RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00575
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050620

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4 (Food Service Specialist) medically separated by the Informal Physical Evaluation Board for “chronic back pain with spondylosis and facet arthropathy without neurologic abnormality” with a disability rating of 10%.   

CI CONTENTION:  “Condition and injury has worsened.  There is more damage than initially determined to the discs, more pain in the lower back.  They based their decision from a range of motion test. I am very flexible normally, but when my injury is apparent, my back goes out I have no flexibility.  I went for the exam when my back was not out.”  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 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 - 20050505	VARD - 20051025	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain with Spondylosis and Facet Arthropathy, w/o Neurologic Abnormality	5242	10%	Spondylosis and Facet Arthropathy at L4-L5 with L5-S1 Nerve Root Compression and Arthritis	5239	10%	20050804	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Low Back Pain Condition.  According to the service treatment records and the MEB narrative summary (NARSUM), the CI had a history of intermittent episodes of low back (LBP) that worsened in October 2004 when she was putting on her boots.  Magnetic resonance imaging (MRI) of the lumbar spine on 20 October 2004 showed degenerative disc disease and spinal arthritis, without significant central spinal canal stenosis or nerve root compromise.  The CI was referred to physical therapy and was evaluated by a pain specialist and an orthopedic surgeon.  Physical therapy, medications and a sacroiliac injection were not helpful, and no surgery was recommended.  The CI was given a permanent profile and a Medical Evaluation Board (MEB) was recommended.	

At the MEB examination (recorded on DD Form 2807 and 2808) dated 19 April 2005, the CI reported constant LBP, increased by activity, with radiation to the left lower extremity (LE) with exertion.  Medications listed included a muscle relaxant, anti-inflammatory, and pain medications for the back condition.  The MEB physical exam noted “minimal tenderness” at L4-5, without muscle tenderness.  There was normal strength and sensation of the LEs and straight leg raise testing was negative bilaterally.  Physical therapy range-of-motion (ROM) measurements on 13 April 2005 documented lumbar flexion of 110 degrees (normal 90) and combined ROM of 240 degrees, with painful motion.

At the VA Compensation and Pension (C&P) General medical exam on 4 August 2005, performed 2 months after separation, the CI reported low back pain and stiffness after activity.  She reported her last use of muscle relaxant and anti-inflammatory medication was approximately one and a half months earlier after moving things from storage to her house.  The exam noted normal posture and gait.  There was tenderness to palpation (TTP) in the lumbosacral region.  Lumbar spine ROM was 65 degrees with combined ROM of 205 degrees.  There was no additional loss of ROM with repetition.  Lower extremity strength and sensation was normal without any focal neurologic signs.  Lumbosacral spine X-rays showed “mild” DDD with normal alignment.  The VA C&P neurological exam, on the same day, noted the CI “never had any radicular symptoms.”  The CI denied weakness, sensory loss, abnormal gait, or other associated neurological symptoms and reported that she was not on any specific medications.  The exam noted no sensory deficits of the LEs or other neurologic abnormalities and was otherwise as noted at the general exam.  The neurologist indicated that the predominate problem was back pain and indicated that there was no evidence of any radiculopathy and the neurological exam was “completely normal.”

At a VA orthopedic C&P exam on 10 August 2005, the CI reported milder low back pain since separation, without radiation to the LEs or paresthesias (abnormal sensory disturbances, often numbness/tingling).  She reported constant LBP graded 1/10, with flare-ups every other day with activities, with pain levels graded 5-7/10, which persisted all day despite use of prescribed medications.  The exam noted painless ROM of the lumbar spine with flexion of 80 degrees and combined ROM of 230 degrees, and there was no additional loss of ROM with repetition.  There was no TTP, or muscle spasm.  The CI was able to heel and toe walk.  Strength, sensation and reflexes of the LEs were normal and SLR was negative.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA both rated the low back condition 10%.  The PEB coded it as 5242 (spinal arthritis) and the VA as 5239 (spondylolisthesis or segmental instability).  The Board agreed that the evidence in record supports a 10% rating of the low back condition according to the current VASRD General Rating Formula for the Spine in effect on the date of separation based upon “local tenderness not resulting in an abnormal gait or an abnormal spinal contour,” or based upon the limitation of thoracolumbar ROM noted at the C&P exams.  The Board reviewed to see if a higher rating was supported, but there was no evidence of sufficient limitation of ROM or muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour.  The Board reviewed to see if a higher evaluation than 10% was achieved coding with 5243 (Intervertebral disc syndrome) and rating based on incapacitating episodes, defined by the VASRD as bed rest prescribed by a physician and treatment by a physician.  However, there was no documentation in record of incapacitating episodes as defined.  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 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 (radiculopathy) as separately unfitting and eligible for additional disability rating.  The CI reported pain radiating into the left LE at the MEB exam, but not at the C&P exams.  The Board noted that in any case, the pain component of a radiculopathy is subsumed under the general spine rating as specified in §4.71a.  There was no evidence at any exam in record of LE weakness or sensory deficits and the VA neurologist indicated there was no evidence of a radiculopathy.  Therefore, the Board concluded that no additional disability rating could be recommended on this basis. 

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 20140120, 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, AR20160002519 (PD201400575)

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