RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02505
BRANCH OF SERVICE:  Army	BOARD DATE:  20150724
Separation Date:  20050722

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Finance Specialist) medically separated for a back condition.  The back condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  “Low back pain (LBP) and lumbar spinal stenosis” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “radiating low back pain” as unfitting, rated 20%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  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 20050519	VA* - Service Treatment Records (STR)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Radiating LBP…	5243	20%	LBP…	5243	20%	STR	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 0	
RATING:  20%	RATING:  20%	

ANALYSIS SUMMARY:

Back.  The CI sustained a low back injury due to a motor vehicle accident (MVA) in March 2003.  The lumbosacral spine X-ray was normal.  The CI underwent chiropractic treatment in June and September 2003 with poor results.  The physical medicine specialist noted complaints of chronic mid to LBP with occasional sharpness but mostly a dull ache.  The CI was referred to physical therapy (PT) for intensive therapy.  The CI underwent a Medical Reclassification in August 2004 (mechanic to finance) due to his physical limitations.  He was in a second MVA on 30 September 2004 and was seen in the emergency room (ER) for evaluation.  The ER physician noted bilateral paraspinal muscle tenderness and spasm, mildly decreased low back range-of-motion (ROM) with normal reflexes.  The CI continued to have tenderness to palpation (TTP) in the thoracic spine and spasm of the paraspinal muscles throughout 2005.  A repeat lumbosacral spine X-ray was normal.  A CT scan in March 2005 documented a midline disc protrusion indenting the thecal sac which caused spinal stenosis and impinged on the right L5 nerve root.

The MEB narrative summary exam approximately 5 months prior to separation documented significant LBP which increased with flexion, running, walking, sit-ups and heavy lifting which limited the CI’s daily function.  He reported dull aching pain in the lumbar spine with occasional flares with sharp pains.  The CI denied any radicular symptoms such as radiating pain into the lower extremities, tingling, weakness or bowel/bladder incontinence.  The CI reported functional limitations of an inability to perform basic soldiering duties, an inability to walk or run without pain and an inability to wear full gear.  The physical exam findings were forward flexion of 45 degrees (normal 90) and a combined ROM of 175 degrees with an antalgic gait, TTP throughout the thoracolumbar spine; and normal strength, sensory and reflex exams.  The DD Form 2808, Report of Medical Examination, findings approximately 3 months prior to separation were TTP, moderate muscle spasm over the thoracic to lumbar paraspinal muscles and normal strength and reflexes.  Straight leg raising (for radicular symptoms) was negative.  ROM was noted as “flexion with fingertips approximately 20 inches from floor.”

The CI did not show for his initial VA Compensation and Pension exam.  The first VA exam was in October 2006, approximately 15 months after separation.  Complaints included pain without radiation and decreased ROM.  Gait was normal and forward flexion was 55 degrees (normal 90) after repetition.  There was no neurologic abnormality noted.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA each rated the back condition at 20%, coded 5243 (Intervertebral disc syndrome).  The General Rating Formula for Diseases and Injuries of the Spine considers the CI’s pain symptoms “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.”  The CI’s limited thoracolumbar flexion of greater than 30 degrees but not greater than 60 degrees, as well as muscle spasm with an abnormal gait both met the 20% rating criteria.  There was no evidence of a non-pain radiculopathy for alternate or additional 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 low back 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 low back 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 re-characterization of the CI’s disability and separation determination.
The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140429 w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB
 
DEPARTMENT OF THE ARMY
ARMY REVIEW BOARDS AGENCY 251 1BTH STREET SOUTH, SUITE 385
ARLINGTON, VA 22202-3531

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, AR20160003045  (PD201402505)

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