RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02644
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080527

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 low back pain.  The low 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).  The “lumbar disc disease of L5-S1” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “L5-S1 annular tear…chronic low back 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 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 20080206	VA* - (~1 Month Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
…Low Back Pain…	5243	10%	Degenerative Disc Disease, Lumbosacral Spine	5243	10%	20080416	
Other x 0 (Not In Scope)	Other 1  	
RATING:  10%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20080523 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Low Back Condition.  The service treatment record (STR) provided limited primary source material.  The first note relating to low back pain was dated 7 November 2005 when the CI indicated it “was a result of manual carries that they did for PT” and the pain had “been present for 5 days.”  Examination revealed bilateral increased lumbar paraspinal tenderness to palpation and a full active range-of-motion (ROM), and treatment was with a muscle relaxant, Robaxin (methocarbamol).  She did not indicate any back pain on her Post-Deployment Health Assessment dated 12 July 2006.  In December 2006 the back pain flared while she was brushing her teeth when she felt like something popped.  The pain was in the area of the buttocks, more on the right than on the left side.  An STR entry dated 8 January 2007 noted the CI had a 2-week history of back pain, which was treated with intramuscular ketorolac (a nonsteroidal anti-inflammatory drug [NSAID]), cyclobenzaprine, a muscle relaxant, and ibuprofen, an NSAID, but the pain persisted.   The CI completed a Post-Deployment Health Reassessment (PDHRA) dated 20 February 2007 and checked off back pain and muscle aches.  A note dated 2 March 2007 indicated the CI had low back pain without radiculopathy for the past 8 months with an insidious onset due to repeated jumps out of trucks while wearing full gear when deployed.   The diagnosis of sacroiliitis of the right side only was made and she was referred for a chiropractic consultation.  On 14 March 2007, an STR entry referred to the fact that the CI rear-ended another vehicle, but sustained no injuries.  An MRI dated 5 May 2007 demonstrated disc protrusion and annular tear at L5-S1.  An orthopedics examination dated 24 July 2007 diagnosed the CI’s condition as lumbar intervertebral disc degeneration and noted the CI’s low back pain began after continuous jumping out of a truck with “full battle rattle” while deployed. The CI described the pain as continuous without bowel or bladder dysfunction and without any saddle paresthesia or radiculopathy.  At least 11 chiropractic treatments were carried out, but the CI’s pain persisted.  

On the DD Form 2807-1, Report of Medical History, dated 19 September 2007, the CI noted recurrent back pain marked by muscle spasms and sharp pains through the buttocks.  The commander’s statement dated 27 September 2007 indicated the CI performed light duty, platoon administrative functions, and any additional company duties.  She was unable to wear any personal protective equipment and was unable to perform her MOS duties as a motor transport operator.  At the MEB physical examination (DD Form 2808) dated 1 October 2007, the examiner CI reported a loss of lordosis and a decreased ROM. 

The MEB narrative summary (NARSUM), dated 25 January 2008, indicated the CI first noted lower back pain in August 2006 when deployed in the absence of specific trauma or injury. She reported constant “sharp” pain in the lower back and stiffness with occasional radiation of pain to the right buttock along with “pinching” lower back pain especially with forward flexion.  Right sided pain was greater than left.  At rest the lower back pain was 4/10 (10 being the worst pain) but increased to at least 6/10 with increased physical activity.  Back pain worsened in spite of a back class, chiropractic treatment, temporary profiles, a home exercise regimen, and medication including anti-inflammatory and muscle relaxant medications.  A focused examination revealed pain on flexion, which limited the ROM as well as pain on extension and right lateral bending.  Straight leg raise (to determine nerve root irritation) was negative bilaterally.  There was tenderness to palpation at L4-5, the right posterior inferior pelvis and the left sacral base.  Muscle spasms were noted.  Neurological examination was unremarkable.

At the VA Compensation and Pension (C&P) examination dated 16 April 2008, performed a month before separation, the CI reported back pain to include the lumbar area as well as in the  interscapular area and in the cervical spine, which are not in the scope of review.  The pain began gradually in August 2006 without a specific history of trauma and was characterized by aching and stiffness, which became sharp with movement and was rated 4/10 (10 being the worst pain).  Relief was obtained with Flexeril (cyclobenzaprine), a muscle relaxant, and ibuprofen, an NSAID.  She had no periods of incapacitation or use of a back brace and could perform all activities of daily living.  On examination she had a normal gait.  The ROMs are annotated in the chart below.  Neurologic examination was unremarkable. 

The 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 ~8 Mo. Pre-Sep
	MEB ~4 Mo. Pre-Sep
	VA C&P ~1 Mo. Pre-Sep
	
Flexion (90 Normal)	 (60)65,60, 60*	“limited”	80*	
Extension (30)	(25)30, 25, 25*	“limited”	30*	
R Lat Flexion (30)	(20)20,20,20*	“limited”	30	
L Lat Flexion (30)	(20)25,25, 20*	-	30	
R Rotation (30)	(30)55,50,55**	-	30	
L Rotation (30)	(30)55,55,55**	-	30	
Combined (240)	185	-	230	
Comment	*Inclinometer measurements; **goniometer measurements; limitation of motion due to pain; localized tenderness of lumbar paravertebral muscles; no muscle spasm or guarding; no abnormal gait or abnormal spinal contour	AROM elicited pain especially forward flexion, extension, and right lateral bending; pain limited ROM forward flexion.	*Mild discomfort; objective evidence of painful motion without acute spasm, weakness, or tenderness; no additional limitations with three repetitions	
§4.71a Rating	10% PEB
20% (inclinometer)	-	10%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using 5243 (Intervertebral disc syndrome) for an L5-S1 annular year and disc protrusion causing chronic low back pain and noted a forward flexion of 65 degrees with a combined ROM greater than 235 degrees.  However, some of the measurements were with an inclinometer rather than with a goniometer IAW VASRD §4.46; and the 65 degrees flexion represented the first of a series of repetitions which decreased to 60 degrees for the next two in the series.  Therefore, IAW DeLuca v. Brown and the VA Fast Letter 06-25, 60 degrees is more representative of the ROM for rating purposes.  Additionally, the normal ROMs in the VASRD “are the maximum that can be used for calculation of the combined range of motion.”  Thus, the combined ROM for rating purposes is 185 degrees, again with the caveat that an inclinometer was used.  The VA assigned a 10% rating using code 5243 for lumbosacral spine degenerative disc disease.  The Board sought a route to a higher rating.  The VA examination performed a month prior to separation is the most proximate and accurate evaluation and is afforded a higher probative value than either the MEB or physical therapy evaluations performed 4 and 8 months prior to separation, respectively.  While the physical therapy measurement of 60 degrees could afford a 20% rating, it has a lower probative value since it was performed using an inclinometer in addition to having been performed 8 months prior to separation.  In the absence of muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour and no incapacitating episodes, a 20% rating is difficult to achieve.  The Board then considered whether an additional rating could be recommended under a peripheral nerve code.  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, the 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 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 20140523, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

02 SEP 2016

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, AR20160003692
(PD201402644)

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