RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00155
BRANCH OF SERVICE:  Army 	BOARD DATE:  20150430
SEPARATION DATE:  20070531

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6 (Petroleum Supply Specialist) medically separated for chronic radiating low back pain.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  Chronic low back pain was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also forwarded migraine headaches, residual foot discomfort after bunion surgery, patellofemoral pain syndrome, goiter, persistent postnasal drainage, adjustment disorder and hypertension for PEB adjudication.  The Informal PEB adjudicated chronic radiating low back pain as unfitting, rated 10% 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 elaborated no specific contention in her application.

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 condition 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 20070419	VA* - (<1 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Radiating Low Back Pain	5299-5237	10%	Mild Degenerative Arthritis of the Lumbar Spine…	5242	10%	20070608	
Other x 7 (Not In Scope)	Other x 9	
RATING:  10%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20070913 (most proximate to date of separation (DOS))

ANALYSIS SUMMARY:  

Chronic Radiating Low Back Pain.  A note dated 19 October 2005 indicated the CI, who had a documented history of a herniated nucleus pulposus presented with back pain and radicular complaints down the left lower extremity, which occurred when she bent over.  The pain subsided somewhat, but she continued to have numbness down the posterior aspect of the leg to the plantar aspect of the foot in an L5-S1 distribution.  Treatment consisted of prednisone (an oral steroid), Vicodin (hydrocodone/APAP-narcotic/pain reliever) and Cyclobenzaprine (a muscle relaxant).  Within 5 days, there was approximately 20% improvement.  Two days later she had a full range-of-motion (ROM), but had non-specific chest pain.  The heart examination was normal; the EKG was normal; and her blood pressure was elevated to 160/108 (normal 120/80), which was treated with a Hydrochlorothiazide (a diuretic).  In a request for a lumbar spine series, it was noted the CI had back problems when deployed and had an MRI in country that showed a disc bulge.  Since then, there had been a sharp increase in pain with radiation to the buttocks, which was exacerbated by running.  The lumbar X-rays performed 27 January 2006 demonstrated minimal degenerative disc and end-plate changes at the thoracolumbar level with no significant degenerative changes of the lower spine.  

An orthopedic consultation was carried out in September 2006 for back pain and bilateral radiculopathy, which persisted despite of physical therapy, nonsteroidal anti-inflammatory medication, Flexeril (Cyclobenzaprine-a muscle relaxant) and narcotics.  A lumbar spine series in October 2006 was interpreted as a “negative exam,” while a follow-up MRI demonstrated L5-S1 disc narrowing and mild dehydration and a moderately small posterior central herniation of the L5-S1 disc.  Neurology evaluation in November 2006 indicated the CI had a burning sensation over the lower part of her back radiating more so on the right than the left.  She had a “sore spot” over the supratrochanteric (hip) region on the right that appeared to be a trigger point with minimal tenderness over the right paralumbar region without specific spinal tenderness.  The ROM of the lumbar spine was restricted on forward flexion by about 30% and backward movements by 10%; and muscle strength and sensation were normal.  The impression was a possible right L5-S1 radiculopathy.  An evaluation by a physical medicine and rehabilitation specialist (PM&R) in 10 December 2006 offered the options of a lumbar zygapophyseal joint (between two adjacent articular processes of adjacent vertebrae) block as well as an injection into the right sacroiliac (SI) joint.  The CI consented and the steroid/anesthetic injections were carried out on 12 December 2006.  Electrodiagnostic studies of the lower extremities performed on 13 December 2006 revealed no evidence of a right L3-S1 radiculopathy, generalized sensory motor polyneuropathy, or entrapment neuropathy.  The examiner felt the SI joints were the source of the CI’s pain.  Bilateral lumbar medial branch blocks were carried out on 9 January 2007.  PM&R evaluation in February 2007 noted flexion to about 70 degrees and agreed with the diagnosis of bilateral SI joint abnormality, right greater than left.  He opined that her primary pain generators included bilateral piriformis and external rotator muscles that contributed to the myofascial pain problems in the gluteus muscles (of the buttocks) bilaterally.  In late February 2007, she experienced more intense discomfort in her low back more so on the right side with radiation to the right buttock, right leg and right hip.  Physical therapy was recommended and instituted on 1 March 2007.

At the DD Form 2808, Report of Medical Examination, dated 25 January 2007, approximately 4 months prior to separation, the CI reported lower back and buttock area pain began in 2002, which was confirmed to be a herniated disc in 2005, but treated by pain management as SI pain.  Numbness and tingling were noted in the back of her legs to the feet.  The examination noted pain with flexion which was 45-50 degrees.  There was no deformation of the spine, but there was point tenderness over the left SI joint.  Straight leg raising was positive more so on the left than the right and there was no weakness.  The examiner’s diagnosis was chronic low back pain with SI joint pain and degenerative disc disease of the spine.  The commander’s statement dated 26 January 2007 indicated the CI was physically incapable of reasonably performing her duties or meeting basic military requirements, was unable to participate in field exercises, and could not be deployed.  A permanent L3 profile was issued on 31 January 2007 for chronic low back pain with limitations of functional military activities and physical fitness testing.  She was restricted from running, heavy lifting, sit-ups, 24 hour duty, and having no more than a six hour work day.

The MEB narrative summary (NARSUM) dated 20 February 2007, approximately three months prior to separation, indicated the CI first noted low back pain in 2002 while deployed and had a history of a falling off a tank wearing MILES (multiple integrated laser engagement system) gear in October 2001, but was uncertain whether it had an impact on her back pain.  Over the following years she had multiple evaluations by orthopedics, physical therapy, and primary care, but she had a continuing problem with burning discomfort in her buttocks.  An MRI showed no significant change other than bulging discs.  When deployed in 2005 she experienced increased pain and inability to straighten up after bending over.  When she returned an MRI demonstrated a small herniated disc, which was felt not to be the etiology of her pain.  She had a radiofrequency ablation of the nerves on the right with a 40% reduction in pain.  Treatment of the left side was planned for the future.  Examination revealed a normal gait with flexion to approximately 45 degrees and extension to 5-10 degrees.  Tenderness was present over the lower lumbar area particularly over the SI joints bilaterally.  Neurologic evaluation was unremarkable.  Toe and heel walking were normal.  She reported pain was usually at a 4/10 level (10 being the worst pain), but it had risen as high as 9/10.  She could not run, had limited sitting time, and had difficulty sleeping in certain positions.

At the VA Compensation and Pension (C&P) examination dated 8 June 2007, performed one week post-separation, the CI reported bilateral pain at the region of the SI joints with right posterior leg pain twice a month described as nagging and burning, not always sharp or dull with an intensity of 4/10.  She reported using Lortab (Hydrocodone-a narcotic and Acetaminophen-a pain reliever) and Amitriptyline, an anti-depressant medication for nerve pain during a flare-up about once or twice a month.  Since she was out of the Army, her occupation as a student was not affected and there was no effect on mobility or incapacitating episodes in the prior 12 months.  Neurologic examination was unremarkable without evidence of spasm.  Straight leg raise tests (to determine nerve irritation) were negative.

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)	NARSUM ~3 Mo. Pre-Sep	PT ~3 Mo. Pre-Sep	VA C&P <1 Mo. Post-Sep	
Flexion (90 Normal)	45	75 (75/75/75)	65	
Extension (30)	5-10	30 (40/40/40)	10	
R Lat Flexion (30)	Normal	30 (45/45/45)	15	
L Lat Flexion (30)	Normal	30 (45/45/45)	30	
R Rotation (30)	--	30 (40/40/40)	20	
L Rotation (30)	--	30 (55/55/55)	20	
Combined (240)	--	225	160	
Comment	Normal gait; tenderness over the lower lumbar area particularly over the SI joints; toe and heel walking normal	Limitation due to pain	Tenderness of the mid lower lumbar vertebra and specific  tenderness of the SI joints, no irregularity in curvature of the spine; gait was steady; posture was erect; pain with forward flexion with difficulty standing back up	
§4.71a Rating	20%	10%	10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5299-5237 (lumbosacral strain) for chronic radiating low back pain.   The VA assigned a 10% rating using code 5242 (degenerative arthritis of the spine) for mild degenerative arthritis of the lumbar spine (claimed as low back pain).  Firm Board precedence requires a functional impairment linked to fitness to support a recommendation for addition of a peripheral nerve rating to Service disability in spine cases.  The pain component of a radiculopathy is subsumed under the general spine rating as specified in §4.71a.  The sensory component in this case has minimal to no functional implications; and, the motor impairment was either intermittent or relatively minor and cannot be linked to significant functional consequence.  Thus, there is no evidence of a separately ratable functional impairment (with fitness implications) from the residual radiculopathy; and, the Board cannot support a recommendation for an additional Service disability rating on this basis. The Board sought a route to a higher rating and noted that the forward flexion ROM was 45 degrees at the time of the MEB examination.  However, examinations subsequent to that examination were more proximate to separation, more in depth and more consistent with each other.  Therefore, a higher probative value to the subsequent examinations is warranted.  As a result, the Board was unable to find a route to a higher 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 radiating 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 radiating 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 20140103, 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, AR20150014346 (PD201400155)

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