RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	 CASE:  PD-2014-02252	
BRANCH OF SERVICE:  Army 	 SEPARATION DATE:  20050202		 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E-4, Motor Transport Operator medically separated for mid and low back pain.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The back condition, characterized as “chronic back pain” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “chronic subjective mid and low back pain without neurologic abnormality, thoracolumbar range of motion limited by pain” as unfitting, rated 10%.  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 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 20041216	VA - based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Subjective Mid and Low Back Pain Without Neurologic Abnormality, Thoracolumbar Range of Motion Limited By Pain	5299-5237	10%	Mechanical Low Back Pain with Thoracic Spondylosis	5010-5237	20%	STR	
Other x 0  (Not in Scope)	Other x 1 (Not in Scope)	STR	
Rating:  10%	Combined:  20%	

ANALYSIS SUMMARY:  

Mid and Low Back Pain.  An early note in the service treatment record (STR) dated 13 September 2002 indicated the CI complained of upper back pain, shoulder pain, and fatigue for a day.  She was diagnosed as having muscular strain and was treated with Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID)) and a profile.  On 23 September 2003 she had tenderness to palpation of the lumbar area bilaterally without spasm.  The NSAID was continued and physical therapy for 7 days was instituted.  In July 2004 she reported that the atraumatic back pain that began during deployment had worsened, but there were no radicular, bowel, or bladder symptoms.  On examination there was a normal gait, no spasm, and a full range-of-motion (ROM).  Treatment consisted of Vioxx (rofecoxib, an NSAID) and Flexeril (cyclobenzaprine, a muscle relaxant).  X-rays of the lumbosacral spine were normal, but the thoracic spine X-rays demonstrated moderate multi-level thoracic spondylosis (arthritic changes) with anterior wedging at T7.  A chiropractic note dated 27 July 2004 indicated the CI had chronic, constant moderate pressure in to the low back with occasional frequent severe sharp episodes in the mid to low back since July 2002.  She had knee strain in May 2002 and a hip fracture in July 2002.  Pain was worse in the morning and especially while lying on her stomach and was aggravated by leaning forward and doing pushups.  Examination of the thoracolumbar spine revealed a full ROM with pain on extension, right lateral flexion and left lateral rotation.  Straight leg tests (to determine nerve root irritation) were positive and there was tenderness to palpation in the thoracic and lumbar regions.  Spinal manipulative techniques were instituted and continued through September 2004.  On 4 October 2004 the CI noted that the chiropractic treatments helped only for a while, but she still had the back pain and was unable to perform her duties.  

A permanent L3 profile was issued in October 2004 for chronic back pain with limitations of all physical fitness training and testing and all military functional activities except wearing a protective mask and all chemical defense equipment.  Additionally, the CI was precluded from jumping, flutter kicks, lifting, ruck or road marching, or wearing or carrying load bearing equipment and a ruck sack.  The commander’s statement dated 7 October 2004 indicated the CI’s disability impacted her performance of duties as a motor vehicle operator because she could not spend long periods of time in a seated position, had difficulty turning the driving wheel of large trucks, and continued bouncing in military vehicles evoked pain.  Additionally, she had difficulty picking up objects and running.  At the MEB examination, the CI checked off recurrent back pain or any back problem on DD Form 2807-1 dated 15 October 2004 and the MEB physical examiner noted decreased ROM flexion on DD Form 2808 dated 20 October 2004.

The MEB narrative summary (NARSUM) dated 2 November 2004 confirmed the history as noted previously.  The physical examination, performed on 20 October 2004, revealed no deformities or swelling of the spine and there was no costovertebral angle tenderness or spasm.  ROM measurements were flexion 70 degrees without pain, extension 20 degrees with pain, right lateral flexion 20 degrees without pain, left lateral flexion 10 degrees with pain, right rotation 40 degrees with pain, and left rotation 50 degrees.  Heel-to-toe walk was within normal limits and neurologic evaluation was unremarkable.  Her condition was stable with the requirement of medications including Flexeril and tramadol (an opioid-like medication).

At the remote VA Compensation and Pension (C&P) examination dated 12 July 2008, performed 41 months after separation, which had little or no probative value, the CI reported she gradually started having back pain because of carrying a heavy backpack, gun, and ammunition and running with those heavy loads on her back.  She was unable to lift more than five to ten pounds and denied any radiation of the pain to the lower or upper extremities.  On examination there was some tenderness on the paravertebral muscles of T6-T8 without muscle spasm.  Flexion was about 90 degrees with no difficulty; lateral bending was about 25 degrees; twisting was 35 degrees bilaterally; and extension was 0-10 degrees.  Neurologic evaluation was unremarkable; straight leg raise was negative bilaterally; she walked on toes and heels with no difficulty; and she could squat halfway down and was able to rise from that position.  The examiner’s diagnosis was spondylosis of the thoracic spine and back pain.  The CI had limitations of prolonged standing, running, jogging, and climbing, but there was no additional limitation of motion on repetition.  She did not need any ambulatory aid; and, there was no adverse impact on activities of daily living or her current occupation.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5299-5237 (lumbosacral strain) for chronic subjective mid and low back pain without neurologic abnormality.   The VA assigned a 20% rating using code 5010-5237 for mechanical low back pain with thoracic spondylosis based on the STR ROMs, but the VA Rating Decision noted there was evidence of some additional functional loss due to painful motion, fatigability, weakness, and lack of endurance following repetitive use to warrant consideration of a higher evaluation based on physical training exercises that involved the lower back as well as with lifting, running and marching rather than on physical examination findings IAW DeLuca v. Brown guidelines.  However, although the NARSUM examiner noted pain on motion, there was neither explicit nor implicit mention of limitation of motion with repetition.  The Board sought a route to a higher rating, but was unable to do so in the absence of ankylosis, a more limited ROM, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour, or incapacitation.  The Board then considered whether an additional Service rating could be recommended under a peripheral nerve code.  Firm Board precedence requires a functional impairment linked to fitness to support a recommendation for addition of a peripheral nerve rating to disability in spine conditions.  Although the pain component of the neuropathy is appropriately subsumed in the spine rating IAW VASRD §4.71, which states that “rating is performed with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease,” there was no sensory component with any significant functional implications and no motor weakness was in evidence.  Therefore, a radiculopathy could not be recommended for additional disability rating.  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 mid and 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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the mid and 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. 

RECOMMENDATION:  The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140513, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander, US Army Physical Disability Agency (AHRC-00), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXXXX AR20160004381 (PD201402252)

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