RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02440
BRANCH OF SERVICE:  Army 	BOARD DATE:  20150604
SEPARATION DATE:  20050304

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 back pain.  The back condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS).  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  “Thoracic back pain secondary to degenerative spondylosis” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded the medically acceptable left wrist condition of De Quervain’s tenosynovitis.  The Informal PEB adjudicated “thoracic back pain, due to degenerative spondylosis, without neurologic abnormity” as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining condition was 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 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 20050119	VA* -  based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Thoracic Back Pain…	5299-5242	10%	Degenerative Spondylosis of the Thoracic Spine…	5299-5242	10%	STR	
De Quervain’s  Tenosynovitis	Not Unfitting	Left Carpal Tunnel Syndrome…	8517	10%	STR	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 3	
RATING:  10%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20050324 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:

Back Condition.  The CI developed back pain while deployed to Iraq in 2003-2004.  Service treatment record (STR) entries in May and June 2004, soon after return from deployment, reported several months of low back pain that was not a consequence of trauma and was gradually worsening.  X-rays showed mild degenerative changes of the thoracolumbar spine.  Despite physical therapy (PT) and medications, the pain did not improve sufficiently to allow full duty performance. 

At a primary clinic evaluation on 27 September 2004 (5 months prior to separation) the CI reported that her back pain started immediately after she jumped from her truck with full armor on while in Iraq in November 2003.  Pain was constant, and running, driving or lifting exacerbated it.  Exam showed tenderness of the lower thoracic spine area and mild discomfort with flexion.  At an evaluation on 8 November 2004, the CI reported that a wrist problem was exacerbated by “lifting heavy objects, lifting babies et cetera.”

At the narrative summary (NARSUM) evaluation on 3 January 2005 (2 months prior to separation) the CI reported that pain was exacerbated by running, driving a truck, and performing push-ups or sit-ups.  Pain was described as constant, and interfered with activities such as dancing and horseback riding.  Examination showed a mild kyphotic posture which was correctable.  Gait was normal.  Tenderness at the T8-T12 level was present.  

At the VA Compensation and Pension (C&P) exam on 13 September 2005 (6 months after separation), the CI indicated that her spine condition prevented push-ups, sit-ups, running or walking further than a mile.  The condition reportedly began while changing a tire while in the military.  Pain was located in the low and mid back, did not radiate, was constant and flared up 2-3 times per week.  Examination showed a steady gait and slight flattening of the lumbar curvature, but no spasm.  Repetitive motion did not cause additional loss of motion.

The goniometric 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)	PT ~5 Mos. Pre-Sep	VA C&P ~6 Mos. Post-Sep	
Flexion (90 Normal)	65	50	
Combined (240)	160	160	
Comment	+Tenderness, painful motion	+Tenderness, painful motion	
§4.71a Rating	10%	20%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5242 code (degenerative arthritis of the spine).  The VA’s initial 10% rating using the same code was later increased to 20% (effective the day after separation) based on the C&P exam described above.  The Board agreed that, based on the limitation of motion reported by the respective exams, the corresponding ratings by the PEB and VA were appropriate (i.e. 10% for flexion greater than 60 degrees but not greater than 85 degrees or combined ROM greater than 120 degrees but not greater than 235 degrees; and 20% for flexion greater than 30 degrees but not greater than 60 degrees).  In deliberating a rating recommendation, the Board consensus was that the Service exam was somewhat closer to the time of separation, and was more consistent with the CI’s report that she was lifting heavy items.  It was therefore assigned higher probative value.  As previously noted, this exam supported a 10% rating, but no higher, based on limitation of motion.  There was no evidence of muscle spasm or guarding severe enough to cause abnormal gait or spinal contour; thus a 20% 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 thoracic back pain condition. 

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that De Quervain’s tenosynovitis (tendinitis at the base of the thumb) was 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.  The CI developed left wrist pain that began while changing tires during her deployment.  Conservative treatment failed and in November 2004 (4 months prior to separation) she underwent a surgical release procedure of the affected tendons.  A temporary profile after surgery restricted left hand use for approximately 6 weeks.  At the final occupational therapy visit in evidence two months prior to separation, the CI was “happy with the outcome.”   She reported being pain free.  The tenosynovitis condition was not permanently profiled or implicated in the commander’s statement, and was not judged to fail retention standards.  It was reviewed and considered by the Board.  There was no performance based evidence from the record that this 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 contended condition and so 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 thoracic back pain condition and IAW VASRD §4.71a, the Board, by a majority vote, recommends no change in the PEB adjudication.  In the matter of the contended De Quervain’s tenosynovitis condition, 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 2014, 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, AR20160000294 (PD201402440)

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