RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01115
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090327

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Food Service Specialist, medically separated for “degenerative arthritis, lumbar spine” and “right lower extremity radiculopathy,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI made no specific contention in their application, but listed diabetes Type II, degenerative disk disease, obstructive sleep apnea, and lumbar spine and radiculopathy conditions for review.  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 - 20090113	VARD - 20090701	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Degenerative Arthritis, Lumbar Spine	5242	10%	Degenerative Disc Disease	5242	10%	20090223	
Right Lower Extremity Radiculopathy	8599-8520	10%	Radiculopathy, Right Lower Extremity	8520	10%		
Diabetes Mellitus Type II, Requiring Insulin Controlled	Not Unfitting	Diabetes Mellitus, Type 2	7913	20%		
Sleep Apnea		Obstructive Sleep Apnea	6847	50%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Degenerative Arthritis, Lumbar Spine and Right Lower Extremity Radiculopathy.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s lumbar spine condition began in 1998 without any specific injury or trauma and he continued to experience lower back pain since that time.  Low back pain associated with right lower extremity pain involving the buttock, posterior thigh, calf, and numbness and tingling increased in severity in July 2007 (see below).  He denied left lower extremity symptoms, bowel or bladder problems and weakness.  He reported his knees “give out occasionally,” be he denied any other weakness.  On examination his low back exhibited tenderness on palpation of the right and left paraspinal regions.  Gait, stance and posture were normal.  Neurological evaluation was unremarkable except for ankle reflexes ¼ bilaterally.  Electrodiagnostic studies in November 2007 confirmed acute L5-S1 radiculopathy without evidence of denervation of the muscle innervated by this level.  There was no evidence of lumbar plexopathy (peripheral nerve abnormalities due to injury or tumor of the lumbar plexus of spinal nerves) or right lower extremity mono-neuropathy or polyneuropathy.  

Magnetic resonance imaging (MRI) studies in December 2007 demonstrated mild degenerative disc disease at L3-4, L4-5, and L5-S1 with mild to moderate neuroforaminal narrowing and mild facet arthropathy at L5-S1 with no abnormal enhancement within the central canal to suggest arachnoiditis (inflammation of the membrane surrounding the spinal cord).  The appearance of the nerve root in the thecal sac was likely a normal variant.  Surgery was deferred and Neurontin (gabapentin for nerve pain) provided good results along with physical therapy, where ROM measurements were full on multiple visits.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated 20 June 2008, 9 months prior to separation, the CI reported lumbar radiculopathy.  The examiner noted slightly decreased lumbar lordosis and active ROM was slightly decreased due to pain.  Straight leg raise (to determine nerve root irritation) results were unclear, but appeared to be positive bilaterally.  Balance, gait, reflexes, and sensation were normal.  There was positive tenderness to palpation at the lower back.  The ROM measurements are in the chart below and were normal.  A NARSUM addendum dated 21 October 2008 indicated the CI received epidural steroid injections that helped him significantly with less tightness and better ROM.  On examination the CI’s gait was normal and he was able to heel/toe walk.  He was mildly tender to palpation of the lower paraspinals.  Neurological examination was unremarkable.  ROM measurements are in the chart below.  There was minimal (1/10) to no pain with the ROM maneuvers.  At a pain management evaluation in September 2008 the CI described his back pain as bilateral, radicular, with shooting sensation of fire into his feet on both sides, big toe through the bottom of the foot to the little toe.  

At the VA Compensation and Pension (C&P) examination in February 2009, performed a month before separation, the CI reported developing back pain on or about 1998 for unknown reasons and bilateral radiculopathy with stinging.  Once a week he had 10/10 sharp pain with normal activity.  He was treated with steroid injections, Norco (hydrocodone, a narcotic and acetaminophen, a pain reliever), Neurontin, and Flexeril (cyclobenzaprine, a muscle relaxer) that helped.  Physical examination revealed a normal gait and posture.  Neurological evaluation was unremarkable and the Lasegue sign (straight leg raising to determine nerve root irritation) was negative.  

The ROM examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.
  
Thoracolumbar ROM
(Degrees)	PT
13 Mos. Pre-Sep	PT/MEB 
6 Mos. Pre-Sep	VA 
1 Mos. Pre-Sep	
Flexion (90 Normal)	30	90	90	
Combined (240)	135	235	240	
Comments	Painful motion	Painful motion and TTP	TTP	
§4.71a Rating	40%	10%	10%	
The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5242 (degenerative arthritis of the spine) citing tenderness and forward flexion of 90 degrees and a combined ROM of 235 degrees.  Additionally, the PEB assigned a 10% rating using code 8599-8520 (incomplete paralysis of the sciatic nerve) for mild right lower extremity radiculopathy.  The VA assigned a 10% rating using code 5242 citing full ROM and tenderness of the lumbar spine and a 10% rating using code 8520 for radiculopathy, right lower extremity.  The Board agreed that a 10% rating was justified for the presence of tenderness and for the combined ROM greater than 120 degrees but not greater than 235 degrees reported on the examinations.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  

The Board then considered the right lower extremity radiculopathy rating of 10% assigned by the PEB and VA.  There was no sensory component with any significant functional implications and no motor weakness was in evidence.  Therefore, a higher rating for a moderate incomplete paralysis using code 8520 radiculopathy could not be recommended, especially since the CI reported improvement after steroid injections.  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 degenerative arthritis, lumbar spine condition or for the right lower extremity radiculopathy condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that diabetes mellitus type II requiring insulin and sleep apnea were not unfitting.  The diabetes mellitus type II requiring insulin and sleep apnea were profiled.  The commander’s statement noted the CI’s current ability to adequately perform the duties were not hindered, except to take a shot occasionally.  The diabetes mellitus requiring insulin was considered to be medically unacceptable, while the sleep apnea was considered to be medically acceptable by the MEB.    

Diabetes Mellitus Type II Requiring Insulin.  The CI was originally diagnosed with diabetes in 2006, which presented with polyuria, polydipsia, and vision changes.  The diabetes was not controlled with oral medications and required insulin.  When the CI took metformin as well as long acting insulin (Levemir) and short acting insulin (Novolog) and lisinopril (for antiproteinuric, cardioprotective, and renoprotective effects) and followed a strict diet, his glucose level was in the 80-110 (normal) range and A1C (measurement of glucose level over 3 months) was 6.5% (normal 4.0% to 5.6%; 5.7-6.4% increased risk of diabetes). He had spikes in the glucose level when he received steroid injections, which required modification of the insulin treatment and discontinuation of the steroid injections.  The CI had no history of diabetic ketoacidosis.  At the time of the NARSUM addendum examination the CI felt well without fatigue, malaise, fever, chills or recent weight change.  He had borderline microalbuminuria (protein in the urine). Electrodiagnostic testing revealed a right L5-S1 radiculopathy without evidence of diabetic neuropathy.  The diabetes was considered to be stable and well controlled, but required both long and short acting insulin as well as oral medication.  

Sleep Apnea.  The CI complained of snoring, excessive daytime sleepiness, witnessed apnea (temporary cessation of breathing), extreme fatigue, morning headaches, memory loss, and restless sleep. In September 2008 the CI was diagnosed with upper airway resistance syndrome with mild obstructive sleep apnea in REM sleep and supine position.  CPAP (continuous positive airway pressure) at 9 cm was recommended along with weight loss and avoidance of sleep deprivation.  With the CPAP the CI felt very well rested in the mornings and throughout the day.   The upper airway resistance syndrome was eliminated with CPAP and the CI was encouraged to improve his compliance to a minimum of 4 hours per night for a minimum of 70% of days. 

There was no performance based evidence from the record that diabetes mellitus and sleep apnea significantly interfered with satisfactory duty performance at separation.  After due deliberation, and 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 of diabetes mellitus and sleep apnea, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the lumbar spine condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the right lower extremity radiculopathy and IAW VASRD §4.124a the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended diabetes mellitus and sleep apnea 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 20140304, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

13 SEP 2016

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, AR20160010964 (PD201401115)

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