RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  xxxxxxxxxxxxxxxxxxxxxx	CASE:  PD-2014-00058
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070312

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Petroleum Supply Specialist) medically separated for chronic low back pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty but was authorized to perform an alternate physical fitness test per PROFILE.  He was issued a permanent P3 L2 profile and referred for a Medical Evaluation Board (MEB).  The “chronic low back pain” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two other conditions (“patellar enthesopathy on the left” and “allergic rhinitis”) for PEB adjudication.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “chronic low back pain” as unfitting, rated 0% with application of AR 635-40.  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.  

CI CONTENTION:  “The VA Rated me @10%. Immediately after Seperating Also knee And Sinus or asthma not Rated.” 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/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 20070207	VA* - (~2 Mos Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	0%	Low Back Strain	5237	10%	20070419	
Patellar Enthesopathy on the Left	Not Unfitting	Patellar Enthesopathy, Left Knee	5260	10%	20070419	
Allergic Rhinitis	Not Unfitting	Chronic Rhinosinusitis with nasal Polyposis	6522	30%	20070419	
Other x 0 (Not In Scope)	Other x 1 	
RATING:  0%	RATING:  50%	
*Derived from VA Rating Decision (VARD) dated 20070515 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Chronic Low Back Pain Condition.  The earliest note in the service treatment record dated 30 November 2004 indicated low back pain began when he hear a crack as he started performing a sit-up and had sharp pain with each subsequent sit-up.  He denied numbness and tingling in the legs and had no loss of bowel or bladder control.  A physical therapist in late December 2004 indicated a normal range-of-motion (ROM) with mild pain at the end of the ROM and instructed the CI about his diagnosis of mechanical back pain and instituted a treatment plan.  In June 2005, the CI re-aggravated his back when physical training and had tenderness of the muscles of the lumbar area.  Treatment consisted of Advil (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID)), Flexeril (cyclobenzaprine, a muscle relaxer), and physical therapy.  A temporary profile was issued to limit sit-ups.  On 10 July 2006, the CI awakened with back pain and recurring lower back spasms, was diagnosed as segmental dysfunction of the costovertebral region, and was treated with methocarbamol (a muscle relaxer).  By 15 July 2005 the CI’s thoracolumbar spine ROM was full and without pain on movement and neurologic evaluation was unremarkable.  In August 2006, the CI reported his medication was not helping the lower back pain that had been present for 2 years.  The NSAID was changed to meloxicam (an NSAID); the methocarbamol was continued; and he was given a temporary profile for a week.  Because of muscle spasms of the lower back in late August 2006, X-rays were performed that revealed no acute osseous abnormalities and sacralization of the last lumbar vertebral body, which was raised as “a cause of pain.”  Physical therapy was resumed in October 2006 where it was noted the CI’s gait was normal and he was tender to palpation from L3-S1 and had increased symptoms with extension and right side bending.  Because of continued pain when running, marching, sit-ups and lifting, he had a limited ROM.  As a result he was given a P3 profile and referred to the MEB on 11 October 2006.  A physical therapist noted the CI’s gait was normal and ROM measurements were flexion 75 degrees, extension 15 degrees and left and right side bending 10 degrees each; all ROMs were limited by pain.  In February 2007, a note indicated celecoxib (an NSAID) and methocarbamol were refilled.  

Post-separation, the CI reported his back spasms were better with Robaxin (methocarbamol) and the meloxicam dose was increased as needed in February 2008.  A rheumatology evaluation in June 2008 indicated the CI had lower back pain since 2004 that was localized and non-radiating with spasms along with mainly morning stiffness and arthralgia, which improved with hot showers, heat, standing and stretching.  X-rays revealed a minimal thoracolumbar curve with a developmental variation of L5.  On examination the CI had tenderness of the left L3-4 paraspinal muscles and forward flexion was 60-70 degrees.  Laboratory tests for ESR (sedimentation rate) and HLA B27 (a genetic marker) were pending, but there were no specific findings for spondyloarthropathy (inflammatory diseases of the spine that cause arthritis).  A VA examination in June 2008 indicated the CI still had back pain, which awakened him three to four nights a week that improved with tossing, turning, or walking and was being treated with Feldene (piroxicam, an NSAID) and methocarbamol.  Examination revealed flexion to 80 degrees without pain and to 90 degrees with pain and extension to 20 degrees with pain beginning at 10 degrees without change with repetition.  A remote X-ray series of the lumbar spine in May 2009 demonstrated shallow levoscoliosis (curvature of the spine to the left) without other abnormalities.  In April 2006, pain persisted and treatment with tramadol (an opioid-like medication) was noted.  Flexion was 80 degrees and extension was to 40 degrees.  

A permanent P3L2  profile issued in October 2006 for chronic lower back pain and retropatellar pain syndrome (see below) with limitation of all military functional activities except wearing a protective mask and all chemical defense equipment as well as physical fitness testing for running and sit-ups.  At the MEB examination dated 30 October 2006, the CI reported chronic lower back pain on a DD Form 2807-1.  On 18 November 2006, the MEB physical examiner noted lumbar sacralization on a DD Form 2808 (by referring to prior X-rays) and muscle spasms, and listed the diagnosis as chronic back pain that failed conservative therapy.  The commander’s statement dated 2 November 2006 indicated the CI could not perform his duties which involved heavy lifting, carrying, and climbing.

The MEB narrative summary (NARSUM) dated 16 January 2007 noted all conservative therapy had been exhausted including physical therapy with the use of all modalities including stretching, strengthening, TENS (transcutaneous electrical nerve stimulation) , ultrasound, pool therapy, as well as OMT (osteopathic manipulation therapy) and pharmacologic therapy.  His condition did not allow him to perform heavy physical requirements of his MOS nor was he able to operate military vehicles when he took certain medications.  He had a normal gait with an active ROM of flexion 75 degrees, extension 15 degrees, and left and right side bending to 10 degrees each.  All ROMs was limited by pain.  On numerous times he had not had any reproducible straight leg raises (to determine nerve root irritation) in his lower extremities or radicular complaints.  

At the VA Compensation and Pension (C&P) examination dated 18 April 2007, performed a month after separation, the CI reported, according the VA Disability Rating (VARD) dated 15 May 2007, paresthesia, decreased motion, stiffness, weakness, and pain.  The ROM measurements were flexion to 80 degrees, extension to 20 degrees, right and left lateral flexion to 20 degrees each, right lateral rotation to 25 degrees and left lateral rotation to 30 degrees.  There was pain with motion and tenderness that was severe enough to cause an abnormal gait or abnormal spinal contour.  The actual C&P examination was in concert with the measurements reported in the VARD; however, no pain on active motion was reported nor was there an additional loss of motion on repetition on examination.  Furthermore, the examiner answered yes to the question whether muscle tenderness was severe enough to be responsible for the abnormal gait or spinal contour, but was on examination both the gait and spinal curvature were normal.  

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)	Clinic ~5 Mo. Pre-Sep
	MEB ~2 Mo. Pre-Sep
	VA C&P ~1 Mo. Post-Sep
	
Flexion (90 Normal)	“LROM”
	75	0-80	
Extension (30)		15	0-20	
R Lat Flexion (30)		10	0-20	
L Lat Flexion (30)		10	0-25	
R Rotation (30)		-	0-25	
L Rotation (30)		-	0-30	
Combined (240)	-	-	200	
Comment	Motion increased pain; no tenderness to palpation, but crepitus with motion	All ROM limited by pain; gait normal	No pain on motion or loss of motion with repetition	
§4.71a Rating	-	10% (PEB 0%)	10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating using code 5299-5237 (lumbosacral strain) for chronic low back pain.  The VA assigned a 10% rating using code 5237 for low back strain.  The Board sought a route to a higher rating and discussed a 10% rating since both the MEB and VA examinations were compatible and reasonably consistent and timely.  However, the Board was unable to find a route to a higher rating in the absence of ankylosis, further decreased ROMs, muscle spasm, guarding, or localized tenderness resulting in an abnormal gait or abnormal spinal contour.  The Board then considered whether an additional Service rating could be recommended under a peripheral nerve code.  A functional impairment linked to fitness is required 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 recommends a disability rating of 10% for the chronic low back pain condition.  

Contended PEB Conditions. Patellar Enthesopathy of the Left Knee and Allergic Rhinitis.  The Board’s main charge is to assess the fairness of the PEB’s determination that patellar enthesopathy on the left and allergic rhinitis 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 knee condition was profiled as L2, albeit as retropatellar pain syndrome, while the allergic rhinitis was not profiled.  Neither condition was implicated in the commander’s statement; however, both were determined not to fail retention standards.  

Patellar Enthesopathy of the Left Knee-A X-ray series dated of the left knee dated 29 November 2004 demonstrated mild medial compartment joint space narrowing and superior patellar enthesopathy (a disorder of the attachment of a tendon or ligament to bone).  A physical therapy note dated 8 December 2004 indicated the CI had bilateral knee pain, left greater than right (although the right knee is not in the scope of review), had bilateral patella alta (elevated knee cap), normal ROMs, a positive left patella grind, tenderness to palpation at the patella tendon and joint line, no laxity and no evidence of a meniscal tear.  In January 2005 the CI noted running made the pain worse, but he was able to bike for the physical fitness test.  In March 2006 his chief complaint was left knee pain and on examination there was crepitus, tenderness on palpation, a full ROM, no effusion, no erythema, no patella shift laterally or medially, and no tenderness of the lateral retinaculum; an apprehension test was negative.  The diagnosis of patellofemoral syndrome was made and treatment was with Indocin (indomethacin, an NSAID) as well as no marching.  At the VA examination dated 18 April 2007, according to the VARD, physical therapy and naproxen (an NSAID) gave temporary relief.  The ROM measurements were flexion 100 degrees and extension 0 degrees.  An X-ray report revealed no demonstrable abnormality.  A 10% rating was assigned based on painful motion; however, the actual physical examination did not indicate any painful motion or loss of motion on repetitive use nor was there any laxity or evidence of a meniscal tear.  Nine months post-separation in January 2008, the CI reported his left knee was painful when he ran or jumped, but a brace helped.  On examination the left knee had slight swelling and the CI had a normal gait. 
						
Knee ROM
(Degrees)	
12 Mo. Pre-Sep
	
VA C&P ~1 Mo. Post-Sep

Left	Left	
Flexion (140 Normal)	
Full ROM	100	
Extension (0 Normal)		0	
Comment	Crepitus, apprehension test negative	No painful motion; no laxity; no evidence of a meniscal tear	
§4.71a Rating	-	VA  10%	

Allergic Rhinitis-The STR did not have any significant details relating to the allergic rhinitis other than a mention of it in the past medical history section and as an “All Other Conditions” diagnosis.  Post-separation a note dated 20 April 2007 indicated the CI reported seasonal allergic rhinitis prior to joining the service with an onset at age 14 or 15.  He reported worsening of bilateral nasal obstruction and the nasal and sinus symptoms following joining the service.  On examination there was no sinus tenderness, facial swelling or proptosis (protruding eyes), but there was right septal deviation.  Large and pale inferior turbinates consistent with allergic rhinitis were present.  Bilateral nasal endoscopies showed multiple enlarged polyps in the middle meatus.  The right nasal airway was almost obstructed and the left was obstructed by 70 to 80%.  There was no visible discharge on either side and there was no fullness or mass in the nasopharynx.  The examiner opined the CI had allergic rhinitis prior to joining the service and it was difficult to determine if the worsening symptoms were part of his service or part of the natur[al] progression of the disease and his symptoms were caused by the combination of allergic rhinitis, nasal polyposis and chronic sinusitis.  A note dated 30 January 2008 indicated the CI used Allegra (fexofenadine, an antihistamine) for nasal symptoms with diminishing relief and used nasal steroids 2 years earlier, but stopped due to little relief of symptoms and epistaxis (nasal bleeding).  Nasal saline and mometasone (a nasal steroid) were added to his treatment and allergy testing and desensitization were recommended.  A note dated 13 June 2008 indicated he had itchy eyes and runny nose with cats and long haired animals.  He was to decrease the nasal steroid and consider allergy testing.  

The aforementioned was reviewed.  All were reviewed and considered by the Board.   There was no performance based evidence from the record that either of the 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 either  of the 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.  As discussed above, PEB reliance on AR 635-40 for rating chronic low back pain was operant in this case and the condition was adjudicated independently of that regulation by this Board.  In the matter of the chronic back pain condition, the Board unanimously recommends a disability rating of 10%, coded 5299-5237 IAW VASRD §4.71a.  In the matter of the contended patellar enthesopathy of the left knee and allergic rhinitis 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 recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Chronic Back Pain 	5299-5237	10%	
RATING	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131223, 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 XXXXXXXXXXXXXXXXXXXXXX, AR20160001846 (PD201400058)

1.  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 to modify the individual’s disability rating to 10% without recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA