RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02549
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030428

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Personnel Information System Management Specialist, medically separated for “chronic lower back pain without neurologic abnormality” with a disability rating of 10%.

CI CONTENTION:  The CI asserts she was not rated for radiculopathy despite evidence documenting this in her medical records.  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 based upon a 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 - 20030123	VARD - 20030430	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Lower Back Pain	5299-5295	10%	Chronic Low Back Pain 	5299-5292	20%	20030221	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain (LBP) condition began in July 2002.  The CI denied any specific injury or trauma associated with the onset of LBP.  In October 2002, magnetic resonance imaging (MRI) showed anterior disc protrusion at the L5-S1 level, with impingement on the thecal sac, causing borderline spinal canal stenosis.  The neural foramina were intact.  She was treated with multiple therapeutic measures, but the LBP persisted and she underwent an MEB.  The MEB forwarded “chronic lower back pain” for PEB adjudication.  

The MEB NARSUM examination on 23 December 2002, 4 months before separation, noted complaints of back pain with radiation into the buttocks and legs.  There was occasional numbness in the legs and feet which increased with physical activity.  The physical examination (PE) showed diffuse tenderness to palpation (TTP) along the paraspinal areas of lumbar spine.  Straight leg raise (SLR) testing for radiculopathy was negative.  Range of motion (ROM) testing showed forward flexion of 85 degrees.  

On 21 February 2003, 2 months before separation, the CI had a VA Compensation and Pension (C&P) examination.  She reported sharp back pain which could radiate into her legs. The pain was worse with prolonged sitting, standing or bending.  She also reported occasional muscle spasms.  On PE, her posture and gait were normal.  There was no weakness, fatigue, TTP, muscle spasm, or muscle atrophy.  SLR testing for radiculopathy indicated a “slight” positive.  Deep tendon reflexes were normal.  ROM testing showed forward flexion of 45 degrees.  The CI had full ROM with rotation and lateral bending.  

At the VA physical therapy visit on 20 January 2004, 9 months after separation, the CI reported pain across the lower back at the belt line, and also a tingling/burning sensation in that region. There was occasional numbness and tingling in the back of both thighs and knees.  On PE, the gait was within normal limits.  There was some TTP at the L4-L5 region.   

The Board directed attention to its rating recommendation based on the evidence.  The PEB used VASRD code 5299-5295 (analogous to lumbosacral strain) and assigned a 10% disability rating for characteristic pain on motion.  The VA used VASRD code 5299-5292 (analogous to limitation of spinal motion) and rated it 20% for moderate limitation of motion.  

The VA Schedule for Rating Disabilities (VASRD) coding and rating standards for the spine, which were in effect at the time of the CI’s separation, were changed on 26 September 2003.  The older standards were based on the rater’s opinion regarding degree of severity, whereas current standards specify certain rating thresholds, with measured degrees of ROM impairment. IAW DoDI 6040.44, the Board must use the VASRD coding and rating standards which were in effect at the time of the CI’s separation.

The Board carefully considered the data from the lower back examinations noted above.  The February 2003 C&P exam was just 2 months before the date of separation (DOS).  At that exam, posture and gait were normal.  On PE of the lower back, there was no weakness, fatigue, swelling, muscle spasm, or atrophy.  ROM testing showed 45 degrees of forward flexion and 10 degrees of extension.  There was full ROM with rotation and lateral bending, and there was pain with motion.  Straight leg raise (SLR) was slightly positive.

Based on a thorough review of the evidence in the treatment record, the Board determined that at the date of separation, the CI’s back condition was best described as “mild” or “slight.”  There was insufficient evidence to support classifying the condition as “moderate” or “severe.”  After due deliberation, the Board determined that a separation disability rating of 10% was warranted.  The Board deliberated a path to a higher rating, using other codes which could be applied to the back pain condition.  The other VASRD codes that were considered did not result in a higher rating, since the record did not show sufficient evidence of a seriously disabling spinal abnormality which would justify a higher rating.   

The Board also considered the matter of peripheral neuropathy.  After reviewing all the information in the record, there was insufficient evidence of a clinically significant neuropathy that interfered with performance of military duties.  The CI had neurological symptoms, however there was no performance-based evidence that the neurological condition impacted her military duties.  Therefore, the Board concluded that there was no unfitting radiculopathy present at the time of separation.  
After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Reasonable doubt), the Board found insufficient cause to recommend a change in the PEB adjudication for the chronic lower back pain.

BOARD FINDINGS: In the matter of the chronic lower back pain, the Board unanimously recommends no change in the PEB adjudication, IAW the VASRD §4.71a which was in effect at the time of separation.  There were no other conditions within the Board’s scope of review for consideration.  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 20140526, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXXXXX AR20160010950 (PD201402549)

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