RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-01441
BRANCH OF SERVICE:  Army 		SEPARATION DATE:  20051027

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Mental Health Specialist, medically separated for an “chronic low back pain, secondary to herniated nucleus pulposus at L5-S1 with radicular symptoms but without localizing motor abnormality,” with a disability rating of 10%.

CI CONTENTION:  The CI contends for her back and left hip.  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 - 20050908	VARD - 20060425	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5243	10%	Degenerative Disc Disease Thoracolumbar Spine with
Radiculopathy 	5243	10%	20060104	
COMBINED RATING:  10%	COMBINED RATING FOR ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Low Back.  The service treatment record (STR) and narrative summary (NARSUM) documented the first care for back pain in October 2004 (12 months prior to separation).  The CI reported insidious onset of back pain without history of trauma.  The examiner documented normal gait, tenderness of the sacroiliac joints, spasm (“diffuse hypertonicity”), with normal strength and reflexes bilaterally.  Radiographic imaging in November 2004 documented narrowing of the T11-T12 vertebral interspace; loss of T12 vertebral height, probably “developmental” in origin; and straightening of the lumbar spine.  At chiropractic visits in November and December 2004 (11 and 10 months prior to separation) and January and February 2005 (9 and 8 months prior to separation), the examiner documented normal range of motion (ROM) of the thoracolumbar and lumbosacral spine, normal strength and reflex testing, and negative nerve tension testing.  Radiographic imaging in February 2005 (8 months prior to separation) documented herniation of L5-S1 disc, normal L1-L5 disc heights with normal foramina (nerve canal exits) bilaterally.  At a neurosurgical consultation in April 2005 (6 months prior to separation), the CI reported weakness and numbness in the left leg with trouble standing, inability to walk and climb stairs.  The examiner documented tenderness in the lower lumbar spine; “limited” forward bending; radiation on the left with nerve tension testing; “little” weakness of the left foot (with both plantar and dorsiflexion); abnormal sensation of the lateral left foot; and normal symmetric strength of the lower extremities.  

Electrophysiologic testing in April 2005 documented no evidence of active left lumbosacral radiculopathy or peripheral neuropathy.  At an orthopedic visit in June 2005 (4 months prior to separation), the CI reported low back pain radiating into the left lower extremity with associated tingling.  The examiner documented forward flexion to 15 degrees (normal 90), normal toe and heel walk, normal strength and symmetric reflexes, with sensory numbness at the left lateral foot and left medial leg.  There was pain radiating to the left leg with nerve tension testing.  At a neurosurgery visit in June 2005, the examiner documented normal gait, normal strength, and normal reflex and sensory exam.  There was tenderness to palpation and no paraspinous muscle spasm.  At chiropractic visits in June, July, September, and October 2005 (4, 3, and 1 month prior to separation), the examiner documented normal ROM of the thoracolumbar and lumbosacral spine, normal strength and reflex testing, and negative nerve tension testing.  Painful motion on flexion and extension were documented during the July 2005 visit.  Radiographic imaging in August 2005 (2 months prior to separation), documented normal thoracic spine, “slight lumbosacral scoliosis” with “accentuated” lumbar lordosis, and normal vertebral body heights and interspaces.  There was no STR documentation of physician prescribed bed rest for incapacitating episodes.  There was no documentation of more significant decrements in ROM.  On the MEB DD Form 2807-1, Report of Medical History, dated 26 April 2005 (6 months prior to separation), the CI reported severe pain; left leg pain; numbness and tingling of the left foot; difficulty sleeping and holding her urine.  On the MEB DD Form 2808, Report of Medical Examination, dated 26 July 2005 (3 months prior to separation), the examiner documented decreased ROM due to pain, bilateral spasms, and positive nerve tension testing bilaterally.

The MEB NARSUM exam was performed on 21 August 2005 (2 months prior to separation).  The CI reported radiating pain and paresthesias of the left foot; having a slower gait and inability to walk further than a quarter mile; and having to sit or lay down after standing more than 10-15 minutes.  The examiner documented painful motion with flexion to 80 degrees (normal 90), extension to 10 degrees (normal 30), lateral bending was to 15 degrees on the right and 30 on the left (normal 30 each), and bilateral rotation to 10 degrees each (normal 30 each).  There was normal strength and reflex testing of the lower extremities.  There was normal heel and toe walk.  Decreased sensation of the left foot (lateral and dorsal surface) was documented.  Nerve tension testing resulted in radiation to the foot.

At a neurology VA Compensation and Pension (C&P) exam dated 4 January 2006 (2 months post-separation), the CI reported daily pain that radiated, paresthesias of the left lower foot, difficulty sleeping, and denied incontinence.  She reported the ability to walk slowly for up to a quarter mile, stand up to 15 min; and sit for 20-30 min with constant change of position.  She denied periods of prolonged bed rest.  The examiner documented normal strength, with normal tandem walk, and no atrophy.  There was a normal reflex exam with decreased sensation in the left great toe and medial foot.  At the general medicine VA C&P exam dated 4 January 2006, the CI reported aggravation of back pain by climbing stairs, cleaning house and prolonged standing (more than 25 minutes).  She reported flare-ups every day for more than an hour and denied use of braces.  The examiner documented a normal gait with no tenderness and no spasms of the back.  Forward flexion was to 85 degrees, and extension was to 20 degrees.  Lateral bending was normal bilaterally.  Right and left rotation as to 25 degrees each bilaterally.  Painful motion occurred with all movements.  There was no evidence of painful motion and no additional loss of ROM following repetition.

The Board directed attention to the rating recommendation based on the above evidence.  The PEB adjudicated the “chronic low back pain” condition as unfitting and rated 10% coded 5243 (intervertebral disc syndrome), citing ROM limited by pain but (sic) forward flexion [of] 80 degrees and tenderness.  The VA rated the “degenerative disc disease thoracolumbar spine with radiculopathy” at 10% coded 5243.  It is clear that the “herniated nucleus pulposus at L5/S1,” “degenerative disc disease of the lumbar sacral spine,” and “degenerative disc disease of the lower thoracic spine,” are related diagnoses contributing to the disability in this case; and, members first agreed that there were no separate conditions which could be reasonably justified as separately unfitting; nor would separate ratings be achievable without violation of VASRD §4.14 (avoidance of pyramiding).  

The Board considered the evidence for a higher than 10% rating.  Due to the significant differences between the orthopedic exam dated 15 June 2005 and the MEB NARSUM and VA exams, the Board carefully considered the whole record in order to develop a consistent picture of the CI’s back condition.  There was a single entry that documented a forward flexion to 15 degrees.  However, there was no other documentation of forward flexion of 30 degrees or less, nor greater than 30 degrees but not greater than 60 degrees in support of a higher rating.  All subsequent exams documented flexion of the thoracolumbar spine greater than 60 degrees in support of a 10% rating.  The Board discussed the probative value of these exams and concluded that the MEB NARSUM and VA exams were more complete and carried higher probative value, and favored the 10% rating recommendation.  There was no documentation of consistent spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour for a higher rating.  There was no documentation of physician prescribed bed rest for incapacitating episodes for a higher rating under code 5243.  There was no evidence of an associated unfitting radiculopathy for consideration of a 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).”  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 adjudication for the thoracolumbar condition.

BOARD FINDINGS.  In the matter of the low back 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 20140320, 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 AR20160008327 (PD201401441)

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
( ) OVA