RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00555
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080127

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E6, Network Systems Operator-Maintainer, medically separated for “lumbosacral strain,” with a disability rating of 10%.

CI CONTENTION:  “I am suffering from things, such as anger, sleepiness, digestive problems, and reoccurring headaches, which were declined.  My other issues have gotten worse with time.”  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 - 20071019	VARD - 20080606	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbosacral Strain	5237	10%	Lumbosacral Strain 	5237	10%	20071204	
Gastroesophageal Reflux Disease (GERD)	Not Unfitting	Gastrointestinal Reflux Disease	7399-7346	0%	20071204	
Hypertriglyceridemia	Not Unfitting	No VA Placement	
Pes Planus	Not Unfitting	Plantar Fasciitis, Right Foot	5284	10%	20071204	
		Plantar Fasciitis, Left Foot	5284	10%	20071204	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Low Back Pain, due to Lumbosacral Strain.  According to service treatment records, this CI’s back condition began in August 2005 after prolonged wearing of full combat gear.  There was no other specific injury or trauma.  In November 2006, X-rays of the back were reported as normal.  In April 2007, magnetic resonance imaging (MRI) was also normal.  At the orthopedic clinic visit on 10 April 2007, the CI reported low back pain (LBP) that was worse with standing, walking or bending.  The pain radiated down the lower extremities.  On examination, range of motion (ROM) was painful and limited.  The examiner’s diagnostic assessment was: “Back strain.”  The CI was seen at the Pain clinic on 24 August 2007 and again on 20 September 2007.  On both occasions, there was no tenderness to palpation (TTP) of the lumbosacral spine.  Lumbar ROM was full, and without pain.  Straight leg raise (SLR) was negative.

Many different therapeutic modalities were tried, including physical therapy (PT), chiropractic care, and epidural steroid injections.  In spite of all treatment efforts, the LBP persisted and a Medical Evaluation Board (MEB) was initiated.  The MEB narrative summary (NARSUM) was dated 1 October 2007.  At that examination, the CI reported a constant dull pain in the lower back.  His symptoms were worse in the right lumbar region, than on the left.  He denied any radiation of pain, either up his back or down into his legs.  He was taking no pain medication.  On physical examination (PE), his thoracolumbar ROM was limited, as shown in the chart below.  

At the VA Compensation and Pension (C&P) examination in December 2007, 2 months before separation, the CI reported difficulty with prolonged standing, prolonged walking, or heavy lifting.  Pain was noted as chronic and daily.  The CI denied radiation of pain, and denied paresthesia of the lower extremities (numbness and tingling).  He also denied any periods of physician-prescribed bed rest during the previous 12 months.  He reported that he had worked in information technology (IT) during his Army career, and he planned on doing similar work after his separation.  As far as off-duty activities, he had reduced his hiking and mountain biking.  He said that during yard work tasks, he needed to take frequent breaks.  He also reported difficulty with moving furniture.    

On PE, the CI did not appear in pain, and his gait was normal.  No assistive devices were used.  PE of the thoracolumbar spine revealed no focal tenderness, no abnormal spinal contour, and no muscle spasm or guarding.  Neurological examination (sensory and motor) was normal.  
The Board directed attention to its rating recommendation based on the evidence.  Both the Army PEB and the VA used VASRD diagnostic code (DC) 5237 (lumbosacral strain), and assigned a 10% disability rating.  The Board agreed that a 10% rating, was justified for limitation of forward flexion not greater than 85 degrees, and combined thoracolumbar ROM not greater than 235 degrees.  There was insufficient evidence of muscle spasm or guarding severe enough to result in abnormal gait or spinal contour, thus the next higher 20% rating was not justified on that basis.  There was no documentation of incapacitating episodes which would provide for a higher rating under DC 5243 (intervertebral disc syndrome).  There was insufficient evidence of significant peripheral nerve impairment which would provide for additional rating using a neurological code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board found insufficient cause to recommend a change in the PEB adjudication for the chronic LBP condition.  

Contended Conditions.  Three conditions were adjudicated by the PEB as not unfitting, and therefore not ratable.  These three conditions were: gastroesophageal reflux disease (GERD), hypertriglyceridemia and pes planus.  The Board’s main charge with regard to these conditions is to assess the fairness of the PEB determination as 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 GERD, hypertriglyceridemia and pes planus conditions were not profiled or implicated in the commander’s statement, nor were they judged to fail retention standards.   All three conditions were reviewed and considered by the Board.  There was no performance-based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  After due deliberation, and in consideration of the preponderance of the evidence, the Board found insufficient cause to recommend a change in the PEB fitness determination for the any of these other PEB conditions.  Therefore, no additional disability ratings are recommended.  

BOARD FINDINGS: In the matter of the lumbosacral strain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended GERD, hypertriglyceridemia and pes planus, the Board unanimously recommends no change in the PEB determination 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 20140121, 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, AR20160007255 (PD201400555)

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