RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01854
BRANCH OF SERVICE:  Army	BOARD DATE:  20150512
SEPARATION DATE:  20060405

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Carpentry and Masonry Specialist) medically separated for back pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness requirements.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic thoracic spine pain” condition was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “chronic thoracic back pain” as unfitting, rated 10%, citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please review all conditions.”

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/Naval 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 20060215	VA* – ~6 Mos. Post-Separation	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Thoracic Back Pain	5237	10%	Degenerative Disc Disease, Thoracic Spine	5242	10%	20061017	
Other x 0 	Other x 1	
RATING:  10%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20070321 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Chronic Thoracic Back Pain.  A note dated 19 July 2004 indicated the CI developed thoracic back pain 1 day earlier possibly from working 10-hour shifts pouring cement, which may have caused irritation.  Physical therapy (PT) was commenced and good relief was obtained with thoracic paraspinal stretches within 2 days.  A thoracic spine series, dated 13 April 2005, revealed Schmorl’s nodes (protrusions from a disc into contiguous vertebrae) about T5 while the rest of the thoracic spine was normal.  Osteopathic manipulation and PT were carried out from May 2005 through July 2005, but pain did not significantly improve with PT and a pain clinic referral was recommended.  A pain clinic note, dated 9 November 2005, indicated the CI was taking Elavil (amitriptyline - for nerve pain), which seemed “to help somewhat.”  Examination of the CI’s thoracic spine showed a normal curvature, which was tender on palpation, while his gait and stance were normal.  Treatment consisted of trigger point injections with follow-up as needed. 

A permanent L3 profile was issued on 30 November 2005 with limitations of military functional activities including not wearing personal protective equipment.  Physical training testing was also limited with additional restrictions of no sit-ups, flutter kicks, jumping or lifting more than 20 pounds.  On the MEB DD Form 2807-1, Report of Medical History, dated 6 December 2005, the CI annotated he had back problems since June of 2004.  On the DD Form 2808, Report of Medical Examination, dated 14 December 2005, tenderness to palpation was noted in the midline of the thoracic and cervical spine and in the rhomboid area between the scapulae, the right greater than the left.  There was no muscle spasm or scoliosis.  The commander’s statement, dated 16 December 2005, indicated that due to his back pain, the CI could not put up walls, push a screed (a tool for removing excess concrete), or lift heavy objects.  Therefore, he was unable to do work expected of a carpenter/masonry specialist and the back pain limited his physical fitness readiness.

The MEB narrative summary (NARSUM), dated 20 January 2006, indicated the CI lifted a power screed that weighed over 200 pounds while deployed and injured his back.  Pain and tightness in the middle and upper back increased over the next 2 days and treatment consisted of nonsteroidal anti-inflammatory, muscle relaxants, and PT.  In spite of a lack of improvement, the CI completed his deployment and was able to continue functioning in his MOS.  In the spring of 2005, pain increased without any specific inciting event.  Muscle relaxants, nonsteroidal anti-inflammatory medication, and PT were again instituted, but were ineffective after several months.  The pain was described as a dull ache between his shoulder blades and was worse with heavy lifting and increased physical activity.  A magnetic resonance imaging on 18 October 2005 showed mild anterior wedging of the T7 vertebral body and end-plate irregularities consistent with Schmorl’s nodes and was consistent with the thoracic X-rays of 13 April 2005.  On 9 November 2005, a series of three trigger point injections was performed without any significant improvement in symptoms.  As a result of continued pain, the CI was unable to perform all functions of his MOS and was unable to deploy.  The NARSUM-focused examination findings were the same as the MEB physical examination of 14 December 2005.  The range-of-motion (ROM) was full in all planes without any significant aggravation of his symptoms.  The CI’s gait was normal as was the neurologic examination.  He had increased pain with heavy lifting including his 20-pound daughter and was unable to do the more physically demanding requirements of his MOS including putting up sheet rock and hanging ceiling tiles.

At the VA Compensation and Pension examination, dated 17 October 2006 and performed 6 months after separation, the CI reported he had chronic back pain that radiated to his shoulders and arms bilaterally, that he did not take any pain medications, and he that noted warm baths helped somewhat, but not completely.  Flare-ups occurred once or twice a week when lifting children or during weather changes.  He was able to perform activities of daily living and stayed home with his children.  On examination there was no gross abnormality of the thoracic and lumbar spine and there was tenderness over the thoracic spine and paravertebral muscles.  A thoracic spine series, dated 18 October 2006, was normal.  Remote examinations beyond 12 months post-separation offer little or no probative value, but highlighted the multiple treatments the CI received to relieve his pain.
The ROM evaluations 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 ~ 2 Mo. Pre-Sep	VA C&P ~6 Mo. Post-Sep	
Flexion (90 Normal)	Full in all planes	90	
Extension (30)	-	30	
R Lat Flexion (30)	-	30	
L Lat Flexion (30)	-	20	
R Rotation (30)	-	30	
L Rotation (30)	-	30	
Combined (240)	-	230	
Comment	Tender to palpation in the thoracic region midline and between the scapulae; no spasms; normal gait; neurological exam normal	Tenderness over the thoracic spine and paravertebral muscles; pain at the last 10 degrees of each motion; DeLuca negative	
§4.71a Rating	PEB 10%	VA 10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5237 (lumbosacral strain) for chronic thoracic back pain marked by paraspinal muscle and thoracic spine tenderness.  The VA assigned a 10% rating using code 5242 (degenerative arthritis of the spine) for degenerative disc disease of the thoracic spine.  The Board considered whether an additional rating could be recommended under a peripheral nerve code.  Firm Board precedence requires a functional impairment linked to fitness to support a recommendation for addition of a peripheral nerve rating to disability in spine conditions.  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, the radiculopathy could not be recommended for additional disability rating.  The Board sought a route for a higher rating, but was unable to find one based on the absence of ROM limitations, gait disturbance, abnormal spinal contour, and/or incapacitating episodes.  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 thoracic back pain 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 chronic thoracic back pain 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.

RECOMMENDATION:  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 20140430, 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 XXXXXXXXXXXXXXXXXXX, AR20150018396 (PD201401854)

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