RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-00618
BRANCH OF SERVICE:  Army		SEPARATION DATE:  20080219

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5, Multichannel Systems Operator, medically separated for “lumbago, thoracic spine, post-traumatic,” and “injury from terrorist explosion, blast from mortar,” with a disability rating of 10%.  

CI CONTENTION:  He was not evaluated for his PTSD or TBI condition.  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 - 20081212	VARD - 20080414  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Thoracic Back Strain	5237	10%	Chronic Thoracic Strain 	5237-5025	10%	20080307	
PTSD	Not Unfitting	PTSD	9411	30%	20080309	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Thoracic Strain.  The service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) documented a combat-related upper back injury from a fall (second floor window) in June 2004 in Iraq.  The CI was treated in-theater and reported persistent upper thoracic pain after redeployment in February 2005.  There was no extremity radiation or associated neurological complaints, and imaging (X-ray, CT, and MRI) was normal.  Multiple STR entries documented a normal gait and spinal contour, grossly normal range of motion (ROM), and normal neurological findings (5/5 strength).  There were no STR entries to the contrary and no documentation of incapacitating episodes.  There was no surgical indication, and conservative treatment did not result in sufficient improvement to allow unrestricted duty.  The MEB forwarded “lumbago, thoracic spine, post-traumatic” and “injury from terrorist explosion, blast from mortar” for PEB adjudication.  
  
The NARSUM examination was conducted 22 August 2007 (6 months pre-separation) and documented constant pain “between the scapulae [shoulder blades]” rated 5-9/10 and exacerbated by lifting (> 15 pound), overhead activities, walking (1000 meters), running (400 meters), standing (30 minutes), and sitting (1 hour).  The physical examination recorded a normal gait and spinal contour, tenderness, and normal neurologic findings.  Measured ROM was flexion to 90 degrees (normal) with a combined ROM of 240 degrees (normal), specifying painful motion.         

A VA Compensation and Pension (C&P) examination was conducted 7 March 2008 (3 weeks after separation) and documented constant pain rated 6/10 (radiation or neurological symptoms denied) exacerbated by “things that jar his spine” and carrying more than 25 pounds.  The physical examination recorded a normal gait and spinal contour, tenderness, and detailed normal neurologic findings (normal reflexes and sensation, motor 5/5).  Measured ROM was flexion to 80 degrees with a combined ROM of 240 degrees, specifying painful motion.         

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated 10% under code 5237 (thoracolumbar strain), citing tenderness and “non-deforming muscle spasm.”  The VA, based on the C&P examination, rated “chronic thoracic strain with myofascial pain syndrome” under the hyphenated code 5237-5025 (fibromyalgia), but cited the VASRD §4.71a spine criterion of limitation of flexion for its 10% rating.  There was no ROM evidence supporting a rating higher than 10%, no evidence for abnormal gait or contour to support a 20% rating, no evidence for ratable peripheral nerve impairment which would provide for additional rating, and no documentation of incapacitating episodes which would provide for a higher rating under that formula.  After due deliberation, and 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 of the thoracic spine condition.    

Chronic Post-Traumatic Stress Disorder (PTSD).  The CI engaged in three deployments to Iraq, with one preceding and one following the 2004 deployment referenced above.  There were a paucity of mental health (MH) treatment notes in the available STR, although some STR references and VA records documented a period of outpatient treatment in 2007 with a diagnosis of “chronic” PTSD.  The NARSUM listed Prozac (an anti-depressant) on the medication list, and addended an STR entry (15 October 2007, 4 months prior to separation) documenting a psychiatric opinion for the MEB that the condition met retention standards and “does not qualify for a medical board.”   The commander’s performance statement mentioned that the CI “still has ... anxiety attacks,” but noted that he was serving in an administrative capacity with some supervisory responsibilities.  There was no psychiatric profile throughout service.  A VA mental disorders C&P examination on 9 March 2008 (3 weeks after separation) documented that the CI was not engaged in MH treatment or taking any psychiatric medications, and was interested in pursuing work in telecommunications.

The Board directed attention to its recommendation based on the above evidence; and, its main charge was an assessment of the fairness of the PEB’s determination that the chronic PTSD was 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.  Although the CI may have manifested some MH symptoms at separation, there was no performance-based evidence countering the MEB psychiatric opinion that that there was no MH impairment severe enough to preclude retention.  The S1 profile, the commander’s statement and the lack of any evidence from the STR suggesting significant functional MH impairment all supported a conclusion that the MH condition was not unfitting.  After due deliberation in consideration of the preponderance of the evidence, members agreed that there was insufficient cause to recommend a change in the PEB fitness determination for the chronic PTSD.

BOARD FINDINGS:  In the matter of the thoracic spine condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended post-traumatic stress disorder, the Board unanimously recommends no change from 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 20140127, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXX AR20160010864 (PD201400618)

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