RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01993
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20090121

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E3, Cargo Specialist, medically separated for “chronic low back pain,” with a disability rating of 20%.

CI CONTENTION:  The applicant makes no specific contention in their application.  The applicant’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 - 20080923	VARD - 20100310	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5243	20%	L5-S1 Disc Degeneration with Right Paracentral Annular Fissure and Bilateral Foraminal Stenosis	5243	10%	20090831	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:

Chronic Low Back Pain (LBP).  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic low back pain condition began in November 2003 without any specific injury or trauma.  Magnetic resonance imaging studies in June 2007 showed slight disc desiccation of L4-S1 and disc protrusion at L4-5.  At the time of the orthopedic clinic appointment on 24 March 2008, performed 10 months before separation, the CI reported LBP mostly on the right side with occasional radicular pain past the knee to the foot. The pain was worse with standing.  The CI denied weakness and bladder/bowel dysfunction.  On examination the lumbosacral spine did not demonstrate a normal curvature.  There was tenderness to palpitation (TTP) and painful motion.  The range of motion (ROM) was normal.  Straight leg raise (SLR) testing for radiculopathy was negative.  Gait, motor strength, sensation and reflexes were normal.  A diagnosis of intervertebral disc degeneration was rendered.  During the physical therapy clinic appointment on 8 April 2008, 10 months before separation, the CI reported 8/10 pain before ROM and 10/10 pain after ROM.  The forward flexion was 30 degrees (90 degrees normal) with a combined ROM of 150 degrees (240 degrees normal).  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic low back pain for PEB adjudication.  The MEB NARSUM examination on 13 May 2008, 8 months prior to separation, noted complaints of LBP with associated radicular pain into her foot.  The LBP was exacerbated by heavy lifting, bending stooping and prolonged standing.   The physical examination showed normal gait, motor strength, reflexes and sensation.  SLR testing for radiculopathy was negative.  There was mild localized tenderness about the proximal hip and lumbosacral spine.  During the physical therapy clinic appointment on 19 September 2008, performed 4 months before separation, the CI reported 8/10 LBP before ROM testing and 9/10 LBP after ROM testing.  On examination there was no TTP, muscle spasms, or abnormal spinal contour or abnormal gait.  The ROM was forward flexion of 10 degrees and a combined ROM of greater than 95 degrees and not greater than 120 degrees with pain throughout the ROM expressed by guarding and groaning.  The examiner noted that between ROMs the patient demonstrated approximately 90 degrees of forward flexion during self-stretching.  The ROM was clarified during the family health clinic 2 days later on 22 September 2008.  At that time the physician examiner indicated the actual active forward flexion was 90 degrees with pain beginning at 45 degrees and stated “this finding of painful, but mechanically normal ROM is explained by the finding of L4-S1 degenerative changes (PT has no L5 disc due to congenital sacralization) and subsequent paravertebral muscle spasm”.  After repetitions the CI maintain full ROM, but complained of pain at 35 degrees of forward flexion.

At the time of the VA physical therapy consult appointment on 7 July 2009, performed 6 months after separation, the CI reported LBP with bilateral lower extremity numbness, right greater than left.  On examination the CI was able to ambulate without a noticeable deviation in her gait and she had a normal spinal curvature.  There was TTP at L4 and L5, posterior superior iliac spine and the sacroiliac area.  The lumbar flexion was 8 inches from the floor, which approximate 80-90 degrees of thoracolumbar forward flexion with increased pain with repeated motions without radicular symptoms.  There was a positive SLT bilaterally at about 55 degrees with back pain and hamstring tightness.  The assessment at that time was chronic LBP but no radicular symptoms.  At the VA Compensation and Pension (C&P) examination on 31 August 2009, performed 7 months after separation, the CI reported 7-8/10 LBP when standing or laying and bilateral paresthesia into her legs.  The physical examination showed a normal gait, spinal contour, motor strength, reflexes, and sensation without spasm, guarding, weakness, tenderness or pain with motion.  The ROM was forward flexion of 0-80 degrees with a combined ROM of 230 degrees.  There were no additional limitations after repetitions.  Lasegue’s signs were negative for radiculopathy.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic low back pain condition 20% coded 5243 (intervertebral disc syndrome), citing limitation of forward flexion.  The VA rated the back condition 10% coded 5243 (intervertebral disc syndrome), based on the VA C&P examination 7 months after separation, citing limitation of forward flexion and combined ROM.  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), reported on the (physical therapy and family health clinic examinations.  The Board concluded there was no evidence to support a rating higher than the rating adjudicated by the PEB.  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.  There was no associated radiculopathy for separate peripheral nerve rating.  While the CI may have experienced radiating pain from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There was no objective evidence of a radiculopathy with functional impairments such as weakness with a direct impact on fitness that were separately functionally impairing for duty.  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 concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic low back pain condition.

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.  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 20140218, 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 AR20160006830 (PD201401993)

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