RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX.	CASE:  PD-2014-02025
BRANCH OF SERVICE:  Army	BOARD DATE:  20141230
SEPARATION DATE:  20041120

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Light Wheel Vehicle Mechanic) medically separated for chronic low back pain (LBP).  The LBP condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The low back condition, characterized as degenerative disc disease with herniated nucleus pulposus and subjective symptoms of numbness in the anterior thighs, were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “chronic low back pain with muscle spasm” as unfitting, rated 10%.  The CI made no appeals and was medically separated.

CI CONTENTION:  “My condition is and was more damaging then the military projected and rated me.”  

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 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 IPEB – Dated 20040706	VA* - (3 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain with Muscle Spasm	5243	10%	Lumbar Spine DDD with Herniated Nucleus Pulposus	5237	20%	20040902	
Other x 0 (Not in Scope)	Other x 1	
Combined:  10%	Combined:  20%	
*Derived from VA Rating Decision (VARD) dated 20041201 (most proximate to date of separation (DOS))

ANALYSIS SUMMARY:

Chronic Low Back Pain.  The CI was aeromedically evacuated from Iraq in September 2003 after experiencing LBP not associated with a history of injury or trauma.  Radiographic imaging in October 2003 was normal except for a disc protrusion at L5-S1 with mild impingement on the left S1 nerve root.  Despite steroid injections, nerve blocks, physical therapy and a variety of medications, his back pain did not sufficiently improve.

A physical medicine evaluation on 8 December 2003 (11 months prior to separation) reported radiating pain and numbness in the left leg.  Exam noted mild to moderate lumbar muscle spasm and an antalgic gait.  There was no neurologic weakness of the lower extremities.  An MEB neurosurgical consultation on 3 March 2004 (9 months prior to separation) reported a complaint of bilateral leg weakness and left leg numbness and tingling.  The CI declined a surgical option.  An electrophysiologic (EMG) study of the left lower extremity was performed on 4 March 2004 due to complaints of numbness in both feet (but worse in the left), radiating pain and difficulty walking due to back pain.  The EMG was normal.

At the narrative summary (NARSUM) exam on 25 May 2004 (6 months prior to separation), the CI complained of lumbar pain with radiation to shoulder, hips and legs; and intermittent numbness of both thighs was present.  Back pain was aggravated by back extension, bending, lifting, and prolonged standing, sitting or walking.  Pain awakened him from sleep and caused difficulty putting on footwear.  He took narcotic pain medication 2-3 times per day.  Exam showed spinal muscle spasms and an “inability to stand erect.”

At the VA Compensation and Pension (C&P) exam on 2 September 2004 (3 months prior to separation), the CI reported he had been on approximately 2 months of bed rest, but the time frame and whether or not bed rest was physician prescribed was not stated.  He complained of constant pain that radiated down the entire left leg in a non-dermatomal distribution.  He could not run, but could walk one mile without difficulty.  Examination reported a normal gait, although it was described as variably abnormal “depending on observation.”  There was no muscle spasm, and spinal contour was normal.  One sign of non-physiologic pain was noted.  Lower extremity muscle strength and sensation were normal.  A physical medicine examination on 20 July 2005 (8 months after separation) noted exaggerated lumbar lordosis and slight thoracic scoliosis, but was silent regarding gait, guarding or muscle spasm.

The range-of-motion (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 6 Mos. Pre-Sep	VA C&P 3 Mos. Pre-Sep	VA PM&R 8 Mos. Post-Sep	
Flexion (90 Normal)	30 (25/30/30)*	40**	20	
Combined (240)	120	140	N/A	
Comment	+Painful motion	+Tenderness, painful motion	+Tenderness, painful motion	
§4.71a Rating	40%	20%	40%	
	*Inclinometer used for all planes of motion
	**After five repetitions in all planes

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5243 code (intervertebral disc syndrome).  Using the 5237 code (lumbosacral strain), the VA initially rated the condition at 20%, but later increased it to 40% effective the day after separation.  The increased rating appeared to be based on a C&P exam performed on 4 April 2006.  In assigning probative value to the examinations in evidence, the Board noted that: (1) the MEB NARSUM exam relied on an inclinometer to measure lumbar motions, which provides numbers that do not correlate with the goniometric normal values reflected in the VA Schedule for Rating Disabilities (VASRD); (2) the VA C&P exam was the most proximal to separation and provided the most details relevant to rating criteria; (3) the VA physiatry exam 8 months after separation was not identified as goniometric, did not provide rotation measurements (thus preventing calculation of combined ROM), did not provide measurements after repetition, and was silent regarding other ratable data such as muscle spasm or guarding causing abnormal gait or spinal contour.  Therefore, Board members assigned preponderant probative value to the VA C&P evaluation performed 3 months prior to separation, which supported a 20% rating for forward flexion greater than 30 degrees but not greater than 60 degrees.

The Board also considered rating intervertebral disc disease under the alternative formula for incapacitating episodes, but could not find sufficient evidence which would support the next higher 40% rating under that formula.  Finally, the Board further deliberated if additional disability was justified for possible lower extremity radiculopathy.  The CI complained of radiating pain and intermittent lower extremity numbness, tingling and weakness.  However, electrodiagnostic studies were normal, and examiners recorded normal neurologic findings, including muscle strength.  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.  There is no evidence in this case of functional impairment attributable to peripheral neuropathy.  While the CI experienced some radiating pain, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  The Board therefore concludes that additional disability 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 chronic low 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.  In the matter of the chronic LBP condition, the Board unanimously recommends a disability rating of 20%, coded 5243 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.

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

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Low Back Pain	5243	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140501, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

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 XXXXXXXXXXXXXXX, AR20150010376 (PD201402025)

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,   I accept the Board’s recommendation to modify the individual’s disability rating to 20% without recharacterization 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:

Encl			     XXXXXXXXXXXXXXX
			     Deputy Assistant Secretary of the Army
			         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA