RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	      CASE:  PD-2014-01478
BRANCH OF SERVICE:  Army                                                                   SEPARATION DATE:  20060614

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Food Service Specialist, medically separated for “chronic low back pain” with a disability rating of 10%.  

CI CONTENTION:   The CI asserts that medical issues/conditions were not considered during the Physical Evaluation Board (PEB).  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 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 - 20060224	VARD - 20061130	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5242	10%	Degenerative Disc Disease at L4-L5	5237	40%	20060920	
Endometriosis and Adhesions	Not Unfitting	Endometriosis	7629	0%	20060913	
Gastroesophageal Reflux Disease	Not Unfitting	Gastroesophageal Reflux Disease	7346	10%	20060920	
Recurrent Headache	Not Unfitting	Headaches	8199-8100	0%	20060920	
Cervical Degenerative Disc Changes	Not Unfitting	Cervical Spine Condition	5237	NSC	20060920	
Stress Changes at Knees and Feet	Not Unfitting	Chondromalacia, Bilateral Knees 	5099-5014	0%	20060920	
		Arthritis, Left Knee	5003-5257	NSC	20060920	
		Right Knee Arthritis	5003	NSC	20060920	
		Plantar Fasciitis, Left Foot	5276	0%	20060920	
		Arthritis of the Feet	5003-5271	NSC	20060920	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS: 90%	

ANALYSIS SUMMARY:  

Low Back Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the low back condition began after a fall in basic training, approximately 16 months prior to referral to the MEB.  Lumbar spine magnetic resonance imaging (MRI) showed multilevel interfacet arthropathy (joint disease) and an L4-L5 central disc protrusion.  A pain management examination documented a normal gait (normal toe/heel) and normal (5/5) bilateral lower extremity strength.  Lumbar spine range-of-motion (ROM) was decreased with flexion and extension both decreased by 10 degrees.  The right sacroiliac (SI) joint was tender and the flexion, abduction, external rotation, and extension ([FABERE] assesses hip and SI joint pathology) test was positive.  The examiner recounted the findings of the MRI and scheduled epidural steroid injections (ESIs).  Pain management performed two ESIs.  The physical medicine and rehabilitation (PM&R) examination was documented as “significant for a painful, antalgic gait to the right lower extremity.  There was marked grimacing, groaning, and crying throughout the exam; superficial tenderness diffusely at the low back; diffuse, neurologically ‘non-anatomic’ ‘breakaway weakness’ to the right lower extremity; and some distraction/inconsistency to pain elicited by hip flexion and other maneuvers during the exam.  This accounted for 4/5 positive Waddell's Signs [psychogenic, or nonorganic, manifestations of pain].”  The electro-diagnostic study (EMG) performed by PM&R was mildly abnormal with no evidence of a right lumbosacral radiculopathy (nerve root irritation or injury) by accepted criteria.  There was evidence of injury isolated to the right mid and lower lumbar dorsal primary rami and an unspecified right lower extremity lumbosacral radiculopathy was possible.  The examiner recounted the findings of the MRI and EMG.  The impressions listed mechanical and myofascial low back pain with underlying lumbar spine degenerative changes, “4 out of 5 positive Waddell's signs” indicated that psychological factors might be contributing to the condition, and low clinical suspicion for a lumbosacral radiculopathy.  The examiner recommended further ESIs as indicated per pain management, physical therapy (PT), and a referral to behavioral medicine, for evaluation and treatment of any existing psychopathology.  

The Report of Medical Examination for the MEB (DD Form 2808) documented thoracolumbar ROM flexion of 85 degrees (90 normal), extension of 20 degrees (30), right rotation of 55 degrees (30), left rotation of 40 degrees (30), and bilateral lateral flexion of 20 (30) degrees.  In the 12 December 2005 NARSUM, 6 months before separation, the CI complained of increasing low back pain beginning 2 months after her basic training injury.  The CI failed conservative management (activity modification, PT, ESIs, and medication) and was not deemed a surgical candidate.  Under physical examination, the examiner stated “Please see DD Form 2808 for the majority of normal findings.”  The focused physical examination documented “heel and toe walk intact” and lumbar tenderness.  Motor, sensory, deep tendon reflexes (DTRs), and straight leg raise (SLR) tests (assesses for herniated disc causing sciatic nerve root [L5-S1] radiculopathy) were intact.  There were 2/5 (sensory changes and distraction) psychogenic, or nonorganic, manifestations of pain (Waddell’s signs).  Thoracolumbar ROM measured by goniometer was flexion of 85 degrees (90), extension of 20 degrees (30), right rotation of 55 degrees (30), left rotation of 45 degrees (30), and bilateral lateral flexion of 20 (30) degrees.  The examiner cited the findings of the MRI and EMG.  The diagnosis listed lumbar spondylosis (spine degenerative disease) with intermittent right radicular symptoms.  Lumbar and thoracic spine diagnostic imaging (X-ray) was unremarkable.  

The 20 September 2006 VA Compensation and Pension (C&P) examination, 3 months after separation, recounted the history of injury and interventions.  The CI complained of lumbar spine stiffness and pain with pain radiating to both buttocks and posterior thighs to the knees.  She did not wear a brace or use any ambulatory aids.  The CI denied bowel incontinence but reported periodic urinary incontinence since giving birth.  Pain was exacerbated by standing (>10 minutes) and walking (1 block) and her multiple pain complaints had not been relieved by previously prescribed medications (Methadone, Robaxin, and Flexeril).  The physical examination documented “… she initially arose from the chair in the waiting area and walked to the examination room with a normal gait and no limp. … after the examination when she was walking there was grimacing and there was some forward flexion of the spine.”  The thoracic spine examination revealed paraspinous muscle tenderness from T1 to T7.  The lumbar spine examination revealed generalized L1 to S2 paraspinous muscle, SI joints, and buttocks tenderness.  There was no spasm of any of the paraspinous muscles.  There were 2/5 (tenderness to light skin touch and axial rotation) psychogenic, or nonorganic, manifestations of pain (Waddell’s signs).  Active ROM was flexion of 30 degrees (90), extension of 0 degrees (30), bilateral rotation of 10 degrees (30), left lateral flexion of 10 degrees (30), and right lateral flexion of 0 (30) degrees.  There was some grimacing and tearing during ROM testing of the lumbar spine and the CI was unable to complete repetitive motion testing.  The SLR tests were negative, pathologic reflexes were absent, and strength, sensation, and DTRs were normal.  The impression listed chronic low back pain, secondary to congenital spinal stenosis, and possible herniated disc by MRI.  The examiner opined that there was significant functional overlay as evidenced by the positive Waddell signs, low pain tolerance, and somatization (physical symptoms not explained by known medical disease).  The examiner documented that there was no physiologic reason for the severe loss of motion and no evidence of nerve root irritation or radiculopathy by exam.  A lumbar spine MRI showed degenerative disc disease (DDD) at L4-L5 and L5-S1.  A pain management examination documented the back was painful to touch all over from her head to sacrum.  The ROM was characterized as “… she has good range of motion in her back, except on extension ….”   The SLR tests were negative, extremity strength was 4/5, and sensation and DTRs were normal.  The MRI findings of L4-L5 and L5-S1 degenerative joint disease (DJD) were recounted.  The examiner recorded “She also expresses some Waddell signs with axial loading by head compression.  Also, pain behavior is grossly out of proportion to the test stimulus, physical examination ….”  The assessment listed myofascial pain.  

The 3 June 2007 C&P examination, 12 months after separation, recounted the history and interventions.  The CI complained of constant 5/10 low back pain with radiation to both buttocks and down the back of the legs to the knees.  Pain was characterized as a sharp, stabbing, pressure, and ache.  Pain was exacerbated by walking (1 block) and reduced to 4/10 by medications (Tramadol, Hydrocodone).  She complained of associated back and neck spasms but denied bowel incontinence but reported periodic urinary incontinence since pregnancies/deliveries.  The CI used no braces, canes or crutches.  She reported 3 incapacitating episodes the last year lasting 4 days.  The physical examination documented a normal gait.  The thoracic spine examination revealed a normal curvature with no deformities or tenderness.  The lumbar spine examination revealed lower back pain with flexion, extension, and rotation.  Active ROM was flexion of 50 degrees (90), extension of 15 degrees (30), bilateral rotation of 15 degrees (30), and bilateral lateral flexion of 15 (30) degrees.  Active ROM did not produce weakness, fatigue, or incoordination and there was no additional loss of ROM with repetitive movement.  The SLR tests produced low back pain, but were not positive for radiculopathy.  There was no muscle spasm and no muscle atrophy.  Pathologic reflexes were absent, and strength, sensation (except decreased right lower extremity pinprick sensation), and DTRs were normal.  The examiner recounted the MRI findings.  The impression listed chronic low back pain and DJD at L4-L5 and L5-S1.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5242 code (degenerative arthritis of the spine), citing chronic low back pain, secondary to multi-level interfacet arthropathy, without neurologic deficit, tenderness, and ROM greater than 240 degrees.  The VA assigned a 40% rating under the 5237 code (lumbosacral or cervical strain) based on the VA C&P examination 3 months after separation, citing L4-L5 DDD, herniated disc, lumbar spondylosis, spinal stenosis, intermittent right radicular symptoms, paraspinous muscle tenderness, no paraspinous muscle spasm, ROM, no physiological reason for the severe loss of motion, no evidence of nerve root irritation or radiculopathy by examination, positive Waddell signs, significant functional overlay, somatization, numerous physical symptoms caused by psychological problems, and no underlying physical problem can be identified.  The ROM values in 3 of 5 proximate examinations (MEB DD Form 2808, MEB, and pain management) were consistent with the 10% rating (flexion of greater than 60 degrees but not greater than 85 degrees; or a combined ROM of greater than 120 degrees but not greater than 235 degrees of the thoracolumbar spine).  The higher 20% rating would require (flexion of greater than 30 degrees but not greater than 60 degrees; or a combined ROM of not greater than 120 degrees of the thoracolumbar spine).  The ROM values in the C&P examination 3 months after separation were consistent with the 40% rating, the ROM values in the C&P examination 12 months after separation were consistent with the 20% rating.  Recognizing the temporal relationship to the date of separation, the board considered the relative probative value of the proximate exams.  The Board assigned more probative value to the MEB examination because it documented comprehensive thoracolumbar spine ROM measurements with a goniometer while the C&P examinations documented lumbar spine ROM without a goniometer specified.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  While the CI complained of pain radiating into the bilateral lower extremities, the mildly abnormal EMG showed no evidence of a right lumbosacral radiculopathy.  There was no evidence in this case that motor weakness or sensory impairment existed to any degree that could be described as functionally impairing.  The Board therefore concluded that additional disability rating was not justified on this basis.  While the CI reported incapacitating episodes, there was no documentation of incapacitating episodes that would justify a minimum rating under the alternative formula for rating intervertebral disc disease.  While the proximate examinations documented tenderness, there was no evidence of muscle spasm, abnormal spinal contour, or abnormal gait.  Other routes to a rating higher than the PEB’s 10% were considered, but there was no evidence of additional functional loss from repetitive use to warrant application of VASRD §4.45.  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 low back condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the endometrosis and adhesions, gastroesophageal reflux disease, recurrent headache, cervical degenerative disc changes, and stress changes at knees and feet conditions were not unfitting.  While the endometrosis and adhesions condition was profiled and implicated in the commander’s statement, it was not judged to fail retention standards.  The balance of the contended conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed and considered by the Board.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  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 any of the contended conditions and so no additional disability ratings are recommended.

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.  In the matter of the contended endometrosis and adhesions, gastroesophageal reflux disease, recurrent headache, cervical degenerative disc changes, and stress changes at knees and feet 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 20140211, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

22 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, AR20160008331 (PD201401478)

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