RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00164
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061107

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E6, Field Artillery Automated Tactical Data System Specialist, medically separated for “chronic low back pain” and “right lower extremity weakness and sensory loss,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The applicant contends for a higher rating.  The applicant’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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:  

SERVICE PEB - 20060828	VARD - 20070220	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	10%	Degenerative Disc Disease…Right Lower Extremity Weakness….	5242	10%	20061010	
Right Lower Extremity	8599-8520	10%					
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  The CI first reported low back pain (LBP) after falling form a military vehicle while deployed in late 2002.  Radiographs were reported as degenerative changes in the lumbosacral spine.  In addition to back pain, the service treatment record (STR) inconsistently indicated the CI experienced radicular pain and paraesthesia into one or both lower extremities, often in a non-anatomic dermatome pattern.  Magnetic resonance image (MRI) of the lumbar spine performed in March 2005 was normal.  The CI’s treatment included medications, restrictions, manipulations, epidural steroid injections, facet injections, and external bracing without complete resolution of back pain and or radicular symptoms.  He was permanently profiled in July 2006 and referred to an MEB.  There were no periods of VASRD-defined incapacitation.  

At the MEB narrative summary (NARSUM) examination on 15 May 2006 (6 months prior to  separation), the CI endorsed “lower back pain radiating down the middle back of his left leg, also throbbing down his right leg on to both the first and fifth digits.”  Additionally, he endorsed the inability to do sit-ups, push-ups, run, or upper body weight training.  His physical examination (PE) revealed a normal gait.  There was no comment IRT spinal range-of-motion (ROM) or the presence of painful motion.  There was right-sided sensory deficit in S-1 spinal distribution and 4/5 strength as compared to the normal left lower extremity.  His final listed diagnosis was ‘radicular lower back pain without anatomical correlate due to lumbosacral trauma’.  

At the VA Compensation and Pension (C&P) examination performed on 10 October 2006 (1 month prior to separation), the CI endorsed 6-8/10 constant LBP described as sharp, burning, stabbing, aching, and stinging in nature and associated with “…bilateral radiculopathy and weakness to legs.”  The VA PE revealed painful and limited motion of the lumbar spine.  Motor and sensory examinations were normal/intact.  His gait was not affected.  Right-sided straight leg raise was noted as painful.  His diagnosis was listed as thoracolumbar strain with degenerative disk disease and bilateral sacroiliac joint dysfunction and radiculopathy bilateral lower extremities.  
The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% under an analogous 5299-5237 code (lumbosacral strain) citing limited motion and tenderness.  The VA assigned a 10% rating using the 5242 code (degenerative arthritis of the spine) based on the VA C&P examination a month before separation citing painful or limited motion.  The Board considered its rating recommendation for the low back condition based on the VASRD General Rating Formula for Diseases and Injuries of the Spine.  Board members first agreed that the VA examination received near exclusive PV secondary to time reference to separation.  Absent compensable ROM, the evidence of painful motion is supported by VASRD §4.59 at 10%.  

Right Lower Extremity Weakness and Sensory Loss Condition.  The STR contained various exams that revealed 4/5 strength in the right lower extremity as well as decreased right-sided sensation in the S-1 spinal distribution as depicted in the NARSUM.  Board members acknowledged and agreed with the PEB’s analogous coding under VASRD §4.124a identifying the sciatic nerve as being affected and further concluded that the maintenance of a normal gait in such a setting would closely be depicted as a mild condition.  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’s adjudication for the right lower extremity condition.

BOARD FINDINGS:  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 right lower extremity condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  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 20131227, 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 XXXXXXXXXXXXXXXXXX, AR20160005535 (PD201400164)

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