RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01668
BRANCH OF SERVICE:  Army	DATE OF SEPARATION:  20090925

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Wheeled Vehicle Mechanic) medically separated for intervertebral disc derangement L5-S1, rated at 20%.

CI CONTENTION:  The applicant contends that he should have been rated at a higher percentage for his condition.  His complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  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 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:  

IPEB - Dated 20090731	VA* - (~1 Mo. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Intervertebral Disc Derangement L5-S1	5299-5243	20%	Lumbar Strain with L2-S5 Disc Bulging 	5237	10%	20091030	
Other MEB/PEB Conditions x 0 (Not in Scope)	Other x 0	
RATING:  20%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20100121 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Intervertebral Disc Derangement L5-S1 Condition.  A note dated 30 April 2008 indicated the CI complained of lower back pain radiating to the legs when running and performing sit-ups.  There was a full thoracolumbar range-of-motion (ROM) with lumbosacral tenderness on palpation.  X-rays of the lumbar spine were normal on 30 April 2008.  Treatment consisted of meloxicam (a nonsteroidal anti-inflammatory drug (NSAID)), tramadol (an opioid-like medication), and a profile.  An MRI performed on 3 October 2008 for L5 left lumbar radiculopathy demonstrated disc bulges and mild to severe bilateral neural foraminal stenosis, worse in the lower lumbar spine, with no central canal stenosis.  Methocarbamol (a muscle relaxer) and naproxen (an NSAID) were added to the treatment protocol in November 2008. The thoracolumbar spine did not demonstrate a full ROM, but there was no pain during movement.  Neurological evaluation was unremarkable.  Orthopedic evaluation in December 2008 indicated there had not been any physical trauma, back surgery, manipulative treatment, or physical therapy.  The CI described the pain as constant; it shot down the left leg; and it was worse when sitting and then trying to stand.  The diagnosis of lumbar radiculopathy was made based on L4-L5 and L5-S1 neuroforaminal stenosis along with a clinically positive left straight leg raise test (to determine nerve root irritation) and the complaint of left sided radicular pain.  Treatment consisted of Motrin (ibuprofen, an NSAID), Flexeril (cyclobenzaprine, a muscle relaxer), and a physical therapy consult.  The orthopedic consultant felt much of the pain may have been due to muscle spasm.  A chest X-ray in May 2009 showed a mild degree of mid left thoracic scoliosis, but was otherwise normal.  A permanent L3 profile was issued in May 2009 for lumbar degenerative disc disease and L5 spondylosis with limitations of all functional military activities and physical fitness testing.  The commander’s statement dated 21 May 2009 indicated the CI’s physical limitations set by his profile did not allow him to perform his duties to the maximum extent required to meet the physical demands of a light wheel vehicle mechanic.  The MEB narrative summary (NARSUM) dated 9 July 2009 noted the CI’s history and reviewed all of the visits and findings related to his back pain and left-sided radicular pain.  The CI noted the pain with a severity of 7-8/10 (10 being the worst pain) was intermittently sharp and it shot especially into the left lower extremity all the way to the lateral aspect of the foot.   Coughing and sneezing were painful as was sitting more so than with standing.  There were no bowel or bladder problems.  Examination performed on 28 May 2009 noted tenderness to palpation of the lumbosacral spine with a positive straight leg raise.  Sensation and motor exams were normal as were balance, gait, stance, reflexes, and peripheral nerves.  ROM measurements were performed on 22 June 2009 by a physical therapist are in the chart below.  There was some muscle guarding into the left buttock and tenderness to palpation from L3 to L5 as well as along the left sacroiliac joint.  The CI had an antalgic gait.   The diagnosis was L5 to S1 intervertebral disk derangement with lumbago.  At the VA Compensation and Pension (C&P) examination, performed a month after separation, the CI reported constant pain of the lower back, leg, and foot, which was exacerbated by physical activity and relieved by Percocet (oxycodone, a narcotic and acetaminophen, a pain reliever).  He had no incapacitation in the prior 12 months, but his functional impairments were limited movement and no heavy lifting.  Examination revealed no evidence of radiating pain on movement and there was no spasm, guarding, weakness, or ankylosis.  Straight leg raise was negative bilaterally and there was symmetry of spinal motion with normal curves of the spine.  The ROM measurements, in the chart below, were normal with limitation of motion after repetition by pain and fatigue.  The ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, are summarized in the chart below.

Thoracolumbar ROM
(Degrees)	MEB/PT ~3 Mo. Pre-Sep
	VA C&P ~1 Mo. Post-Sep
	
Flexion (90 Normal)	(60)55/56/58	90	
Extension (30)	(15)14/16/17	30	
R Lat Flexion (30)	(25)22/24/25	30*	
L Lat Flexion (30)	(25)21/23/24	30*	
R Rotation (30)	(25)25/25/26	30*	
L Rotation (30)	(25)21/23/23	30*	
Combined (240)	175	240	
Comment	Muscle guarding into left buttock; antalgic gait with no AD, mild thoracic kyphosis with forward head	No spasm or guarding; *pain at 30 degrees	
§4.71a Rating	PEB 20%	VA 10%	
The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating using code 5299-5243 (Intervertebral disc syndrome) for intervertebral disc derangement L5-S1.  The VA assigned a 10% rating using 5237 for lumbar strain with L2-L5 disc bulging.  The Board sought a route for a higher rating but was unable to find one in the absence of ankylosis, forward flexion less than 30 degrees, or incapacitation.  The Board then considered whether an additional rating could be recommended under a peripheral nerve code.  Although the pain component of the neuropathy is appropriately subsumed in the spine rating IAW VASRD §4.71, which states that “rating is performed with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease,” there was no sensory component with any significant functional implications and no motor weakness was in evidence.  Therefore, a radiculopathy could not be recommended for additional disability rating.  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 intervertebral disc derangement L5-S1 condition.  

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the intervertebral disc derangement L5-S1 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 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 XXXXXXXXXXXXXXXXXX, AR20160003263 (PD201401668)

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