RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00770
BRANCH OF SERVICE:  ARMY	Date of sepAration: 20070201

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

CI CONTENTION:  The CI requests the board consider all conditions.  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 - 20061024	VARD - 20070720	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Mechanical Low Back Pain	5299-5237	10%	Recurrent Chronic Low Back Strain	5242	0%	20070427	
Depressive Disorder, NOS	Not Unfitting	Major Depressive Disorder	9499-9433	30%	20070427	
Chronic Plantar Fasciitis	Not Unfitting	Bilateral Pes Planus/Plantar Fasciitis	5276	0%	20070427	
Chronic Medial Tibial Stress Syndrome	Not Unfitting	Bilateral Shin Splints	5299-5262	Not Service Connected	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

Low Back Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain condition began in 2005 performing light lifting activity while still on a postpartum profile.  Persistent pain was evaluated with radiographic imaging studies, which were normal.  There was no surgical indication.  
Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty, and she was referred for an MEB.  The MEB forwarded “chronic mechanical low back pain nonradicular” for PEB adjudication.  

Examination by physical therapy (PT) on 18 July 2006 (6 months prior to separation), showed thoracolumbar flexion of 55 degrees after 3 repetitions (normal 90 degrees) and combined range of motion (ROM) of 165 degrees (normal 240 degrees).  Painful motion was present.  The examination was silent regarding gait, spinal contour, tenderness and muscle spasm.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated 9 August 2006, the CI reported chronic back pain that was worse with standing greater than an hour.  Physical examination showed painful motion and tenderness, and normal lower extremity neurologic findings.  ROM was not assessed, and there was no mention of gait, spinal contour or muscle spasm.

The NARSUM evaluation on 3 October 2006 (4 months prior to separation), recorded a chief complaint of daily low back pain that waxed and waned.  She experienced difficulty with standing greater than 30 minutes, sitting greater than 30 minutes, or lifting over 20 pounds.  She was unable to run.  She denied radiating pain or lower extremity weakness.  A physical examination was not performed.  Review of the available records found no instances of physician-prescribed bed rest for back pain.

At the VA Compensation and Pension (C&P) examination on 27 April 2007 (3 months after separation), the CI reported intermittent stiffness and weakness that occurred as often as twice per day and lasted for 6 hours.  Physical activity and stress aggravated her condition, and medication and rest relieved it.  There was no radiation of pain.  The CI stated that physician-prescribed bed rest was recommended 1-2 times per month.  Physical examination showed a normal gait and spine appearance, and no muscle spasm or tenderness.  Forward flexion was 90 degrees and combined ROM was 240 degrees.  There was no painful motion.  Provocative testing for possible nerve root irritation was positive, but lower extremity neurologic findings were normal. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the analogous 5237 code (lumbosacral strain).  The VA assigned a 0% rating using the 5242 code (degenerative arthritis of the spine), and cited normal examination findings as a rationale.  Board members debated if a rating higher than the PEB’s 10% was warranted.  Because the C&P examination provided the most comprehensive assessment and was the most proximal to separation, it was assigned preponderant probative value in the Board’s deliberations.  The next higher 20% rating required flexion greater than 30 degrees but not greater than 60 degrees, combined ROM not greater than 120 degrees, or muscles spasms or guarding severe enough to cause an abnormal gait or spinal contour.  Since none of these stipulations were present, a 20% rating was not justified.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS), or evidence of ratable peripheral nerve impairment which would provide for additional 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 condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that depressive disorder NOS, chronic plantar fasciitis and chronic medial tibial stress syndrome were 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.  

Depressive Disorder NOS.  A psychiatric addendum on 9 August 2006 described a history of post-partum depression beginning in June 2005 and which required treatment.  Symptoms improved and by February 2006 medication and counseling were discontinued.  Symptoms of depression returned in June 2006 when she learned she would be medically boarded for her back condition in the context of a temporary separation from her husband for his employment.  Treatment was re-instituted.  The examiner concluded that the prognosis was good with compliance with therapy. 

Plantar Fasciitis and Chronic Medial Tibial Stress Syndrome (Shin Splints).  According to the NARSUM examiner, the CI was unable to run in part because of a “longstanding diagnosis of chronic shin splints and chronic plantar fasciitis from a prior profile in 2003.”  The MEB examination indicated that the only reason for referral to a MEB was the back condition and that the previous profile for chronic foot pain was P2.  There was no mention by the CI or the examiner of medial tibial stress syndrome.  The available STR was otherwise silent regarding these conditions.  The final permanent L3 profile (dated 13 October 2006) included the unfitting back condition as well as chronic plantar fasciitis and chronic medial tibial stress syndrome.

The commander’s statement specified only the back condition as an impediment to performance of duty.  Although the final permanent profile listed plantar fasciitis and medial tibial stress syndrome, all restrictions were applicable to the spine; and lower body weight training was allowed.  On the Report of Medical Assessment (DD Form 2697) the CI cited specific profile restrictions as limiting her ability to perform her job, but mental health symptoms were not mentioned.  All of these 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 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 and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the chronic low back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended depressive disorder NOS, chronic plantar fasciitis and chronic medial tibial stress syndrome 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 20140127, with attachments
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, AR20160007260 (PD201400770)

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