RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01167
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080212

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard, E5, Multiple Launch Rocket System Crewmember, medically separated for “chronic low back pain due to intervertebral disk syndrome” with a disability rating of 20%.  

CI CONTENTION:  “…diagnosed with PTSD…and am currently in treatment for depression and PTSD…”  The applicant’s complete submission, with attachments, 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 - 20090218	VARD - 20080326	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain due to Intervertebral Disk Syndrome	5243	20%	Disc Bulge at L4-5 and L5-S-1 with Degenerative Changes	5242	20%	20070702	
Adjustment Disorder with Anxiety	Not Compensable	No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back pain condition began in May 2006 after engaging in pre-deployment training.  His pain progressively worsened, but the pain did not radiate down his legs.  He completed 20 visits of physical therapy, which included massage and muscle relaxation treatments with minimal improvement.  There was no specific injury or trauma noted in the record.  An MRI and CT scan showed some disc bulging.  The CI’s pain was considered moderate and constant using the AMA pain rating scale.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “low back pain” for PEB adjudication.  

At the VA Compensation and Pension (C&P) examination in July 2007, performed 7 months before separation, the CI reported low back pain and soreness in the mid back region after prolonged sitting, standing and walking.  He described pain as sharp and dull and worsening with physical activity.  Since May 2006, CI complained of radiating pain lasting about 5 minutes extending to left buttocks.  The CI rated his pain at 2/10 at best and 7/10 at worst.  His medications included narcotic (fentanyl) and ibuprofen (nonsteroidal anti-inflammatory) taken in the evening as needed.  The physical examination revealed tenderness to palpation throughout lower back and the use of lidocaine patches extending from L1 to the pelvis.  ROM is summarized in the chart above.  There was no spasm or abnormal gait noted.  There was normal motor strength, and reflexes and sensory examinations were normal.  The X-rays were negative for intervertebral disc space narrowing, spondylolysis and spondylolisthesis.  The examiner cited neurosurgery notes indicated there was no recommendation for surgery.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated October 2007, 4 months prior to separation, the CI reported chronic back pain with numbness in the lower back and some tingling in his arm and legs, a herniated disc and degenerative disc disease.  The CI indicated he had had a discogram and radiofrequency ablation with a suggestion to look into surgery.  Physical examination showed mild tenderness to palpation in the L/S spine and flexion of the back induced pain.  

The MEB NARSUM examination on 18 October 2007 (4 months prior to separation) noted complaints of low back pain and pain was elicited by lying flat on his back and stomach.  He could perform physical activities on the treadmill using a back brace.  The CI used fentanyl, ibuprofen and Flexeril (muscle relaxant) for pain relief.  Physical examination showed all motions were limited by pain.  The CI reported pain with examination maneuvers not expected to elicit pain based on the known pathology.  The straight leg raise test (for radicular symptoms) was limited by pain.  There was no regional weakness or sensory loss.  

Neurology assessment in November 2007, 3 months prior to separation, documented a normal gait with no motor, sensory or reflex deficits.  There was no point tenderness.  An MRI of the lumbar spine noted at L3-L4 a minimal “broad-based disc bulge without evidence of central canal stenosis or narrowing of neural foramina.”  At L5-S1, there was a mild “broad-based disc bulge with superimposed central disc protrusion” and mild facet arthropathy.  

At the VA C&P examination in January 2009, performed 11 months after separation, the CI reported no change in back or radiating pain.  His medications included narcotic (fentanyl) and ibuprofen (nonsteroidal anti-inflammatory) taken in the evening as needed.  The physical examination revealed tenderness with pain-limited ROM as summarized in the chart above.  Gait, motor, sensory and reflex exams were normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under the 5243 code (intervertebral disc syndrome), citing tenderness, intermittent spasm and mild limitation of motion to 60 degrees flexion.  The VA assigned a 20% rating using the 5242 code (degenerative arthritis of the spine) based on the VA C&P examination 7 months before separation and the Service exams, citing 60 degrees of forward flexion.  The VA decreased the back rating to 10% based on the post-separation VA examination.  

The Board weighed the probative value of the various examinations in evidence.  The VA examination’s probative value was decreased due to its remoteness from separation.  The NARSUM examination was the most detailed and closest to separation and was adjudged to have the highest probative value for rating.  The Board agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees) reported on the NARSUM examination.  

There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS).  The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The CI had a herniated disc with radicular pain and paresthesias (numb and tingling sensation).  However, physical examinations proximate to separation revealed no objective findings of radiculopathy that would impact duty performance.  There was no associated radiculopathy for separate peripheral nerve rating.  While the CI may have experienced radiating pain from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There was no objective evidence of a radiculopathy with functional impairment (such as weakness) that directly impacted fitness for duty.  The Board therefore concluded that an additional disability rating was not justified on this basis.  

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 pain due to intervertebral disc syndrome condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the diagnosis of “the diagnosis of “Adjustment Disorder with anxiety” was not compensable but could be administratively unfitting.  The adjustment disorder is a condition not constituting a physical disability, IAW DoDI 1332.38 in effect at the time.  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 the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the chronic low back pain due to IVDS condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended adjustment disorder with anxiety condition, the Board unanimously agrees that it cannot recommend it for additional disability rating.  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 20140113, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXXXXX AR20160008284 (PD201401167)

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