RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01104
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050225

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E5, Personnel Admin Specialist, medically separated for “thoracic back pain, without neurologic abnormality,” with a disability rating of 10%.

CI CONTENTION:  The CI requested review all MEB/PEB conditions considered for being unfit for duty and rated.  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 - 20041221	VARD - 20060124	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Thoracic Back Pain without Neurologic Deficits	5299-5237	10%	Lumbar Strain	5237	10%	20050630	
Low Back Pain	Not Unfitting					
Right Breast Pain	Not Unfitting 	No VA Placement	
Fibroid Uterus…	Not Unfitting	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Thoracic Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the thoracic pain condition began approximately 3 years prior to referral for MEB.  The CI reported that she was noted to have an abnormal electrocardiogram (EKG) following a medical procedure.  She underwent an extensive cardiac evaluation and was told she did not need a pacemaker.  Two years prior to referral for MEB, the CI sought care for right upper chest pain and again was noted to have an abnormal EKG.  She received a second comprehensive cardiac evaluation which included EKGs, an echocardiogram (heart ultrasound), an exercise stress test (EST), and a head-up tilt table test.  The EKGs revealed a first degree atrioventricular (AV) block (delay or interruption of heart rate impulse from the atria to the ventricles [PR interval]).  The echocardiogram showed mild mitral valve thickening with trivial mitral valve regurgitation.  The CI performed well on her treadmill EST with no chest pain or arrhythmias.  The tilt table test was negative and did not elicit symptoms or cause an inappropriate rapid or slow heart rate (tachycardia or bradyarrhythmia).  The cardiologist advised the CI it was safe for her to resume physical training.  At a cardiology follow-up, the CI complained persistent sharp chest pains.  They were characterized as “needle-point like pains predominantly in the left axilla and left neck.” The pain could last all day and night and persist over several days in a row.  The assessment listed advanced first degree AV block.  The cardiologist opined that her description of chest pain was clearly not anginal (pain from reduced blood flow to heart muscle) in nature and most likely non-cardiac.  The CI underwent a second EST which revealed normal functional capacity, normal blood pressure response, and appropriate heart rate response to exercise.  The EST was interpreted as clinically positive (chest discomfort) and electrically negative (no arrhythmias or pathologic EKG changes).  A military cardiology evaluation for the MEB recorded the CI experienced a single episode of syncope (abrupt and transient loss of consciousness, absence of postural tone, with rapid spontaneous recovery) while standing, hot, and tired after a PT test.  The cardiologist noted the history of first degree AV block by EKG and recounted the findings of workup by civilian cardiology.  He documented that she had chronic musculoskeletal axillary pain with movements, which lasted seconds, and had no angina.  The assessments listed first degree AV block, possible mitral valve prolapse (MVP) with no significant prolapse or regurgitation by echocardiogram, and syncope.  The cardiologist opined that it was mostly likely vasovagal syncope (“common faint” neural reflex results in usually self-limited systemic hypotension characterized by bradycardia and/or peripheral vasodilation).  He documented that the CI had no criteria for an MEB and that he would not start medical therapy or restrict her duty.  A thoracic spine X-ray was normal.  The NARSUM, 4 months before separation, documented a history of thoracic and subscapular pain that was present 25-50% of the time.  Symptoms occurred at approximately one mile of running or walking and prevented her from completing a run or alternate APFT, carrying a rucksack, or lifting over 10 pounds.  The examiner recounted the extensive work-up for atypical chest pain and indicated the CI required no Profile limitations based upon her cardiac workup.  Symptoms required an anti-inflammatory medication but no narcotics.  The examiner referred to the DD Form 2808 for the majority of normal findings.  The focused physical examination documented an intact heel and toe walk.  The back examination revealed tenderness in the upper thoracic area with radiation to the scapular musculature.  The straight leg raise (SLR) tests (assess for herniated disc causing sciatic nerve root [L5-S1] radiculopathy) were recorded as intact.  Thoracolumbar spine range of motion (ROM) was flexion of 110 (90 normal), extension of 20 (30 normal), bilateral rotation of 45 (30 normal), and bilateral lateral flexion of 30 (30 normal) degrees.  Strength, sensation, and deep tendon reflexes (DTRs) were normal.  The diagnosis listed slight and occasional thoracic back pain.  The examiner opined that the CI had thoracic back pain, which had previously been concerning for atypical cardiac chest pain, but the work-up had been negative for a cardiac etiology.  

The Compensation and Pension (C&P) examination recounted the history and interventions.  The CI complained of intermittent, sharp, 8/10 mid-back pain with radiation to the buttocks.  Pain occurred three times per month and each time lasted for an hour.  The pain exacerbations had no specific triggers, resolved without intervention, and she did not require medication to function.  Pain did not cause incapacitation, functional impairment, or result in any time lost from work.  The physical examination documented a normal posture and gait.  The thoracolumbar spine revealed no ankylosis, tenderness, muscle spasm, or complaints of radiating pain on movement.  The bilateral SLR tests were negative.  Active thoracolumbar spine ROM was flexion of 90, extension of 20, bilateral rotation of 30, and bilateral lateral flexion of 30 degrees.  Spine ROM was additionally limited following repetitive use by pain.  It was not additionally limited following repetitive use by fatigue, weakness, lack of endurance, or incoordination.  There were no signs of intervertebral disc syndrome with chronic and permanent nerve root involvement.  Strength, sensation, DTRs, and pulses were normal.  The examiner recounted the findings of the normal lumbar spine X-ray.  The diagnosis listed lumbar strain. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5237 code (lumbosacral or cervical strain), citing thoracic back pain, without neurologic deficit, combined ROM of 240 degrees and tenderness to palpation.  The VA assigned a 10% rating under the 5237 code (lumbosacral or cervical strain) based on the VA C&P examination 4 months after separation, citing thoracic back pain, normal gait, normal spinal curvature, no muscle spasms, no tenderness and evidence of painful limited ROM.  While the PEB and VA cited thoracic back pain, current VASRD normal ROM values (in effect since 26 September 2003) address the thoracolumbar spine segment.  The VASRD no longer addressed thoracic and lumbar spine segments separately.  The thoracolumbar ROM values in the NARSUM and C&P examinations were consistent with the 10% rating (flexion of greater than 60 degrees but not greater than 85 degrees; or a combined ROM of greater than 120 degrees but not greater than 235 degrees of the thoracolumbar spine).  The higher 20% rating would require flexion of greater than 30 degrees but not greater than 60 degrees; or a combined ROM of not greater than 120 degrees of the thoracolumbar spine.  There was no documentation of incapacitating episodes, or evidence of ratable peripheral nerve impairment, which would provide for additional or higher rating.  The Board agreed there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.40, §4.45, and §4.59).  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 for the thoracic back pain condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the right breast pain, fibroid uterus with intermittent pelvic pain, and low back pain conditions 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.  While right breast biopsy was profiled, fibroid uterus with intermittent pelvic pain and low back pain were not.  Right breast pain, fibroid uterus with intermittent pelvic pain, and low back pain were not implicated in the commander’s statement and were not judged to fail retention standards.  All conditions were reviewed and considered by the Board and there was no performance based evidence from the record that 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 contended right breast pain, fibroid uterus with intermittent pelvic pain, and low back conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the thoracic back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended right breast pain, fibroid uterus with intermittent pelvic pain, and low back 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 20140303, 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 XXXXXXXXXXXXXXXXXXXX, AR20160007270 (PD201401104)

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