RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02099
BRANCH OF SERVICE:  Army	BOARD DATE:  20150406
SEPARATION DATE:  20050328

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Food Services) medically separated for chronic back pain.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty, but she was authorized to perform alternate physical fitness testing.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “thoracic and lumbar spine:  chronic myofascial pain, with slight scoliosis” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also forwarded nine other conditions (please see Rating Comparison Chart below) for PEB adjudication.  The Informal PEB found the “chronic myofascial pain involving the thoracolumbar spine area” unfitting, and rated it 10%.  The remaining nine conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider 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 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:

Army IPEB – Dated 20050224	VA* – (~ 4½ mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Myofascial Back Pain	5099-5021	10%	Thoracolumbar Myofasciitis	5021-5239	20%	20050810	
Myofascial Neck Pain	Not Unfitting	Cervical Spine Myofasciitis 	5021-5237	10%	20050810	
Major Depressive Disorder	Not Unfitting	Mental Health Disorder 	9434-9413	10%	20050810	
Fibrocystic Breast Disease	Not Unfitting	Fibrocystic Breast Disease 	7699-7628	NSC	20050810	
Right Shin Pain	Not Unfitting	Chronic Right Shin Pain	5299-5262	0%	20050810	
Psoriasis	Not Unfitting	Psoriasis	7816	0%	20050810	
Human Papilloma Virus	Not Unfitting	Human Papilloma Virus	7628-7819	NSC	20050810	
Hearing Loss, Left Ear	Not Unfitting	Left Ear Hearing Loss	6100	NSC	20050810	
Allergic Rhinitis	Not Unfitting 	Allergic Rhinitis with Polyps	6820-6522	NSC	20050810	
Migraine Headaches	Not Unfitting 	Tension Headaches 	8199-8100	NSC	20050810	
Other x 0 (Not In Scope)	Other x 5 	
RATING:  10%	RATING:  50%	
*Derived from VA Rating Decision (VARD) dated 20050909 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Chronic Myofascial Back Pain (Thoracolumbar).  This CI has had a long history of back pain.  Her back pain started in 2002, during Advanced Individualized Training.  There was no history of any specific trauma or injury associated with the onset of pain.  She was treated with conservative measures, and her back pain resolved.  In March 2003, she deployed overseas with her unit.  She worked as a cook at the dining facility.  While deployed, her back pain returned.  This was attributed to long hours on her feet, heavy lifting, and wearing combat gear.  X-rays showed mild scoliosis.  In September 2003, she was seen by orthopedics.  The examiner’s assessment was: “Postural kyphosis and sacroiliac (SI) joint pain.”  Many treatment modalities were tried, to help alleviate her symptoms.  In September 2004, magnetic resonance imaging of the lumbar spine showed normal alignment, normal vertebral height, no evidence of disc disease, and no significant abnormality.

On 21 October 2004 a MEB narrative summary (NARSUM) addendum examination was conducted, approximately 5 months prior to separation, the CI’s back was examined by a physician.  There was no obvious scoliosis or other deformity noted, though the Board did note scoliosis and kyphosis in the CI’s medical history.  Range-of-motion (ROM) was normal.  Gait, muscle strength, and neurological exam were all normal.  The MEB NASUM examination was conducted on 15 February 2005, a one month prior to separation.  The CI reported pain in the low and mid back.  The pain was aggravated by bending, lifting, twisting, prolonged sitting, or any type of impact activity.  On examination of the back there was diffuse lumbosacral tenderness, but no spasm or deformity.  Straight leg raise was negative bilaterally.  A detailed neurological exam showed normal deep tendon reflexes, and normal muscle strength.  During sensory testing there was decreased sensation in the right lower extremity, along the outer calf and foot.  The examiner determined this was of “unclear clinical significance.”  The ROM referenced by the NARSUM was taken during the MEB DD Form 2808, Report of Medical Examination exam on 10 November 2004, 4 months prior to separation, and is summarized in the chart below.

The CI was medically separated from service on 28 March 2005.  On 10 August 2005, the CI had a VA Compensation and Pension (C&P) exam.  She reported that the back pain occasionally radiated into the right leg.  She could walk about a block, but this caused increased pain in the back.  She could do all of her normal activities, and she was able to drive.  On examination her gait was normal.  There was slight scoliosis of the thoracic spine, and normal lordosis of the lumbar spine.  Some tenderness was present, but no tightness or muscle spasm was noted.

The ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, are summarized in the chart below.

Thoracolumbar ROM
(Degrees)	NARSUM Addendum
~ 5 mos. Pre-Sep	NARSUM
~1 month Pre-sep
DD Form 2808
~ 4½ mos. Pre-Sep	VA C&P
~4½ mos. Post-Sep	
Flexion (90 Normal)	90	45	(90) 95	
Extension (30)	30	20	30	
R Lat Flexion (30)	30	25	30	
L Lat Flexion (30)	30	25	30	
R Rotation (30)	30	(30) 35	30	
L Rotation (30)	30	(30) 40	30	
Combined (240)	240	175	240	
Comment	Pain with motion	Pain with motion	Pain with motion	
§4.71a Rating	10%*	20%	10%*	
*10% rating IAW §4.59 (painful motion)

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s coded the chronic back pain analogously with codes 5099-5021 (myositis) rated at 10%.  The VA coded the back condition with codes 5021-5239 (myositis-spondylolisthesis or segmental instability) rated at 20%.  As depicted in the ROM chart above, there is a large ROM measurement disparity between examinations with obvious implications for the Board's rating recommendation.  The Board deliberated the probative value of these conflicting evaluations, with review of the overall evidence for corroboration.  It is noted that prior to the MEB and over the 9 months period from MEB to the C&P examination, the STR and C&P examination reflect chronic back pain but a stable course with some decreased sensory testing in the right lower extremity found during the MEB NARSUM examination.  The Board found no indication of the severe ROM impairment reflected by the MEB DD Form 2808 exam evidence.  There is no ready clinical explanation for the MEB DD Form 2808 exam’s deterioration in ROM, or for why flexion was the only plane of motion significantly affected.  The Board determined that the VA ROM measurements were the only complete set of ROM measurements that was fully compliant with VASRD §4.46 (accurate measurement) and supported a 10% rating.  Members agreed that a recommendation for a 20% rating was not adequately supported solely by the flexion measurement (limited by subjective pain) at the time of the MEB DD Form 2808 exam.

The Board next tried to find a path to a higher rating.  The VA granted the back condition a 20% rating based on muscle spasm severe enough to result in an abnormal spinal contour such as scoliosis.  However, after review of the evidence, the Board determined that there was no muscle spasm or guarding severe enough to cause an abnormal gait or abnormal spinal contour evidence found during the MEB and VA examination period.  Additionally, there was no evidence of incapacitating episodes for a rating under the VASRD intervertebral disc with incapacitating episodes rating formula.  Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board agreed that a disability rating of 10% for the chronic myofascial back pain was appropriately recommended in this case.

The Board also considered the matter of radiculopathy.  After review of all the information in the record, there was insufficient evidence of a clinically significant radiculopathy that interfered with performance of military duties.  Therefore, the Board determined that there was no unfitting radiculopathy present at the time of separation and concluded therefore, that this condition could not be recommended for additional disability rating.

Other PEB conditions.  Nine other conditions were adjudicated by the PEB as not unfitting.  These other conditions were:  myofascial neck pain, major depressive disorder, fibrocystic breast disease, right shin pain, psoriasis, human papilloma virus, hearing loss, allergic rhinitis, and headaches.  The Board’s main charge with respect to these nine other conditions is to assess the appropriateness of the PEB’s fitness adjudication.  These conditions were reviewed by the action officer and considered by the Board.  The Board noted that these nine conditions were not profiled, and none of the conditions were specified as failing retention standards.  There was no indication from the record that any of these conditions significantly interfered with satisfactory duty performance.  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 these conditions.  Therefore, no additional disability ratings are recommended.

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 myofascial back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the myofascial neck pain, major depressive disorder, fibrocystic breast disease, right shin pain, psoriasis, human papilloma virus, hearing loss, allergic rhinitis, and headaches, the Board unanimously recommends no change from the PEB determination as not unfitting.  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 20140506, 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 XXXXXXXXXXXXXXXXXXXX, AR20150014214 (PD201402099)

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:

Encl						     

CF: 
(  ) DoD PDBR
(  ) DVA