RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02459
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20081027

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Tracked Vehicle Mechanic, medically separated for “mechanical low back pain” and “limitation of supination, right (dominant) elbow,” rated 10% and 10%, respectively, with a combined disability rating of 20%.  

CI CONTENTION:  The CI made no specific contention in the application.  The CI’s 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 Physical Evaluation Board (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:  

SERVICE PEB - 20080731	VARD - 20090203	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mechanical Low Back Pain	5299-5237	10%	Lumbosacral Strain	5237	10%	20080929	
Limitation of Supination, Right (Dominant) Elbow	5213	10%	Fracture Right Radial Head (Dominant)	5052-5213	30%	20080929	
			Residual Scar Right Elbow	7805	0%	20080929	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Mechanical Low Back Pain.  According to service treatment records (STR), the Medical Evaluation Board (MEB) narrative summary (NARSUM), and orthopedic addendum, the CI’s mechanical low back pain condition began in 2000 after falling off a bunk.  Radiographic (X-ray) studies in September 2005 showed mild scoliosis, and multilevel loss of disc height.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty. The MEB forwarded “chronic low back pain” for PEB adjudication.  
At the MEB examination (recorded on DD Forms 2808) dated 29 February 2008, 8 months pre-separation, the examiner documented tenderness of the paraspinal muscles at L4-S1 and pain with flexion and extension.  The gait was normal and straight leg raise testing for radiculopathy was negative.  

A chiropractic visit in April 2008 ,7 months pre-separation, followed by two visits in May 2008 ,6 months pre-separation and one additional visit in June 2008, 4 months pre-separation, all documented tenderness, muscle spasm, painful motion and normal gait.  At a physical therapy clinic visit May 2008, flexion was to 90 degrees (normal), with painful motion noted during all movements.  

At the time of the orthopedic addendum to the MEB NARSUM on 10 June 2008, 5 months pre-separation, the CI reported frequent spasms and two episodes which left him bed-ridden since 2004.  He reported intermittent sharp back pain and muscle spasms, with episodes occurring 2 to 3 times per week lasting several hours.  He reported inability to lift greater than 50 pounds, stand for more than 30 minutes to 1 hour if moving around, or stand stationary for more than 15 minutes without developing back spasms.  The examiner documented a normal gait and straight leg raise testing for radiculopathy was negative and referenced the ranges of motion documented by physical therapy in May 2008.  

At the VA Compensation and Pension (C&P) examination on 29 September 2008, 1 month pre-separation, the CI reported he had been placed on quarters on 5 to 10 occasions for back pain.  He described radiating 7/10 pain into both legs occurring 1 time per week lasting for 1 day.  The physical examination showed normal gait, posture and curvature of the spine.  There was no evidence of weakness, spasm or tenderness.  The neurologic examination was normal for strength, sensation and reflexes.  Forward flexion of the thoracolumbar spine was to 90 degrees (normal) with objective evidence of painful motion.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB rated the mechanical low back pain condition 10% coded analogous 5299-5237 (lumbosacral strain), citing painful motion.  The VA also rated the lumbosacral strain condition 10% coded 5237 (lumbosacral strain), based on the VA C&P examination 1 month pre-separation, citing objective pain on motion.  

The Board agreed that a 10% rating, but no higher, was justified for limitation of combined range-of-motion (greater than 120 degrees but not greater than 235 degrees) reported on the MEB, NARSUM orthopedic addendum examination and documentation of painful motion throughout the service treatment record.  Although there was muscle spasm, it was not severe enough to result in abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no evidence of intervertebral disc syndrome resulting in incapacitating episodes requiring bed rest prescribed by a physician to warrant consideration of rating under the alternate VASRD formula based on incapacitating episodes due to intervertebral disc syndrome.  There was no evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve rating.  There was no associated radiculopathy for separate peripheral nerve rating.  While the CI may have experienced radiating pain from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There was no objective evidence of a radiculopathy with functional impairments such as weakness with a direct impact on fitness that were separately functionally impairing for duty.  The Board therefore concluded that additional disability 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 mechanical low back pain condition.  

Limitation of Supination, Right (Dominant) Elbow.  According to STR and the MEB NARSUM, the CI fractured the elbow (comminuted radial head fracture) after a fall in February 2006.  Surgical replacement of the radial head was performed in March 2006.  At an orthopedic visit in October 2006, 2 years prior to separation, the CI reported pain with lifting and decreased extension.  Radiographic evaluation in October 2006, May 2007 and February 2008 documented a stable prosthesis, normal alignment and calcifications.  Despite treatment, the right elbow condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “elbow stiffness and pain” for PEB adjudication.  

At two separate orthopedic visits in January and February 2008, 9 and 8 months pre-separation, the CI reported chronic pain while performing his job.  The physical exams showed tenderness of the radial head, with “neutral” supination (thumb up position), normal pronation (normal is hand facing down), flexion to 125 degrees (normal 145) and lack of extension by 30 degrees (normal 0).  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated February 2008, 8 months pre-separation, the CI reported daily pain, tingling, and numbness, and inability to fully rotate his arm and wrist.  Physical exam showed tenderness of the radial head, and pain limited supination, pronation, and extension.  

At the MEB NARSUM examination performed on 13 March 2008, 7 months pre-separation, the CI reported that lifting, stretching and extension activities, and weather changes caused pain and he had numbness of the elbow and entire forearm.  Physical examination showed flexion to 130 degrees, extension to 25 degrees, pronation to 80 degrees, and supination to 0 degrees (neutral).  

At the VA Compensation and Pension (C&P) examination in September 2008, 1 month prior to separation, the CI reported aching and stiffness, limitation of supination and pronation, inability to lift greater than 20 pounds, and becoming ambidextrous.  Physical examination showed flexion to 135 degrees, supination to 55 degrees, and pronation to 40 degrees.  No additional limitations were noted after repetition.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5213 code (supination and pronation, impairment of), citing limitation of motion.  The VA assigned a 30% rating using the analogous code 5052-5213 (elbow replacement [prosthesis]; supination and pronation, impairment of), based on the VA C&P examination 1 month prior to separation, and citing limitation of supination and pronation.  

There was pre-separation evidence of limited supination (5213) to 30 degrees or less for a 10% rating.  However, VASRD code 5052 (elbow replacement, prosthesis) allows analogous coding and a minimum rating of 30% for the dominant extremity when there is “intermediate degrees of residual weakness, pain or limitation of motion.”  This was supported both the NARSUM and VA pre-separation examinations that documented pain limited motion of a prosthetic joint.  There was no evidence of elbow ankylosis for rating under 5205.  There was no evidence of flexion limited to 90 degrees or less (5206) or limitation of extension to 90 degrees (5207) for a higher rating.  There was no evidence of flail joint for a higher rating under 5209 or 5210 or evidence of nonunion for a higher rating under 5212.  There was no evidence of motion lost beyond the middle of the arc for a higher rating under limitation of pronation (5213).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% analogously coded 5052-5213 (elbow replacement [prosthesis]; limitation of supination, right (dominant) elbow).  

BOARD FINDINGS:  In the matter of the mechanical low back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the limitation of supination, right (dominant) elbow condition, the Board unanimously recommends a disability rating of 30%, coded 5052-5213 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  

The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Mechanical Low Back Pain	5299-5237	10%	
Right Radial Implant with Residuals	5052-5213	30%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140417, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20160011084, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXXXXX:

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 40% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board's recommendation and record of proceedings for your information.

The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.

The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.   Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXXX.

A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,

Enclosure