RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02110
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20050629

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3, Motor Transport Operator, medically separated for “chronic low back pain with a compression fracture of L1,” rated at10%.

CI CONTENTION:  The applicant requests all conditions be considered.  His 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 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:  

 IPEB – Dated 20050429	VA* - (~8 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain with a Compression Fracture of L1	5235	10%	Residuals of L-1 Compression Fracture	5235	10%	20060222	
Retropatellar Pain Syndrome (RPPS)  	Not Unfitting	Retropatellar Pain Syndrome, Left Knee	5299-5257	10%	20060222	
		Retropatellar Pain Syndrome, Right Knee	5299-5257	10%	20060222	
Anxiety Disorder  	Not Addressed	Adjustment Disorder with Depressed Mood and Anxiety	9440	30%	20060222	
Other x 0 (Not In Scope)	Other x 1 (equals SC, NSC & deferred)	
RATING:  10%	RATING:  50%	
*Derived from VA Rating Decision (VARD) dated 20060321 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Chronic Low Back Pain with a Compression Fracture of L1.  The narrative summary (NARSUM) detailed that the CI injured his low back in a parachute jump in September 2004 (9 months before separation).  Initial imaging (X-rays and CAT scan) showed a compression fracture of the first lumbar vertebra, and follow-up imaging showed a final compression deformity of 28%.  The CI was hospitalized and then placed in a hypertension back brace for 3 months.  He continued to have pain and was unable to stand or sit upright for more than 25 minutes despite treatment with nonsteroidal anti-inflammatory drugs, muscle relaxants, and narcotic pain medications.  

At an orthopedic evaluation on 16 February 2005 (4 months pre-separation), the CI had good muscle tone and strength of the extremities, had no loss of sensation, and was tender “from L4-S1 and in no other place.”  The examiner stated, “His lumbosacral spine motion seems quite good.”  At a physical therapy evaluation on 17 March 2005 (3 months pre-separation), the CI had antalgic gait, pain with active range of motion (ROM) of the back, forward flexion of 40 degrees (normal 90), and combined ROM of 95 degrees (normal to 240).  A DD Form 2808, Report of Medical Examination, was completed on 25 March 2005.  The CI had tenderness at the L1 vertebra level, the neurological exam was intact, there was no muscle wasting, and he had pain with ROM of the back.  

At the VA Compensation and Pension (C&P) spine exam performed on 22 February 2006 (8 months post-separation), the CI reported that his back pain radiated to his right leg.  He was taking narcotic and non-narcotic analgesics and a muscle relaxant.  On examination he limped on his right leg (also noted in the joint exam), flexion was 70 degrees, and combined ROM was 170 degrees.  The examiner stated, “He loses 5 additional degrees after repetitive movement of the lumbar spine.”  

The Board directed its attention to its rating recommendation based on the above evidence.  The IPEB rated the condition at 10% under code 5235 (vertebral fracture), citing the combined passive ROM.  The VA rated the condition at 10% under code 5235, based on forward flexion following repeated use.  The physical therapy examination on 17 March 2005, which was closer to the date of separation than the VA C&P examination, supported a 20% rating based on the active ROM.  The close temporal alignment of the physical therapy examination is of significant import, as it must remain the Board’s definitive benchmark in its recommendations.  There was no pathway to a higher rating under any alternate code, no evidence of additionally ratable peripheral nerve impairment, and no documentation of incapacitating episodes which would provide for a higher rating under that formula.  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 condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determinations that retropatellar pain syndrome and anxiety disorder 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.  

Retropatellar Pain Syndrome (RPPS).  The CI was seen in primary care in June 2003 for a contusion of the left knee after falling in a foxhole, but no follow-up for the injury was documented in the service treatment record (STR).  At an orthopedic evaluation for the back on 16 February 2005 (four months pre-separation), the CI was noted to have genu valgus (bow-legged) deformity of the lower extremities, universal ligamentous laxity (“loose joints”), some crepitation (grinding) of the patellofemoral joints (kneecaps), and good muscle tone and strength of the lower extremities.  The examiner diagnosed patellofemoral malalignment, which was not disqualifying.  A DD Form 2807-1, Report of Medical History, was completed in conjunction with the DD Form 2808 on 25 March 2005 (three months pre-separation).  The CI stated that he had bilateral knee pain (located at the lateral patella) with running which improved with rest, and was not associated with swelling or giving out.  The examination of the lower extremities was “normal,” and no diagnosis was made.  The NARSUM listed RPPS as a not-disqualifying condition, with no additional history or examination.  The MEB listed the same diagnosis as a non-disqualifying condition.  The condition was not listed on the DA Form 3349, Physical Profile, on 16 February 2005.  In a performance statement to the PEB, the commander mentioned the CI’s compression fracture but not the knees.  

The RPPS condition was not profiled; it was not implicated in the commander’s performance statement; and, it was not judged to fail retention standards.  There was no performance based evidence from the record that the RPPS condition significantly interfered with satisfactory duty performance.  After due deliberation 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 the RPPS condition; thus no additional disability ratings can be recommended.  

Anxiety Disorder.  Review of the STR divulged that the CI was first seen in Behavioral Health on 12 October 2004 (one month after his back injury and nine months pre-separation), complaining of “feeling depressed” since his back injury.  A week later he was diagnosed with adjustment disorder.  In March 2005 he was diagnosed with adjustment disorder with depressed mood and “continued” on citalopram (an antidepressant) and trazadone (used for depression and anxiety).  The CI’s mood was “irritable” and his GAF (Global Assessment of Functioning) was 55 (moderate symptoms OR moderate difficulty in social, occupational, or school functioning in social, occupational, or school functioning.).  On 1 April 2005 his mood was described as angry, and he requested a prescription for an anxiolytic for when he was “really wound up.”  Three weeks later the CI was concerned about many stressors and, when asked to focus on one, he discussed his inability to pay for the fees for his son to enter Tae Kwon Do.  His mood was “defeated,” his GAF was 55 again, and the diagnosis was adjustment disorder with mixed emotions.  On 13 May 2005 (one month pre-separation) the CI stated that his anxiety had been “greatly helped” by the new medication, and that he did not need it every day.  He had no suicidal or homicidal ideation.  His diagnosis was adjustment disorder with mixed emotions and he was released without limitations.  

The commander’s performance statement did not note any mental health diagnosis or issues, and he stated that the CI remained in good spirits, was dedicated to the unit, and always displayed high morale.  All temporary profiles (DA Form 3349) and the permanent one at separation were designated S1, and no psychiatric diagnosis was listed on any profile.  Anxiety disorder was listed in the Past Medical History segment and as a final diagnosis in the NARSUM, and was classified as not disqualifying.  The MEB listed anxiety disorder as a non-disqualifying condition, and it was not addressed by the IPEB.  

The Board directed attention to its recommendation based on the above evidence.  The Board noted that there was some variance regarding the specific diagnosis for the CI’s mental health condition, including adjustment disorder, post-traumatic stress syndrome (PTSD), and depressive disorder.  Board members agreed that the STR convincingly established that the mental health condition (irrespective of the specific diagnosis) was stable at separation and did not interfere with the CI’s ability to perform the duties of his MOS.  After due deliberation 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 the anxiety disorder and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the chronic low back condition, the Board unanimously recommends a disability rating of 20%, coded 5235 IAW VASRD §4.71a.  

In the matter of the contended retropatellar pain syndrome condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  In the matter of the contended anxiety disorder condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Chronic low back pain with a compression fracture of L1	5235	20%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140514, 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 XXXXXXXXXXXXXXXXXX, AR20160002803 (PD201402110)

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, accept the Board's recommendation to modify the individual's disability rating to 20% without re-characterization 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:

CF:
( ) DoD PDBR
( ) DVA