RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01934
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080630

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E5, Motor Transport Operator, medically separated for “chronic low back pain” with a disability rating of 20%.  

CI CONTENTION:  “The Board only granted me 10% for back problems (herniated disk) and 10% for knee problems (patellofemoral pain syndrome) while VA granted me a compensation for my back, my knee and for major depression with symptoms of PTSD.”  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 - 20080401	VARD - 20081010	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain…	5299-5237	20%	Lumbar Disc Disease L5-S1…	5243	10%	20080902	
Depressive Disorder NOS	Not Unfitting	Depressive Disorder, NOS…	9434	10%	20080905	
Right Knee Patellofemoral Pain Syndrome	Not Unfitting 	Right Knee Patellofemoral Pain Syndrome	5299-5257	10%	20080902	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in July 2006 when she fell down a flight of stairs.  She strained her back again while lifting heavy gear while deployed in February 2007.  Radiographic studies showed a bulging disc that touched the S1 nerve roots.  Electrodiagnostic studies performed on 3 July 2007 were negative for radiculopathy.  There was no discussion of a surgical solution, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “low back pain” 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 ~9 Mo. Pre-Sep	Phys Med ~8 Mo. Pre-Sep	VA C&P ~2 Mo. Post-Sep	
Flexion (90 Normal)	45 (47)	45 (45 50 47)	40	
Combined (240)	150	155	180	
Comments	                   --	Painful motion	Painful motion; tenderness; guarding; and spasm	
§4.71a Rating	20%	20%	20%	

During the MEB examination (recorded on DD Forms 2807 and 2808) dated 16 October 2007, 9 months prior to separation, the CI reported numbness on her left leg.  Physical examination showed decreased ROM as indicated in the chart above.  At the physical medicine and rehabilitation ROM study on 13 November 2007, the CI had decreased ROM as indicated in the chart above with pain on flexion.  

The MEB NARSUM examination on 6 December 2007, 7 months prior to separation, noted complaints of back pain exacerbated by prolonged standing, sitting and walking.  Physical examination showed tenderness.  Examination testing for radicular signs was negative.  The neurological examination was normal with normal reflexes and sensation.  

At the primary care clinic visit on 28 January 2008, 5 months prior to separation, the CI reported back pain that was worse with movement and resembled a shock-like sensation.  The pain no longer radiated, but she did have muscle spasm and back stiffness.  On examination the CI had tenderness to palpation and muscle spasm.  Her spinal contour was normal, but the examination was silent regarding gait.  

At the 2 September 2008 VA Compensation and Pension (C&P) joints evaluation, performed 2 months after separation, the CI reported decreased motion, spasms, and low back pain with radiation of pain to the left thigh.  Precipitating factors were prolonged sitting, prolonged standing, and sleeping on her stomach.  The CI also reported no specific incapacitating episodes for her lower back during the previous 12 months.  Physical examination showed spasm, guarding, and tenderness, but none of these were severe enough to result in abnormal gait or spinal contour.  She also had weakness in her right lower extremity at 4 of 5 with knee extension.  Sensation and reflexes were normal.  

At the 9 September 2008 VA Compensation and Pension (C&P) general evaluation, performed 2 months after separation, the CI reported that her back pain was mild to moderate and increased with prolonged sitting, prolonged standing, carrying, and bending.  Physical examination showed normal motor strength, reflexes and sensation.  The CI had tenderness, but no muscle spasm or guarding.  Examination testing for radicular symptoms was negative.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 20%, coded 5299-5237 (analogous to lumbosacral strain).  The VA also rated the back condition 20% coded 5243 (intervertebral disc syndrome), based on the VA C&P examination 2 months after separation, citing forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees.  The Board agreed that a 20% rating, but no higher, was justified for limitation of flexion greater than 30 degrees but not greater than 60 degrees as reported on the physical medicine and VA examinations.  The Board considered whether a higher rating (§4.7) was achieved by using the alternate rating formula based on incapacitating episodes due to intervertebral disc syndrome (IVDS).  Although the CI had intervertebral disc disease there were no incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula for IVDS.  The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The CI had symptoms of radiating pain documented in the treatment records; however, electro-diagnostic studies showed no evidence of neuropathy or radiculopathy.  The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting.  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 was minimal evidence in this case that motor weakness existed to any degree that could be described as functionally impairing.  The Board therefore concluded that an 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 concluded that there was insufficient cause to recommend a change in the PEB adjudication for the back condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that right knee patellofemoral pain syndrome and depressive disorder, NOS, 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:  

Right Knee Patellofemoral Pain Syndrome:  This condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  No knee condition was forwarded by the MEB to the PEB for adjudication.  Radiographic studies to include MRI and X-rays were normal.  There was no performance-based evidence from the record that the condition 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 her right knee condition and so no additional disability rating is recommended.  

Depressive Disorder NOS:  Although this disorder was profiled and considered to fail retention standards, the CI’s commander reported that the CI maintained a good appearance; related civilly with supervisors and co-workers; didn’t have problems remembering locations and procedures; asked questions and requested help when appropriate; maintained an acceptable level of attention and concentration to carry out instructions; communicated well with others; and sustained an ordinary routine without special supervision.  At the MEB mental status examination, the examiner noted that the CI made good eye contact; was pleasant and cooperative; was alert, awake, and oriented in all three spheres; that her thought processes were logical, coherent and goal directed with no evidence of flight of ideas or any looseness of associations; that her thought content revealed no auditory or visual hallucinations; that the CI denied suicidal, homicidal or paranoid ideation; that her social and test judgment was deemed to be adequate.  At the C&P mental disorder examination performed 2 months after separation, the CI reported startled response whenever she got close to a truck; intolerance to crowds; social withdrawal; irritability; depressed mood with crying bouts; palpitations; anxiety; restlessness; trouble sleeping; hyper vigilance; and increased appetite.  Her Global Assessment of Functioning was 70 (mild symptom range is 70-61).  There was no performance-based evidence from the record that the condition 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 her depressive disorder condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended right knee and depressive disorder NOS 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, 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 AR20160011306 (PD201401934)

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