RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01232
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090329

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Transportation Management Coordinator, medically separated for “lumbosacral strain,” with a disability rating of 10%.

CI CONTENTION:  The CI requests that his PTSD, lumbar strain, sleep apnea, as well as other unnamed disabilities, be reviewed and he receive a higher rating.  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 - 20081220	VARD - 20090826	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbosacral Strain…	5237	10%	Lumbar Strain	5237	10%	20090729	
Obstructive Sleep Apnea	Not Unfitting	Obstructive Sleep Apnea	6847	50%	20090729	
Hypertension	Not Unfitting	Essential Hypertension	7101	0%	20090729	
Anxiety Disorder	Not Unfitting	Post-Traumatic Stress Disorder	9411	70%	20090729	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:  

Lumbosacral Strain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in 2005 without any specific injury or trauma.  It became worse in 2006 after he twisted it during combative training.  Radiographic studies (MRI) showed facet disease and ligamentum flavum hypertrophy with no nerve root impingement.  At the neurosurgery evaluation on 23 July 2008, the CI reported back pain with carrying a load, wearing body armor, standing, walking, or prolonged sitting.  He also reported radiating pain down the back of both legs after walking for extended distances.  He denied weakness or change of sensation in the lower extremities.  On examination his gait, spinal contour, motor strength, reflexes, and sensation were normal.  There was no tenderness or spasm noted.  Straight leg raise testing was positive at 70 degrees with pain radiating to the back.  His range of motion (ROM) was described as “good” and he could forward flex so that his fingertips were within 20 cm from the floor.  The examiner concluded that 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 the CI was referred for MEB.  The MEB forwarded “lower back pain from degenerative disc and facet disease” for PEB adjudication.

At the MEB NARSUM examination on 30 October 2008, 5 months prior to separation, the CI reported back pain that was exacerbated by prolonged sitting or standing, and with lifting or bending.  On examination his ROM was decreased as indicated in the chart above.  His gait, spinal contour, and reflexes were normal.  His bilateral lower extremity motor strength was decreased to 4/5.  There was tenderness to palpation and mild muscle spasm.  The examiner noted “flare-ups at extremes of flexion or lifting…”  He also had “slight generalized low back pain on right straight leg raise.”  

At the 29 July 2009 VA Compensation and Pension (C&P) evaluation, performed 4 months after separation, the CI reported that when he was active, his back pain radiated into both legs.  However, the examiner noted that “his description [of radiating pain did] not follow an anatomic nerve distribution.”  He has pain with sitting and lifting more than 15 pounds.  He reported no incapacitating episodes.  Physical examination showed near normal ROM as indicated in the chart above with painful motion in all planes of movement.  There was no additional limitation with repetitive movements.  His gait, spinal contour, motor strength, sensation, and reflexes were normal.  There was no tenderness to palpation noted. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain), for localized tenderness and forward flexion limited to between 61 and 85 degrees.  The VA also rated the back condition 10% coded 5237, based on the VA C&P examination 4 months after separation, citing combined ROM of the thoracolumbar spine greater than 120 degrees, but not greater than 235 degrees.  The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion greater than 60 degrees but not greater than 85 degrees and/or combined ROM greater than 120 degrees but not greater than 235 degrees as reported on the NARSUM and VA examinations proximate to separation.  Although there was some evidence of muscle spasm, it was not severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  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.  There were symptoms of radiating pain documented in the treatment records; however, radiographic studies (MRI) showed no radicular nerve involvement, and physical examination by neurosurgery revealed no objective findings of radiculopathy that would impact duty performance.  The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting.  While the CI may have suffered additional pain from the nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  Therefore the critical decision is whether or not there was a significant motor weakness which would impact military occupation-specific activities.  There was very limited evidence in this case that motor weakness existed to any degree that could be described as functionally impairing.  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 back condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that obstructive sleep apnea, hypertension, and anxiety disorder were not unfitting.  The hypertension and anxiety disorder were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  There was no performance-based evidence from the record that either of these conditions significantly interfered with satisfactory duty performance at separation.  

Sleep Apnea.  The August 2008 Neurology examination noted the CI was having difficulty using the equipment but was only in his second week of use.  The standard measure of sleepiness functional impairment had declined by four points although there was still significant daytime sleepiness.  Treatment was not yet optimal but he was scheduled to have corrective surgery the following month.  The neurologist opined his difficulties with sleep were multifactorial, including sleep apnea but his anxiety was also likely contributing.  His commander stated that he “worked well, complained about lower back problems but was tired at times.”  He also stated that the CI was able to work the entire duty day including physical training from 0630-0730 and clerical work with computers from 0900 until 1700.  The commander indicated that the CI was able to sustain an ordinary routine without extra supervision.  The NARSUM examination noted he was taking four medications, all of which were associated with drowsiness.  The sleep apnea was profiled, but only at a level 2, which, according to Army Regulation 40-501, chapter 7-3d (2), indicated that the CI possessed a medical condition or physical defect that may have required some activity limitations.  The MEB evaluated his sleep apnea and determined that it met medical retention standards.  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 for hypertension, anxiety disorder, or sleep apnea and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended hypertension, anxiety disorder, 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 20140228, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

28 JUL 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, AR20160009953 (PD201401232)

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