RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00208
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070529

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Motor Transport Operator, medically separated for “chronic back pain,” with a disability rating of 20%.  

CI CONTENTION:  The applicant contends for her unfitting back condition and two conditions not identified in the disability evaluation system.  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 - 20070410	VARD - 20081010	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain,..,w/o Neurologic Abnormality	5299-5242	20%	Degenerative Disc Disease, Lumbar Spine	5237	20%	20080903	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain w/o Neurologic Abnormality.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had a previous history of low back pain (LBP) that flared-up in late 2006 without any specific injury or trauma, exacerbated by training for deployment. 

Imaging studies done in October 2006 and January 2007 showed marked degenerative changes at L4-5 with a herniated nucleus pulposus, and lumbar scoliosis to the left.  There was no surgical indication.  Despite treatment, the CI’s back condition could not be adequately rehabilitated to meet the physical requirements of her military specialty and she was referred for an MEB.  

At the MEB examination dated 8 February 2007, 3 months prior to separation, the physical examination noted an antalgic gait and the CI was unable to heel or toe walk.  There was tenderness to palpation (TTP) of the lumbar region and range-of-motion (ROM) limited by severe pain.  Testing for spinal nerve tension was positive on the right (straight leg raise testing-SLR) and there was decreased motor strength limited by pain.  

At the MEB NARSUM examination performed on 26 March 2007, 2 months prior to separation, the CI complained of LBP and right leg pain, and with some decreased sensation.  Physical examination noted the CI walked with a cane and had an antalgic gait.  There was TTP with lumbar muscle spasm noted and maneuvers to elicit signs of nerve root tension (radicular symptoms) were positive on the right.  Lower extremity strength and reflexes were normal and the examiner noted “some subjective decrease in sensation...on the right.”  The physical therapy MEB ROM examination performed on 7 March 2007 noted ROM to be measured with use of an inclinometer.  Other findings were the same as noted on the MEB NARSUM examination, with tenderness, muscle spasm, antalgic gait, abnormal spinal contour, and ROM limited by pain.

At the VA Compensation and Pension (C&P) examination on 3 September 2008, performed 16 months after separation, the CI reported LBP pain radiating down the right leg, with “needle to tingling” feeling, use of a cane, ability to function during times of pain and normal activities of daily living.  She reported no lost work time due to the back condition in the past 12 months.   Physical examination showed an abnormal posture and gait and use of a walker.  There was TTP of the lumbar muscles without spasm.  There was no additional limitation of motion after five repetitions.  Lower extremity strength, sensation, and reflexes were normal and SLR testing was negative.

The PEB assigned a 20% rating under an analogous 5299-5242 code (degenerative arthritis of the spine), citing antalgic gait due to muscle spasm and guarding.  The VA also assigned a 20% rating using the 5237 code (lumbosacral strain), citing ROM criteria.  

The Board noted that there was only one quantitative ROM in evidence prior to separation which was the noted physical therapy (PT) MEB ROM.  The PT evaluation, 2 months before separation, reported ROM measured with an inclinometer (not compliant with VASRD requirement of use a goniometer) as 10 degrees of flexion and 55 degrees combined ROM.  The measurements were labeled TL, however, no details were provided regarding the number of inclinometers used or placement for the Board to confirm if the measurements reflected TL ROM (normal flexion 90 degrees and combined ROM 240 degrees) or isolated lumbar ROM (normal flexion 60 degrees).  The C&P examination was 16 months after separation, which the Board acknowledges is somewhat outside the 12-month period for special consideration of post-separation VA evidence by the Board in its rating recommendation; however, it is the only other quantitative ROM in record.  At the C&P examination the “lumbar spine” ROM was 60 degrees, and combined ROM was 190 degrees.  The Board reviewed the evidence and noted that at both the PT MEB ROM and MEB NARSUM examinations, the presence of muscles spasm along with an antalgic gait was noted, but the C&P examination there was no muscle spasm present.  From this the Board concluded that muscle spasm contributed to the CI’s limited ROM prior to separation.  Additionally, as elaborated above, the PT measurement is not clearly documented and may have reflected total thoracolumbar flexion of approximately 40 degrees (if include normal isolated thoracic ROM with the 10 degrees of flexion measured by inclinometer noted.)  With this uncertainty regarding the pre-separation ROM evidence in mind, the Board deliberated the “fair and equitable” rating of the CI’s disability due to the low back condition at the time of separation.  After lengthy deliberations, based on the CI’s low back pathology as objectively evidenced by imaging studies and the improved C&P examination after separation (with no additional interventions noted), IAW VASRD 4.7 (Higher of two evaluations), Member consensus was that the “disability picture more nearly approximates the criteria” for the 20% rating.  The Board considered whether a higher rating was achieved by using the alternate rating formula based on incapacitating episodes due to intervertebral disc syndrome.  Although the CI had intervertebral disc syndrome (disc disease causing back pain and sciatica), there were no incapacitating episodes requiring bed rest prescribed by a physician documented in record to warrant consideration of rating under the alternate VASRD formula.  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 peripheral nerve impairment due to the back condition as separately unfitting and eligible for additional disability rating.  Proximate to separation the CI had RLE radiating pain and paresthesias, however, sensation, and reflexes were normal throughout the record.  At the MEB examination, pain limited strength was noted, but at the C&P examination LE strength was normal.  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 fixed sensory deficit associated with functional impairment exists in this case, the Board cannot support a recommendation for additional rating based on peripheral nerve impairment.

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.  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 20131221, 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, AR20160005867  (PD201400208)   

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