back condition limited his duty performance, but noted that he was a “model soldier.”  The psychiatric profile was S1 throughout the service.

The acute stress reaction condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  There was no performance based evidence from the record that any MH condition 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 acute stress reaction condition and so no additional disability rating 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 low back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended right shoulder, right arm and acute stress reaction 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 20131023 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, AR20150015444 (PD201301969)

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						     
						         
CF: 
(  ) DoD PDBR
(  ) DVA