RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00008
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060612

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Equipment and Chemical Repairer) medically separated for a low back condition.  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 profile and referred for a Medical Evaluation Board (MEB).   Chronic mechanical lower back pain due to degenerative disc disease was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated chronic low back pain, secondary to degenerative disc disease and facet arthropathy, without neurologic deficit as unfitting, rated 10% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION: His low back condition continues to worsen.  He was not evaluated for PTSD condition.  His complete submission is at Exhibit A.

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 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 20060403	VA* - (~1 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain…	5242	10%	Strain, Lumbar Spine	5237	10%	20060512	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 4 	
RATING:  10%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20080229 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:

Low Back.  A note in the service treatment record dated 28 July 2005 indicated the CI had pain in the left back with deep inspiration for a week.  He denied a recent upper respiratory infection, cough, or fever.  He did weight lifting and first noticed the pain when doing laundry.  A chest X-ray series was normal with no focal air space process seen.   At an evaluation the next day, the CI noted no pain radiating to the legs and no muscle spasms.  Other than exhibiting lumbosacral spine pain elicited by motion, the examination was normal.  Treatment of the lower back sprain was with cyclobenzaprine (a muscle relaxant), and a profile.  A physical therapy evaluation on 23 August 2005 noted Motrin (Ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID)) and Flexeril did not help and the CI was taking Tylenol #3 (acetaminophen, a pain reliever, and codeine, a narcotic) at night.   Significant spasms were present in the left lower thoracic region with tenderness from T8 to L1.  Range-of-motion (ROM) measurements were flexion 80 degrees and extension 20 degrees.   Multiple physical therapy sessions helped, but the CI did not have a total resolution of the back symptoms, which he experienced after running or increased activity.  Methocarbamol (a muscle relaxer) was prescribed on 19 October 2005.  A CT scan revealed a minimal Schmorl’s node (disc protrusion into an adjacent vertebra) defect in the right side of the inferior L5 vertebral body.  There was no evidence of disk herniation at the L3, L4, or L5 disk levels.  The CI saw a spine specialist who made the diagnosis of lumbar spondylosis with facet arthropathy (arthritic changes) and noted minimal disc bulges at L3-L4 and L5-S1 with no significant nerve element compression.  An MRI of the lumbar spine was reported to be negative, but on review by the spine specialist, there was a hint of a possible very slight posterior annular tear and a possible small left paracentral annular tear, some facet arthropathy, and some increased fluid in the joints, which was interpreted as L4-L5 and L5-S1 facet arthropathy with facet mediated pain.  The CI underwent a bilateral lumbar medial branch test block procedure on 9 December 2005 and had 4 hours of significant relief, but the pain returned; however, he was able to stop taking the Tylenol #3 and the muscle relaxer.  The pain thereafter was described as a dull aching pain with occasional sharp pain.  

The CI reported on the DD Form 2807-1, Report of Medical History, dated 26 January 2006 recurrent back pain and “bulging di[s]cs,” while the MEB physical examination dated 27 January 2006 indicated tenderness to palpation at L2-L5 with bilateral paralumbar muscle tenderness to palpation and decreased ROM with pain.  The MEB narrative summary dated 6 February 2006 noted the CI had “lower backaches” when deployed with any precipitating injury.  He was able to work through them, but when he failed a fitness test run, the CI stated it was because the run caused severe lower back pain without radicular, bowel, or bladder problems.  In spite of physical therapy and one epidural steroid injection, the pain continued and was worse with bending, squatting, or running.  Physical examination revealed the CI had a normal gait and tenderness to palpation from L2 to L5 with moderate tenderness to palpation in the paralumbar muscle areas.  Supine straight leg raising (to determine nerve root irritation) caused low back pain at 80 degrees bilaterally, but seated straight leg raising was negative.  ROM measurements were flexion 70 degrees and extension 30 degrees, both of which were limited by pain, right lateral flexion 45 degrees, left lateral flexion 40 degrees, right rotation 40 degrees and left rotation 35 degrees.  Extensive physical therapy and medication did not provide relief of the CI’s lower back pain; the CI was not a candidate for surgery.  

A permanent L3 profile was issued in on 6 February 2006 and approved on 21 March 2006 for chronic low back pain due to degenerative disc disease with limitations of all functional military activities except wearing a protective mask and chemical defense equipment and no unit fitness training, physical fitness testing or ruck marching.  The commander’s statement dated 27 February 2006 indicated the CI’s lumbar degeneration prevented him from lifting, standing and bending over for long periods of time and as a result he was physically incapable of reasonably performing his duties of doing maintenance on vehicles and lifting heavy equipment and was totally incapable of performing his duties in a combat environment due to his bulging and deteriorating disks.

At the VA Compensation and Pension (C&P) General examination dated 12 May 2006, performed a month prior to separation, the CI reported stiffness, weakness, and traveling pain to the thighs due to the spine condition.  The pain occurred constantly and was described as crushing, burning, aching, sharp and cramping with a severity of 7/10 (10 being the worst pain).  Pain could be elicited by physical activity and relieved by rest and medication.  The CI experienced no incapacitation and did not lose any time from work.  On examination there was no evidence of radiating pain on movement.  Muscle spasm was absent.  There was tenderness on the midline of the lumbar area.  Straight leg raising was negative and there was no ankylosis.  The ROM was full with pain beginning at 80 degrees flexion and 20 degrees extension.  The joint function of the spine was additionally limited by pain and lack of endurance after repetition.  There were no signs of the intervertebral disc syndrome with chronic and permanent nerve root involvement.  Neurologic evaluation was unremarkable.

The 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)	MEB ~4 Mo. Pre-Sep	VA C&P ~1 Mo. Pre-Sep	
Flexion (90 Normal)	70	90	
Extension (30)	30	30	
R Lat Flexion (30)	(30)45	30	
L Lat Flexion (30)	(30)40	30	
R Rotation (30)	(30)40	30	
L Rotation (30)	(30)35	30	
Combined (240)	220	240	
Comment	Normal gait; tender to palpation from L2 to L5; no sacroiliac joint tenderness; and moderate tenderness to palpation in the paralumbar muscle areas.	Joint function was limited by pain and lack of endurance during repetition.	
§4.71a Rating	PEB 10%	VA 10%	

The Board directed its attention to its rating recommendation based on the above evidence. The PEB assigned a 10% rating using code 5242 (Degenerative arthritis of the spine) for chronic low back pain, while the VA also assigned a 10% rating using code 5237 (Lumbar spine strain).  The Board sought a route for a higher rating, but in the absence of ankylosis, more limited ROMs, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, the Board was unable to do so. The Board then considered whether an additional rating could be recommended under a peripheral nerve code.  Firm Board precedence requires a functional impairment linked to fitness to support a recommendation for addition of a peripheral nerve rating to disability in spine conditions.  Although the pain component of the neuropathy is appropriately subsumed in the spine rating IAW VASRD §4.71, which states that “rating is performed 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,” there was no sensory component with any significant functional implications and no motor weakness was in evidence.  Therefore, a radiculopathy could not be recommended for additional 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.

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 20131217, 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 XXXXXXXXXXXXXXXXXXX, AR20150018762 (PD201400008)

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