RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02699
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060822

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve E3, Quartermaster and Chemical Equipment Repairer, medically separated for “chronic low back pain,” with a disability rating of 0%.  

CI CONTENTION:  “Released for medical reasons due to back & leg.”  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 - 20060530	VARD - 20070808	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain 	5237	0%	Herniated Nucleus Pulposus L4-5	5243	10%	20070607	
			Left Sciatica; Left Leg to Toe	8599-8520	10%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic low back pain began in July 2005 during a deployment to Afghanistan, after lifting an armor plated panel from a demining tractor.  In October 2005, radiographic evaluation (MRI) documented an L4-S1 herniated disc with L5 nerve root displacement.  At the neurosurgery clinic examination on 30 December 2005, 8 months pre-separation, the CI reported constant 4/10 pain that intermittently radiated into the left lower extremity, worsened by prolonged walking and sitting.  Physical examination showed a normal gait, normal (5/5) strength, normal reflexes, and decreased sensation to the left leg.  There was paraspinal tenderness, and forward flexion was “decreased” with painful motion.  There was positive testing for radiculopathy (straight leg raise test) on the left.  The examiner opined that there was no surgical indication given “very mild” degenerative changes and recommended continued conservative treatment.  Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “chronic low back pain with left radiculopathy, HNP L4-5 (L) and L5-S1” for PEB adjudication.  

At an emergency room (ER) visit on 12 March 2006, 5 months pre-separation, the examiner documented ambulation with a limp.  At the MEB examination (recorded on DD Form 2807 Report of Medical History and DD Form 2808 Report of Medical Examination) dated 23 March 2006, 5 months pre-separation, the physical examination showed pain with percussion, no spasms, and no muscle atrophy.  Testing for radiculopathy (straight leg raise test) was positive on the left, and pain radiating to the upper leg occurred during examination.  There was decreased sensation of the lower left extremity.  Lower extremity strength and reflexes were normal bilaterally (5/5).  Painful motion was elicited with forward flexion and extension.  At a 4 April 2006 physical therapy (PT) examination, 4 months prior to separation, forward flexion was to 80 degrees.  Pain was noted with passive flexion.  

At an ER visit in October 2006, 2 months after separation, the examiner documented tenderness with spasm, with normal lower extremity strength (5/5) and sensation.  At a physical medicine visit in April 2007, 8 months post-separation, the examiner documented “marked straightening” of the lumbar lordosis, “markedly limited” forward flexion from 0-30 degrees, extension with pain, and a normal heel toe gait.  At the VA Compensation and Pension (C&P) examination dated 7 June 2007, 10 months after separation, the CI reported being employed part-time as a truck driver with no lost time from work over the past 12 months.  The pain was daily, lasted for hours, and radiated to the left leg and foot.  He reported use of a back brace and the ability to walk up to a mile.  The CI reported weakness and a fall due to decreased foot sensation.  He denied unsteadiness, paresthesias or numbness.  On physical examination, there was an antalgic gait, with no evidence of spasms, guarding, tenderness or weakness.  Posture was normal with no abnormal curvature.  Lower extremity strength and reflexes were normal with decreased sensation of the left lower extremity.  Forward flexion was to 75 degrees with pain and repetition did not result in additional loss of motion.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB assigned a 0% rating under the 5237 code (lumbar spine strain), citing passive ROM limited by pain (likely application of AR 635-40).  The VA assigned a 10% rating using the 5243 code (intervertebral disc syndrome) based on the VA C&P examination citing limitation of flexion to 70 degrees with objective evidence of pain.  The VA also awarded a 10% rating for the CI’s left lower extremity radiculopathy using the analogous coding 8599-8520 (sciatic nerve, paralysis of, mild) citing incomplete paralysis below the knee which was mild.  

The Board deliberated the totality of the record and agreed that a 10% rating, but no higher, was justified for limitations of flexion (greater than 60 degrees but not greater than 85 degrees) or combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the PT and VA examinations.  Although there was one entry that documented abnormal curvature and flexion to 30 degrees (PT examination, 8 months after separation), the Board agreed that this was not reflective of the overall disability at the time of separation.  There was no consistent evidence of spasm or guarding severe enough to result in an 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 (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under that VASRD formula.  

The Board next considered if there was additional evidence for a functionally impairing radiculopathy at the time of separation.  Radiographic and electrodiagnostic studies supported some level of radicular nerve irritation or involvement, but physical examinations (physical medicine, PT, MEB NARSUM, and VA C&P) proximate to separation revealed no objective findings of radiculopathy that would impact duty performance (findings were sensory in nature).  While the CI may have suffered additional pain from the nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  Therefore the critical decision is whether or not there was a significant motor weakness which would impact military occupation-specific activities.  There was no evidence in this case that motor weakness existed to any degree that could be described as functionally impairing.  The Board therefore concluded that an 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 recommends a disability rating of 10% for the chronic low back pain condition, coded 5242.  

BOARD FINDINGS:  In the matter of the chronic low back pain condition, the Board unanimously recommends a disability rating of 10%, coded 5242 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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Low Back Pain	5242	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140604, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 AR20160016965 (PD201402699)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 10% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA