RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01717
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061021

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Food Service Specialist, medically separated for “chronic low back pain” with a disability rating of 0%.

CI CONTENTION:  “Please consider all conditions.”  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 – 20060911	VARD - 20070703	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	0%	Degenerative Disease of the Lumbosacral	5242	10%	20070606	
			Radiculopathy and Sciatica Right Lower Extremity 	8520	10%	20070606	
			Radiculopathy and Sciatica Left Lower Extremity	8520	10%	20070606	
Migraines	Not Unfitting	Migraine Headaches	8100	0%	20070606	
Hypertension	Not Unfitting	Hypertension	7101	10%	20070606	
Hiatal Hernia with Gastroesophageal Reflux	Not Unfitting	Hiatal Hernia with Reflux and Linear Ulcerations on Antrum	7346	10%	20070606	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in 2000 while she was on a field exercise.  The CI denied any specific injury or trauma.  Magnetic resonance imaging (MRI) done on June 2006 showed a disc bulge and degenerative disc disease changes from L4-S1.  She underwent a series of epidural steroid injections (steroid and anesthetic injection into epidural space to reduce inflammation and pain), spine facet joint injections (anesthetic injection on spine facet joints), and radiofrequency denervation (radiofrequency ablation of medial branch nerves that supply spine facet joints) between January 2006 and June of 2006 for pain.  There was no surgical indication.  Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “chronic low back pain secondary to degenerative disc disease at L4-S1 with radiculopathy and chronic thoracic pain secondary to disc protrusion” for PEB adjudication.    

The range of motion (ROM) examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Thoracolumbar ROM
(Degrees)	MEB ~7 Mo. Pre-Sep	VA C&P ~9 Mo. Post-Sep	
Flexion (90 Normal)	50	70	
Combined (240)	185	170	
Comments	Painful motion  guarding	Tenderness	
§4.71a Rating	20%	10%	

The 14 March 2006 MEB NARSUM examination, 7 months prior to separation, noted complaints of chronic low back pain that was aggravated by prolonged sitting or standing.  Physical examination showed painful motion and guarding.  Thoracolumbar ROM after repetition was limited by pain as recorded in the chart.  

At the 6 June 2007 VA Compensation and Pension (C&P) examination, 9 months after separation, the CI reported low back pain with bending, standing and walking, and the pain radiated to both legs.  The examiner noted lumbar tenderness and a slow, careful gait, but was silent regarding spasm and spinal contour.  Thoracolumbar ROM was limited by pain as recorded in the chart, and there was no additional limitation after repetitive motion.  An electrodiagnostic study performed in June 2006 demonstrated evidence of bilateral L5-S1 radiculopathy (nerve root irritation or injury).  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 0% coded 5237 (lumbosacral strain) citing no abnormal gait, spasm, or tenderness.  The VA rated the back condition 10% coded 5242 (degenerative arthritis of the spine), based on the VA C&P examination 9 months after separation, citing limitation of forward flexion.  Members agreed that the MEB NARSUM examination was more consistent with outpatient notes and more reflective of the anticipated severity based on the clinical pathology.  The Board therefore relied more heavily on the NARSUM measurements, and agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees).  There was no evidence of intervertebral disc syndrome resulting in incapacitating episodes requiring bed rest prescribed by a physician to warrant consideration of rating under the alternate VASRD formula based on incapacitating episodes due to intervertebral disc syndrome.  The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  Diagnostic imaging and electrodiagnostic studies supported some level of radicular nerve irritation or involvement, but physical exams (physical medicine, physical therapy, MEB NARSUM, and VA C&P) proximate to separation revealed no objective findings of radiculopathy that would impact duty performance.  While the CI may have suffered additional pain from the nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  Therefore the critical decision is whether or not there was a significant motor weakness which would impact military occupation specific activities.  There is no evidence in this case that motor weakness 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.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the back condition, coded 5237.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that migraines, hypertension, and hiatal hernia with gastroesophageal reflux were not unfitting.  The migraines, hypertension, and hiatal hernia with gastroesophageal reflux were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  There was no performance-based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance at separation.  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 any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the back condition, the Board unanimously recommends a disability rating of 20%, coded 5237 IAW VASRD §4.71a.  In the matter of the contended migraines, hypertension, and hiatal hernia with gastroesophageal reflux conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  

The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Low Back Pain	5237	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140421, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

JUL 22 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 XXXXXXXXXXXXXXXXXX, AR20160008337 (PD201401717)

1. 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,
accept the Board's recommendation to modify the individual's disability rating to 20%
without re-characterization of the individual's separation. This decision is final.

2. I direct that all the Department of the Army records of the individual concerned be
corrected accordingly no later than 120 days from the date of this memorandum.

3. I request that a copy of the corrections and any related correspondence be provided
to the individual concerned, counsel (if any), any Members of Congress who have
shown interest, and to the Army Review Boards Agency with a copy of this
memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

CF:
( ) DoD PDBR
( ) DVA