RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01792
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030606

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

CI CONTENTION:  The CI asserted that all service connected conditions were not rated by the service.  Additionally, she contended for additional medical issues developed secondary to her initial injury.  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 - 20030122	VARD - 20031120	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain…	5299-5295	10%	Chronic Myofascial Pain with Right/Left Sacroiliac Dysfunction	5237	10%	20031027	
Allergic Rhinitis	Not Unfitting	Allergic Rhinitis	6522	0%	20031027	
Mild Persistent Asthma	Not Unfitting	Asthma	6602	10%	20031027	
Migraine Headaches	Not Unfitting	Migraine Headaches	8100	10%	20031027	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Low Back Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the low back pain (LBP) condition began approximately 7 years prior (1996 fall in bathtub) to referral for MEB.  Lumbar spine diagnostic imaging (MRI) showed mild lower degenerative changes and a small disc bulge at L5-S1.  Whole body diagnostic imaging (bone scan) was normal.  At an internal medicine encounter, the CI complained of a long history of sacroiliac (SI) joint pain with associated LBP.  The physical examination documented that gait, strength, sensation, and deep tendon reflexes (DTRs) were normal.  The assessment listed chronic right SI joint pain with an acute recurrence.  Pain management performed a right SI joint injection with local anesthetic and corticosteroid.  At a physical medicine and rehabilitation (PM&R) follow-up, the CI reported the right SI joint injection improved her pain by 95% and relief lasted approximately 3 days.  The back examination revealed bilateral (R>L) SI joint region tenderness.  The flexion, abduction, external rotation, and extension ([FABERE] assesses hip and SI joint pathology) test was positive on the right and straight leg raise (SLR) tests (assess for herniated disc causing sciatic nerve root [L5-S1] radiculopathy) were negative.  Back range of motion (ROM) was full.  Strength and sensation were normal.  The assessment listed SI dysfunction.  Pain management performed a right L4-S4 lateral branch block (local anesthetic injection on lateral branch nerves that supply the SI joint) with local anesthetic.  Lumbar spine diagnostic imaging (X-ray) was normal and a pelvis X-ray showed mild sclerosis (pathological thickening) of the left iliac wing inferior to the SI joint.  At the 8 August 2002 NARSUM, 10 months before separation, the CI complained of 6 years of chronic right lower lumbar (L4-L5 region) pain following a fall in a bathtub.  The pain was characterized as constant, dull, achy, and 8/10 in intensity.  She reported radiation of pain to her right buttocks, but she denied leg pain, numbness, tingling, weakness, or bowel or bladder dysfunction.  Pain was exacerbated by prolonged sitting, prolonged standing, stairs, running, jumping, bending forward, heavy lifting, and load bearing and she did not experience significant improvement from conservative management.  The back examination revealed normal alignment and right lower lumbar (L4-L5) paraspinal muscle and right SI joint tenderness.  The FABERE test was positive on the right and SLR tests were negative.  Back ROM was full except flexion was limited to 45 degrees because of pain.  Gait, strength, sensation, and DTRs were normal.  The examiner recounted the findings of the MRI, bone scan, and X-rays.  The diagnosis listed chronic myofascial pain/right SI dysfunction.  Pain management performed bilateral SI joint injections with local anesthetic and corticosteroid.  In the MEB addendum by PM&R, the CI complained of constant, dull, 7/10 left SI joint region pain without radiation.  She denied numbness, tingling, weakness, or bowel or bladder dysfunction.  Pain was exacerbated by prolonged sitting, prolonged standing, running, and jumping and she denied relieving factors.  The back examination revealed bilateral SI joint region tenderness.  The bilateral FABERE tests were positive and SLR tests were negative.  Back ROM was full and strength, sensation, and DTRs were normal.  The examiner recounted the findings of the pelvis X-ray.  The diagnosis listed left SI joint dysfunction.  The back examination, at a PM&R follow-up, revealed no tenderness.  The FABERE test was positive on the right and SLR tests were negative.  Back ROM was full and strength and sensation were normal.  The assessment listed bilateral SI joint pain.  At the 27 October 2003 VA Compensation and Pension (C&P) examination, the CI complained of chronic back pain, with very rare radiation to the legs, since a fall in a bathroom.  She experienced some improvement with physical therapy, pain management, and medications.  The pain was aching in nature and was worse on rainy days and during adverse weather conditions.  Her back ROM was not impacted in any way and she could walk considerable distances without difficulty.  The back and neurological examinations were “within normal limits.”  Pain free back ROM was flexion of 95 (90 normal), extension of 30 (30), and bilateral lateral bending of 40 (30) degrees.  A lumbar spine X-ray showed minimal scoliosis (abnormal lateral spine curvature).  The diagnosis listed lumbar strain with minimal scoliosis.

The Board directed attention to its rating recommendation based on the above evidence; noting that the CI was separated just prior to a significant change in VASRD codes and criteria for the spine.  The PEB assigned a 10% rating under an analogous 5295 code (lumbosacral strain) citing chronic low back pain, myofascial pain syndrome, SI joint dysfunction, pain on motion, ROM, L5/S1 degenerative disc disease, no focal neurological deficit, 5/5 strength, and rated for pain on motion.  The VA assigned a 10% rating under the 5237 code (lumbosacral or cervical strain) based on the VA C&P examination 5 months after separation, citing recurrent low back pain, chronic myofascial pain, bilateral SI joint dysfunction, occasional flare-ups, normal lumbar spine ROM, no evidence of painful motion, normal neurological findings, and X-ray findings.  The older codes and criteria were applied to rating by the PEB, and the new codes and criteria were in effect for the VA ratings.  The Board’s recommendation, IAW DoDI 6040.44, must be premised on the VASRD in effect at separation; although, the VA examination evidence remains probative to the Board’s recommendation under the applicable VASRD criteria.  The 2002 VASRD coding and rating standards for the spine, which were in effect at the time of permanent separation, were changed to the current §4.71a rating standards on 26 September 2003.  The older ratings were based on a judgment as to whether the disability was mild, moderate or severe.  The Board must correlate the above clinical data with the 2002 rating schedule; applicable diagnostic codes include: 5292 (limitation of lumbar spine motion); 5293 (intervertebral disc syndrome); 5294 (sacroiliac injury and weakness); and 5295 (lumbosacral strain).  Examinations proximate to separation did not show limitation of motion and there was no evidence of intervertebral disc syndrome or incapacitating episodes requiring bedrest prescribed by a physician.  All members agreed a 10% rating was supported based on characteristic pain on motion under VASRD diagnostic code 5295 (lumbosacral strain).  There was no evidence to support higher ratings under this code such as muscle spasm on forward bending.  At the time of the MEB NARSUM, there was no radiating pain or objective findings to support consideration of a separately unfitting peripheral nerve 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 low back condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the allergic rhinitis, mild persistent asthma, and migraine headache conditions were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  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 allergic rhinitis, mild persistent asthma, and migraine headache 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 20140421, 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 XXXXXXXXXXXXXXXXXXXXX AR2016001 0649 (PD201401792)

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