RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	      CASE:  PD-2014-01652
BRANCH OF SERVICE:  Army	                             SEPARATION DATE:  20090526 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E-7, Automated Logistical Specialist, medically for “degenerative arthritis, thoracolumbar spine with multilevel spondyloarthopathy” and “neuropathic pain left buttock and thigh” rated 10% and 10% respectively, for a combined disability rating of 20%.

CI CONTENTION:  His conditions continue to worsen and negatively impact his daily activities.  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 - 20090203	VARD - 20090714  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Degenerative Arthritis Spine	5242	10%	Lumbar Degenerative Disc Disease	5243	0%	20080908	
Neuropathic Pain Left Buttock and Thigh	8720	10%	Neuropathic Pain Left Buttock and Thigh	8520	NSC		
COMBINED RATING:  20%	COMBINED RATING FOR ALL VA CONDITIONS:  10%	
*Derived from VA Rating Decision (VARD) dated 20090714 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:

Lumbar Spine.  The service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) documented a history of back pain since 2003 which was exacerbated by a motorcycle accident in 2007.  Imaging revealed degenerative changes with spondyloarthopathy (arthritic changes of vertebral attachment processes) and mild to moderate disc disease (L3/4 - L5/S1 with some left neural impingement).  The symptoms worsened despite conservative management, were judged to be non-surgical, and the CI opted for a MEB rather than a specialty referral for further attempt at rehabilitation and pain management.  There were multiple outpatient entries in the STR documenting grossly normal range of motion (ROM), two which noted non-specifically decreased flexion and extension, but none which indicated significant ROM limitation. There were various entries documenting normal gait with none to the contrary, no entries which suggested abnormal spinal contour, and no documentation of incapacitating episodes.   

A VA Compensation and Pension (C&P) examination was conducted 8 September 2008 (8+ months before separation) and documented pain rated 8/10 “only when aggravating factors are present,” the latter listed as “exercise, lifting, prolonged standing, [and] prolonged sitting.”  The VA physical examination recorded a normal gait and the absence of spinal tenderness or spasm.  The VA measured ROM was normal in all planes: flexion to 90 degrees and combined ROM of 240 degrees, specifying the absence of painful motion.  The NARSUM was conducted 24 November 2008 (6 months prior to separation) and documented constant back pain rated 5/10 with exacerbations to 7-9/10 “with increased activity, especially with prolonged sitting and standing.”  The NARSUM physical examination recorded a normal gait and tenderness without mention of spasm or abnormal contour.  Addenda to the NARSUM were physical therapy ROM measurements for the MEB which recorded flexion to 85 degrees and combined ROM of 215 degrees, specifying painful motion and noting the absence of abnormal gait or spinal contour.   

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 10% rating under code 5242 (degenerative arthritis of the spine) was consistent with VASRD §4.71a criteria for the ROM evidence and other ratable findings.  The VA’s 0% rating under 5243 (intervertebral disc syndrome) was consistent with normal ROM without painful motion as recorded by the C&P examiner.  There was no ROM evidence supporting a rating higher than 10%, no evidence for abnormal gait or contour to support a 20% rating, and no documentation of incapacitating episodes which would provide for a higher rating under that formula.  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.  

Neuropathic Pain Left Buttock and Thigh.  Outpatient STR entries for the spine condition documented (albeit inconsistently) the presence of radiating pain to the buttocks and proximal left extremity, without subjective weakness or sensory symptoms.  There were numerous entries (including specialty examinations) which recorded normal strength and neurological findings, with the single exception of one examiner who noted 4/5 left foot dorsiflexion (normalized on repeat exams by the same provider).  A neurology consultant for the MEB from August 2008 documented “pain is mostly in his low back but also pain frequently radiating to the back of the thigh and to the leg ... increases on jogging, walking or running.”  Detailed motor, sensory, and reflex findings were normal.  Electrodiagnostic (EMG) testing was normal with “no evidence of lumbosacral radiculopathy.”  The pre-separation VA C&P examiner did not document radiating pain or neurological symptoms, recorded normal neurological findings with 5/5 strength on examination, and did not diagnose or mention a lumbar radiculopathy.  The NARSUM documented “constant pain in the left posterior buttock and thigh associated with tingling and numbness down his posterior left thigh with prolonged sitting,” but the physical examination recorded 5/5 motor strength in all groups, normal reflexes, and normal sensation.  The NARSUM diagnosis specified disc disease “with radicular symptoms,” but listed no separate diagnosis of spinal neuropathy. 
 
The Board directed attention to its rating recommendation based on the above evidence.  Although a specific diagnosis of neuropathy was not forwarded, the reconsideration PEB conceded a separately unfitting left lower extremity radiculopathy.  This was appropriately coded 8799-8720 (analogous to sciatic neuropathy) and specified mild impairment which confers a 10% rating.  The VA denied service connection, stating in the decision, “Although there is a record of treatment in service for neuropathic pain left buttock and thigh, no permanent residual or chronic disability subject to service connection is shown by the service medical records or demonstrated by evidence following service.”  No alternative coding option was subject to consideration since the PEB code is quite specific for the condition.  Members considered whether a higher rating under code 8720 (20% for “moderate” or 40% for “moderately severe” impairment) could be justifiably recommended.  Given the normal EMG, the absence of any objective motor weakness by numerous examiners, and the lack of any significant functional implications of the subjective sensory deficit, all members agreed that a higher rating was not supported.  After due deliberation, considering all evidence and with deference to reasonable doubt, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication of the left sciatic neuropathy.

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 left buttock and thigh neuropathic condition and IAW VASRD §4.124a, 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 20140416, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

		
SAMR-RB						

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, AR20160006816 (PD201401652)

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