RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01406
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20081126

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Financial Management Technician, medically separated for “chronic lumbar pain,” with a disability rating of 20%.

CI CONTENTION:  His condition should have been rated higher.  His 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 - 20080815	VARD - 20091223	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Lumbar Pain …	5243	20%	Lumbar Disc Disease	5237	10%	20091030 	
Bilateral Tibial Compartment Syndrome	Not Unfitting	Surgical Scars, Right Lower Extremity	7804	10%	20091030 	
		Surgical Residuals, Right Lower Extremity	8699-8623	10%	20091030 	
		Surgical Scars, Left Lower Extremity	7804	10%	20091030 	
		Surgical Residuals, Left Lower Extremity	8699-8623	10%	20091030 	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:    

Lumbar Spine Condition.  The service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) documented a 2005 onset of back pain after a fall.  The pain persisted over the ensuing years with conservative treatment.  There were bilateral lower extremity (BLE) radicular symptoms and some mild (4/5) left lower extremity (LLE) motor deficits which were ultimately attributed to the bilateral compartment syndrome as discussed below.  Initial magnetic resonance imaging (MRI) was interpreted as mild disc disease (L4/5 and L5/S1 without herniation or neural encroachment); but, a follow-up MRI (10 months pre-separation) was interpreted as normal and surgery was not recommended.  A continued trial of conservative treatment (including multiple epidural steroid injections and facet blocks) provided improvement without lasting satisfactory results.  There were multiple outpatient STR entries indicating grossly normal or modestly limited range-of-motion (ROM).  There were multiple entries which documented normal gait, although there was an occasional note of gait disturbance.  There were no STR entries indicating significant ROM limitation or significant and persistent neurologic deficits, and there was no documentation of incapacitating episodes.  
  
The NARSUM examination was conducted on 27 June 2008 (5 months pre-separation) and documented “daily” pain rated 6/10 exacerbated by “high impact activities, repetitive lifting, bending, and twisting.”  The NARSUM physical examination recorded a normal gait and tenderness.  The neurological examination was normal except for some minor (“giveaway” and 4+/4) LLE motor deficits.  The gross ROM observations were “good flexion/extension with pain at extremes” and pain with rotation and side bending.  Formal ROM measurements for the MEB were conducted by physical therapy (PT) on the same day, and these were flexion to 45 degrees (normal 90) and combined ROM of 125 degrees (normal 240).

A VA Compensation and Pension (C&P) examination was conducted on 30 October 2009 (11 months post-separation) and documented chronic back pain rated 7/10 and limitations with prolonged sitting, standing or walking (1/2 mile), twisting, bending, and lifting; but, the examiner specified that there was no interference with usual occupational duties and no incapacitating episodes.  The examiner also specified the absence of any neurological symptoms attributable to the spine.  The VA physical examination recorded a normal gait and spinal contour, “minimal” tenderness, no spasm, and normal neurological findings.  The VA measured ROM was flexion to 70 degrees with combined 190 degrees.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 20% rating under code 5243 (intervertebral disc syndrome) cited the MEB PT flexion of 45 degrees, and was consistent with VASRD §4.71a criteria for the MEB ROM evidence and other ratable findings.  The VA’s 10% rating under code 5237 (lumbar strain) was consistent with the C&P ROM evidence and findings.  The highest supported rating based on the §4.71a spine formula is 20% via the MEB PT ROM; all other evidence is consistent with 10% and there was no documentation of incapacitating episodes which would provide for a higher rating under that formula.  The evidence also made clear that there was no ratable peripheral nerve impairment from the spine condition.  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 of the lumbar spine condition.

Contended Bilateral Tibial Compartment Syndrome.  The diagnosis of this condition appears to have resulted incidentally from electrodiagnostic testing as part of the lumbar spine evaluation.  Nerve conductions studies in February 2008 demonstrated bilateral peroneal nerve denervation consistent with compartment syndrome; and, the diagnosis was confirmed with compartment pressure testing.  On 22 May 2008 (6 months pre-separation), the CI underwent surgery (BLE fasciotomies) and a post-operative orthopedic entry confirmed the absence of complications and projected full recovery.  The NARSUM (a month post-op) documented “very good improvement in his left leg” and “moderate” improvement for the right.  The NARSUM examiner recommended VA follow-up for any residual symptoms and opined that the condition was “not medically disqualifying.”  The commander’s performance statement mentioned the condition but did not specify any limitations that could not be attributed solely to the back, and the BLE condition was not added to the L3 profile for the back.  The post-separation C&P examination documented some mild BLE sensory deficits attributed to the condition, but the motor examination was normal, and the examiner specified the absence of occupational limitations.

The Board’s main charge is to assess the fairness of the PEB’s determination that BLE compartment syndrome was not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The evidence indicates that the condition was improving and not associated with any significant functional deficits at separation, and the later VA evidence corroborates that conclusion.  The condition was not profiled or implicated by the commander, and was judged to meet retention standards.  All members agreed that there was no performance based evidence suggesting that it significantly interfered with duty performance or that it would have precluded continued military service.  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 bilateral tibial compartment syndrome, and it is thus not eligible for rating.

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 contended bilateral tibial compartment syndrome, the Board unanimously recommends no change from the PEB determination 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 20140311, 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, AR20160006062 (PD201401406)

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