RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00409
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070815

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Fire Support Specialist, medically separated chronic low back pain, with a disability rating of 10%.

CI CONTENTION:  The CI contended for his back, PTSD, neck, residual radiculopathy and other illness.  The CI’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 - 20070509	VARD - 20080408	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5237	10%	Lumbar Spine, Degenerative Disc Joint Disease	5010-5237	10%	20080214	
Depression	Not Unfitting	Post-Traumatic Stress Disorder	9411	10%	20080214	
Pes Planus	Not Unfitting	Pes Planus, Bilateral	5276	0%	20080214	
Left Eye Pterygium 	Not Unfitting	Pterygium, Left Eye	6034	0%	20080214	
Obesity	Not Unfitting	No VA Placement	
Hyperlipidemia	Not Unfitting		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS: 3 0%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  A note in the service treatment record (STR) dated 14 May 2003 indicated the CI complained of low back pain after reinjuring his back after moving furniture.  The CI noted that he originally “messed his back up” at JRTC (Joint Readiness Training Center) in 1997.  Treatment consisted of Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID)).  On 23 June 2003 the CI reported not only pain when running, but also loss of feeling in the legs posteriorly.  On examination straight leg raising (to determine nerve root irritation) was negative.  X-rays showed partial ossification of the right sacral spinous ligament.  In April 2004 the CI had sharp pain in the left lumbar area without radicular symptoms and with no lower extremity weakness.  The diagnosis of SI [sacroiliac] joint dysfunction and mechanical low back pain was made and treatment consisted of Mobic (meloxicam, an NSAID) and Flexeril (cyclobenzaprine, a muscle relaxer).  An X-ray series in November 2005 of the lumbosacral spine revealed no evidence of traumatic, neoplastic or significant arthritic changes or evidence of spondylolysis (a defect of a vertebra (pars interarticularis) usually at L-5) or spondylolisthesis (a vertebra overriding another vertebra).  A CT [computerized axial tomography] scan in January 2006 demonstrated an L4-L5 broad-based bulge with mild canal stenosis with possible contact of the L5 nerve roots and an L5-S1 mild broad-based bulge without canal or neuroforaminal (an opening in the vertebral column where nerves pass through) stenosis.  In March 2006 the low back pain worsened to involve the lower extremities when the CI ran or did heavy physical exertion.  He stated: “I also have numbness in both of my legs and sometimes, my feet as well.”  His Military Occupational Specialty as a fire support NCO required he carry an extra weighted rucksack.  The CI also had stress related to an upcoming deployment, separation from family, and denied terminal leave with stop loss.  An MRI [magnetic resonance imaging] dated 11 April 2006 demonstrated a small L5-S1 paracentral disc protrusion, which contacted and minimally displaced the left S-1 nerve root and a diffuse annular bulge at the L4-L5 level was present with minimal crowding of the central spinal canal.  Examination in July 2006 revealed tenderness on palpation of the right and left paraspinal regions.  The lumbar spine had a normal appearance and straight leg raising was negative bilaterally.  No lower extremity weakness was observed; sensation to tactile stimulation was normal; and the CI’s gait and stance were normal.  Examination in October 2006 was similar to that of July 2006 and a P3 profile was recommended for lumbago (lower back pain) and sciatica.  In November 2006 an examination revealed bilateral paraspinal tenderness and lumbosacral muscle spasms with negative straight leg raising and without lower extremity weakness.  Gait and stance were normal.  At the Medical Evaluation Board (MEB) examination on 20 December 2006 the CI reported daily back pain, which was severe at times, but without loss of bowel or bladder control.  Sensory and motor examinations were normal as were the CI’s gait and stance.   

The commander’s statement was undated, but a letter indicated the commander was in charge of the unit from July 2006 through July 2007, and the commander noted the CI was serving in a rear detachment because he had been in extreme pain due to his back, was stressed out at times preparing for deployment, and was incapable of performing tasks to standard and could not deploy with his unit.  A permanent L3 profile was issued on 17 November 2006 for low back pain with limitations of running and sit-ups as part of the physical fitness test and all functional military activities except wearing a protective mask and all chemical defense equipment.  Additional restrictions included no heavy lifting greater than 30 pounds and no loading impact activities to include running, jogging, jumping, side-straddle hop, and ruck marching.  At the MEB examination, the CI reported on DD Form 2807-1 dated 6 December 2006 his back problems were worst at deployment 2004-2005.  He had lower back pain with some upper back pain as well and numbness or tingling of the legs.  On 20 December 2006, the MEB physical examiner noted pain at L4, L5, and S1 and listed the diagnosis as chronic low back pain with intermittent radicular signs.  

The MEB narrative summary (NARSUM) dated 20 February 2007 noted the thoracolumbar spine was normal to inspection and palpation without tenderness or spasms.  There was a 3cm circular area of the anterior distal leg/upper ankle area of decreased sharp and soft sensation.  Otherwise sensation was normal with normal strength of the hips, knees, ankles, and toes.  Reflexes of the knees were 2+ on the right and 1+ on the left due to structural knee changes from an old injury, while at the ankles the reflexes were 2+ bilaterally.   The CI’s gait and stance were normal.  The CI stated he had pain of the lower lumbar area with radiation to the left more than the right with a sensation of loss of strength.  Pain intensity was 8/10 to 3/10 at the best and was exacerbated by activities including moving, lifting greater than 40 pounds, standing more than 1 hour and bending over.  However, the CI was able to report to work even when the pain was severe, although he had numbness and weakness of the legs when running, but no complaints of bladder, bowel or erectile dysfunction.

At the VA Compensation and Pension (C&P) examination dated 14 February 2008, performed 6 months after separation, the CI reported mechanical low back pain in a transverse band across the lower lumbar region.  He denied any lower extremity radicular signs or symptoms other than the inability to run quickly without exacerbating his low back symptoms and had no incapacitating episodes in the prior 12 months.  On examination he walked freely and briskly without an antalgic gait.  The thoracolumbar spine had normal curvature.  There was tenderness of the lumbar spinous processes without tenderness of the lumbar vertebral muscles, sacroiliac joints, or the sciatic notch.  Sensation and motor strength of the lower extremities was normal and straight leg raising was negative bilaterally.  Range of motion measurements were normal and are in the chart below.  There was no apparent pain, loss of motion, weakness, fatigability, or loss of coordination with repetition.

The PEB assigned a 10% rating using code 5299-5237 (lumbosacral strain) for chronic low back pain.  The VA assigned a 10% rating using code 5010-5237 (Arthritis due to trauma-lumbosacral strain) for lumbar spine, degenerative disc disease.  The Board sought a route to a higher rating, but was unable to do so in the absence of ankylosis, forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, or episodes of incapacitation.  The Board then considered whether an additional rating could be recommended under a peripheral nerve code.  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.    

Contended PEB Conditions-Depression, Obesity, Hyperlipidemia, Pes Planus, and Left Eye Pterygium.  The depression, obesity, hyperlipidemia, pes planus, and left eye pterygium were not profiled or explicitly implicated in the commander’s statement, although the commander noted the CI was “stressed out.” Additionally, the conditions were not judged to fail retention standards.  

Depression.  The CI was seen for an initial intake on 17 October 2006 with the complaints of sadness, anger and pain in the back and legs.  He felt his command had singled him out and disrespected him.  He slept 3-4 hours a night, had a loss of sex drive, and isolated himself by not getting out of bed on weekends.  On examination his mood was sad, but his affect was appropriate.  His thought processes were linear and he had no suicidal or homicidal ideation or intent.  Judgment and insight were good.  He was “operating at a GAF [Global Assessment of Functioning] of 51 or above” (moderate symptoms or moderate difficulty in social, occupational, or school functioning).  The CI was compliant with Wellbutrin (bupropion, an antidepressant) at a follow-up visit on 6 November 2006 and he had shown improvement in stability and coping due to resolution of his concern about deployment with his back problem.  Depressive symptoms persisted; however, the therapist opined that prognosis was good for remission with continued medication and therapy.  On 20 November 2006, the CI was alert and oriented with his mood “okay” with a congruent affect.  Thought process was linear and goal directed.  There was no impairment of insight; concentration was good; memory was intact, and impulsivity was low.  By 25 January 2007 the major depression was determined to be in full remission and the CI’s mood was “really good.” The medication was continued.  A report of mental status evaluation indicated the CI had the mental capacity to understand and participate in the [PEB] proceeding, was mentally responsible, and met retention requirements. The author, a psychiatric nurse practitioner, indicated the CI was evaluated on 22 February 2007 and had been successfully treated for all mental health related disorders.  At the VA initial evaluation for post-traumatic stress disorder on 14 February 2008 a note indicated the CI was being followed at the VA and was taking citalopram (an antidepressant), bupropion, and trazodone (an antidepressant).  He reported feeling discouraged about not having current employment, losses of friends when deployed, and trust issues.  The Axis I diagnosis was adjustment disorder with depressed and anxious mood, alcohol abuse in remission and chronic mild post-traumatic stress disorder and his GAF was 65 (some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships). 

Obesity and Hyperlipidemia.  Not a physical disability.

Pes Planus.  The MEB examiner circled moderate and symptomatic, but did not circle pes planus on DD Form 2808 dated 20 December 2006, but in an examination on the same date an annotation of significant pes planus was recorded.  The CI did have orthotics ordered by a podiatrist, but the CI noted at a VA examination in February 2008 he never received them and he used off-the-shelf plantar arch supports, which were beneficial in relieving his arch pain symptoms.  At the VA examination there was minimal tenderness to palpation and no evidence of foot deformities or abnormal weight bearing.  The diagnosis of mild pes planus was made and was confirmed by weight-bearing X-rays of the feet. 

Left Eye Pterygium.  The CI had a history of a corneal abrasion in 2003 that was treated with antibiotics and a patch and had an irritating pterygium (a benign growth on the conjunctiva) surgically removed from the left medial eye in June 2005.  He had left eye pain 2 months postoperatively that was treated with a topical antibiotic (erythromycin), artificial tears, and Maxitrol (a combination of topical antibiotics (neomycin and polymyxin B) and dexamethasone, a topical steroid).  On examination at the VA the CI had 2+ redness of the nasal aspect in the area where the pterygium was removed and was confirmed by slit lamp examination to be a recurrent pterygium.  However, there was no impairment of vision and the CI’s visual acuity was 20/20 uncorrected.

The aforementioned was reviewed and considered by the Board.   There was no performance based evidence from the record that any 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 the any of the contended conditions; therefore, no additional disability ratings are recommended.

BOARD FINDINGS:  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.  In the matter of the contended depression, obesity, hyperlipidemia, pes planus, and left eye pterygium 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.  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 20140113, 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, AR20160006024 (PD201400409)

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