RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	     CASE:  PD-2014-01246
BRANCH OF SERVICE:  Army	     separation DATE:  20080618

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E-2, Combat Medic, medically separated for “L4-5 and L5-S1 disc herniation,” rated at 10%.

CI CONTENTION: “Her back condition continues to worsen.  The applicant’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 - 20080505	VARD - 20090122	
Condition	Code	Rating	Condition	Code	Rating	Exam	
L4-5 and L5-S1 Disc Herniations	5243	10%	Lumbar Disk Herniation	5243	10%	20081031	
COMBINED RATING:  10%	COMBINED RATING FOR ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Low Back Pain Condition.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic back condition began in October 2007.  The CI did not recall any specific trauma other than doing sit-ups and push-ups with her rucksack.  Lumbar X-rays in November 2007 were normal, but magnetic resonance imaging (MRI) in February 2008 showed disc herniation at L4-L5 and L5-S-1 with mild deviation of the left S1 nerve root.  Despite treatment including physical therapy (PT), profiles and pain medication the CI’s back condition could not be adequately rehabilitated to meet the physical requirements of her military specialty and she was referred for an MEB.  

At the time of the orthopedic clinic appointment on 18 March 2008 (3 months prior to separation), the CI reported pain was localized to the left lower back with occasional radiation into her left lower extremity, and was associated with numbness in the left leg.  She denied injury or trauma.  Pain was rated at 6/10 in severity and worsened with all activities.  On examination, the thoracolumbar spine had a normal appearance and gait was normal.  Tenderness of the paraspinal lumbar muscles was present, but muscle spasm was absent.  The straight leg raise test (SLR) was negative for nerve root irritation.  Lower extremity sensation was normal, but muscle strength testing noted “mild weakness” in the left L5-S1 distribution “that could be related to pain.”  On the MEB examination (DD Form 2007) the CI reported tingling in the left hand and foot, and marked “No” for impaired use of legs.

At the MEB NARSUM examination on 28 March 2008, the CI’s chief complaint was chronic low back pain, and there was no mention of lower extremity problems. Pain was aggravated by prolonged sitting, standing, walking, running and lifting greater than 15 pounds.  Pain severity was reported as 7-8/10.  During flare-ups, which typically occurred once every two weeks, range-of-motion (ROM) and coordination were limited.  Physical examination showed a “slight antalgic gait” and tenderness at L4 to S1 with bilateral paraspinal muscle spasm.  However, the examiner did not link spasm with the abnormal gait.  Thoracolumbar flexion measured 3 times with a goniometer was 90 degrees (65-86-90; normal 90 degrees) and combined ROM was 240 degrees (normal 240 degrees).  Bilateral SLR testing was negative.  Although reflexes in the left lower extremity were noted to be slightly reduced compared to the right, sensation and muscle strength were normal.

At the VA Compensation and Pension (C&P) examination (4 months after separation), the CI reported her back pain was a result of lifting bunk beds and wall lockers.  The CI reported constant lower back pain that radiated to the legs, and was associated with tingling in her legs.  Pain was achy and sharp, rated 6/10 in severity and elicited by physical activity and relieved by rest.  Although she was prescribed pain medications, she did not take them due to pregnancy.  However, at the time of pain she could function without medication.  Periods of incapacitation was denied.  Although she could vacuum, drive a car, walk, shop and push a lawn mower, she could not perform gardening activities or take out the trash due to her back condition.  She worked in a job as a stacker.  Examination showed a normal gait and spinal contour.  Painful motion was present but tenderness and spasm were absent.  There was no evidence of radiating pain on movement.  Thoracolumbar flexion was 85 degrees and combined ROM was 225 degrees.  SLR testing was reportedly positive bilaterally, although it was stated that there was no sign of intervertebral disc syndrome with chronic and permanent nerve root involvement.  Neurological examination of the lower extremities showed normal motor, sensory and reflex findings.  The examiner rendered a diagnosis of lumbar spine strain with left lower extremity radiculopathy.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10% coded 5243 (intervertebral disc syndrome), citing tenderness, forward flexion and combined ROM.  The VA also rated the back condition 10% under the same code, citing slightly limited and painful back motion.  Although a 10% rating was justified for the presence of tenderness, muscle spasm and painful motion noted on the NARSUM exam, and for limited flexion and combined ROM on the VA exam, the Board noted that muscle spasm possibly associated with an abnormal gait was also noted on the NARSUM examination.  However, this finding was not present on any other exam, and the Board concluded that there was not a sufficient basis for a 20% rating (i.e. for muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis).  The Board also considered whether a higher rating (§4.7) was achieved by using the alternate rating formula based on incapacitating episodes due to intervertebral disc syndrome.  Although the CI had intervertebral disc disease there were no incapacitating episodes requiring bed rest prescribed by a physician to warrant consideration of a rating under that formula.  The Board finally considered if there was evidence of peripheral nerve impairment which justified a separate rating.  Although the CI experienced radiating pain, and the VA examiner diagnosed left lower extremity radiculopathy, there was no objective evidence of functional impairment with a direct impact on fitness.  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 is no examination evidence in this case, such as left leg weakness, which could be associated with functional impairment.  The Board therefore concluded that 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.  

BOARD FINDINGS:  In the matter of the L4-5 and L5-S1 disc herniations condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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 20140310, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXXXX AR20160005876 (PD201401246)

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