RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01710
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20030821

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Medical Supply Specialist, medically for “chronic low back pain,” with a disability rating of 10%.  

CI CONTENTION:  The CI had several other medical conditions during the medical evaluation process that were not evaluated by the PEB that she still receives care for.  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 - 20030428	VARD - 20030822	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5293 5299 5295	10%	Degenerative Disc Disease, Lumbosacral Spine	5293-5295	10%	20030521	
Migraine Headaches	Not Unfitting	Migraine Headaches	8100	10%		
Paroxysmal Positional Vertigo		Vertigo	6299	NSC		
Patellofemoral Syndrome, Bilateral Knees		Patellofemoral Syndrome, Right Knee	5099-5019	0%		
		Patellofemoral Syndrome, Left Knee,	5099-5019	0%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back condition began in July 1998 after heavy lifting.  She did not report any radiating pain, numbness, tingling or motor weakness in her lower extremities and denied bowel or bladder dysfunction.  At an orthopedic visit in September 2001 (23 months pre-separation), the examiner documented a forward flexion of 45 degrees (90 normal), limited by pain.  At a visit in April 2002 (16 months pre-separation), there was documentation of muscle tenderness and a “slow” gait.  In May 2002 an MRI documented L5-S1 broad-based posterior disc bulge with possible bilateral S1 nerve root impingement.  There were no electrodiagnostic studies performed and surgery was not recommended.  Lower back pain continued despite conservative treatment and could not be adequately rehabilitated to meet the physical requirements of her military specialty.  A permanent profile was issued and she was referred to the MEB.  There was no STR documentation of physician prescribed bed rest for incapacitating episodes.  During the MEB examination in January 2003 (7 months pre-separation), the CI reported pain and tenderness (recorded on DD Form 2807) and the examiner documented tenderness without spasm of the lumbar spine (recorded on DD Form 2808).  An X-ray from January 2003 documented a normal lumbar spine with partial spinal bifida occulta (a birth defect).  

At the NARSUM examination in March 2003 (5 months pre-separation), the CI reported constant 3/10 pain, that worsened to 9/10 with physical activities such as lifting and carrying weight, and sitting, standing or walking for a prolonged period.  The NARSUM examiner recorded the same findings documented during the MEB examination and added a forward flexion that was limited by pain to 50 degrees.  All testing for motor strength and sensory deficit tests were normal.  

At the VA Compensation and Pension (C&P) examination in May 2003 (3 months pre-separation), the CI reported sharp pain over the right paravertebral muscle group, and denied radiation down the legs.  Physical exam showed tenderness and muscle spasms in the right lower lumbar area.  Forward flexion was limited by pain to 70 degrees.  There were no limitations secondary to fatigue, weakness, lack of endurance, or incoordination.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under 5293 code (intervertebral disc syndrome) and analogous code 5299-5295 (lumbosacral strain), citing painful motion.  The VA also assigned a 10% rating using analogous codes 5293-5295 based on the VA C&P examination 3 months pre-separation, citing muscle spasms and flexion to 70 degrees.  

At the time of separation in August 2003, the 2003 standards for rating based on ROM impairment were subject to the rater’s opinion regarding degree of severity; whereas, the current standards specify rating thresholds in degrees of ROM impairment.  When older cases have ROMs in evidence, the Board reconciles (to the extent possible) its opinion regarding degree of severity for the older spine codes.  The Board first considered the disability rating for the back condition using the 2003 VASRD.  The Board considered the evidence for coding under 5295 (lumbosacral strain) and 5292 (spine, limitation of motion, moderate).  Five months pre-separation, there was documentation of forward flexion to 50 degrees that would support a 20% using code 5292 for spine, limitation of motion, at a moderate level; however, there was documentation of improved ROM (to 70 degrees flexion) at the VA C&P exam 3 months pre-separation, which would also support a rating of 10% for a “slight” limitation of motion.  The Board next considered code 5293 for intervertebral disc syndrome which requires quantification of incapacitating episodes and this information was not in evidence for the Board’s review.  There was no mention of any missed work days or bed rest, only the inability to perform her full MOS.  There was no evidence for strength or sensory deficits, or bladder or bowel incontinence or other evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve rating.  None of these coding options afford a greater than 10% rating advantage to the CI.  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 chronic low back pain condition.  

Contended PEB Conditions.  

Migraine Headaches/Vertigo.  According to STR and the MEB NARSUM, the CI experienced migraine headaches and recurrent spells of vertigo.  The neurology MEB examiner diagnosed migraine headaches without aura and paroxysmal positional vertigo; however, the NARSUM and MEB proceedings both determined these diagnoses were not disqualifying.  

Bilateral Knee, Patellofemoral Syndrome.  According to STR and the MEB NARSUM, the CI experienced intermittent pain in both knees.  The NARSUM examiner diagnosed patellofemoral syndrome, bilateral knees; however, the NARSUM examiner and MEB proceedings both determined this bilateral diagnosis was not disqualifying.  

The Board’s main charge is to assess the fairness of the PEB’s determination that the migraine headaches, paroxysmal positional vertigo and bilateral knee, patellofemoral syndrome conditions were not unfitting.  The migraine headaches, paroxysmal positional vertigo and bilateral knee, patellofemoral syndrome 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, and 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 chronic low back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended migraine headache, vertigo and bilateral knee conditions, the Board unanimously agrees that it cannot recommend it for additional disability rating.  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 20140413, 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 AR20160010644 (PD201401710)

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