RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX	CASE: PD-2014-02940 
BRANCH OF SERVICE:  Army	SEPARATION DATE: 20041116 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Automated Supply Specialist) medically separated for “chronic low back pain,” rated at 10%.

CI CONTENTION:  She was not evaluated for her hip condition, shingles or mental health issues.  Her 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 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:  

IPEB – Dated 20040629	VA*  9 months Post-Separation	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Low Back Strain	5237	10%	20050809	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 9	
RATING:  10%	COMBINED RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20051230 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY: 

Low Back Pain.  The Service treatment record (STR) documented complaints of intermittent back pain beginning in January 1999.  The 12 December 2000 lumbar spine X-ray showed straightening of the normal lordosis (anterior spine curvature) but was otherwise a normal study.  The 24 June 2002 lumbar spine, right hip, and pelvis X-rays were negative.  The 26 January 2004 lumbar spine CT was normal.  At the 4 February 2004 Physical Medicine & Rehabilitation (PM&R) encounter the CI recounted a history of right-sided low back pain (LBP) that started in 1999 after the delivery of her child.  She complained of 7-8/10, up to 10/10 pain, in the right posterior superior iliac spine region.  The CI reported associated intermittent radiation of pain into the right leg and sometimes some vague feelings of numbness and tingling.  She denied specific neurological complaints at that time.  Despite medications, the CI had significant pain problems.  Pain was exacerbated by any physical activity to include walking and prolonged sitting.  The physical exam revealed the CI was very tender over the right posterior pelvis (posterior superior iliac spine and medial portion of the ilium) and mildly tender over the left posterior pelvis (posterior superior iliac spine).  She was tender over the right and left greater trochanters (bony prominences on proximal lateral femurs for muscle attachment).  Provocative diagnostic tests were negative.  The range-of-motion (ROM) exam documented the CI could “only flex forward placing her fingertips approximately 10 cm below the tibial tubercle before she will stop because of severe pain.”  Back hyperextension, twisting, and side bending were normal.  The neurological exam was unremarkable, with normal motor, sensory, and deep tendon reflex (DTR) evaluations.  The diagnoses listed right posterior superior iliac spine syndrome, or posterior iliac crest apophysis (a bony outgrowth or protuberance), mild left posterior superior iliac spine syndrome, lumbar myofascial pain, and bilateral trochanteric bursitis.  The physician performed a corticosteroid/local anesthetic injection over the right posterior superior iliac spine region.  The CI reported excellent pain relief stating “her pain has been reduced down to a two or three” and was able to demonstrate improved back ROM.  At the 24 February 2004 pain clinic encounter the CI complained of chronic LBP for 4 years.  She reported associated pain radiation to her right knee with occasional numbness of her right great toe.  The CI had received transient relief from massage, ice, heat, physical therapy (PT), chiropractic treatments, injections, ultrasound, and narcotics.  The physical exam revealed a steady gait with fairly full ROM.  The CI could only flex her back to reach mid-calf without increased pain.  She had three distinct trigger points (tender areas which refer pain to another part of the body) in her right buttock which caused the radiation to her toes.  The physician performed trigger point injections with local anesthetic and trigger point needling.  In a 2 March 2004 pain clinic telephone consultation, the CI reported "great relief" with the trigger point injections, but continued to have some of the "deep" pain.  The plan was to set up for lumbar epidural steroid injection for this pain.  The 30 March 2004 PM&R encounter listed the diagnoses of right posterior iliac crest syndrome, bilateral ischial tuberosity bursitis, mild lumbar myofascial pain, bilateral trochanteric bursitis, right inferior pubic ramus tenderness, and a possible osteitis pubis (inflammation of the pubic symphysis and surrounding muscle insertions).  The examiner opined that the pain condition appeared stable and anticipated a full and complete resolution with a decrease in her workload.  The 12 April 2004 lumbar active ROM measurements for the MEB by PT are in the chart.  The 25 April 2004 lumbar spine MRI was normal.  The narrative summary (NARSUM) documented the CI developed LBP in late pregnancy (December 1999).  During delivery, she felt her tailbone pop.  It took 8 months before she was pain free enough to attempt sit-ups.  The CI failed conservative therapy, her pain worsened and she was placed on a P3 profile.  She was unable to deploy with her unit because of profile limitations.  The CI reported her worst discomfort was a constant, dull, 3-4/10 pain located in the right sacroiliac (SI) joint area.  It was exacerbated by her menstrual periods, prolonged standing, sitting or lying down.  It was relieved by extending her back, medication and ice.  The physical exam revealed tenderness over the bilateral posterior superior iliac spines, ischial tuberosities and greater trochanters.  She had a very tender right SI joint and mildly tender right inferior pubic ramus.  Provocative diagnostic tests were negative.  Five of five Waddell (psychogenic, or nonorganic, manifestations of pain) signs were negative.  The examiner cited the PT lumbar spine ROM measurements performed for the MEB and commented “Although at the time of the patient's appointment with physical therapy, she had somewhat limited range of motion, on today's examination her lumbar spine flexibility is normal.  In fact, the patient is able to palm the floor and arch over backwards such that she can almost do a backwards walkover.  She has normal trunk rotation and side bending.”  Lower extremity DTRs were normal (2+) bilaterally.  The diagnoses listed chronic back pain secondary to osteitis pubis and sacroiliitis (inflammation of the sacroiliac joint).  The examiner documented the condition had been stable for 8 months, no surgery was recommended, and the CI failed retention standards.  On 19 May 2004 the pain clinic physician performed SI joint injections with local anesthetic.  The 9 August 2005 lumbar spine, pelvis, and bilateral hip X-rays were normal.  At the Compensation and Pension (C&P) exam, 9 months after separation, the CI reported LBP, SI joint pain, and sciatica (pain radiating along distribution of sciatic nerve) since 2000.  She complained of constant, burning, aching, 1 to 10 (current 6/10) pain.  The pain was exacerbated by physical activity and menses and was relieved by SI joint injection.  The CI complained of intermittent episodes of sciatica (tingling, numbness, pain, and weakness), as often as 2-4 times a year, which lasted 2 days.  The CI reported three incapacitating episodes, over the past year, for which a physician recommended bed rest (not in evidence).  The ability to perform daily functions during flare-ups was reported as minimally impaired.  The physical exam revealed a normal posture and gait and she did not require an assistive device for ambulation.  The thoracolumbar spine exam revealed tenderness at the right SI joint with no spine ankylosis or muscle spasm.  There were no complaints of radiating pain on movement.  Straight leg raising tests (assess sciatic nerve root compression by a herniated disc) were negative bilaterally.  The thoracolumbar spine ROM is listed in the chart.  Spine joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use.  There were no signs of intervertebral disc syndrome with chronic and permanent nerve root involvement.  The lower extremity neurological exam revealed normal motor, sensory, and deep tendon reflex function.  The diagnosis listed LBP, with no objective factors, and the subjective factor of pain.

The ROM evaluations 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)	MEB/PT ~7 Mo. Pre-Sep
	NARSUM ~6 Mo. Pre-Sep
	VA C&P ~9 Mo. Post-Sep
	
Flexion (90 Normal)	65 (60, 60, 65)	NORMAL	80	
Combined (240)	>150	NORMAL	220	
Comment	Painful motion noted	Tenderness noted	Tenderness noted; muscle spasm absent	
§4.71a Rating	10%	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The Informal PEB rated the low back condition 10%, coded 5237 (lumbosacral strain).  The PEB cited chronic LBP, ROM reduced by pain, paraspinous muscle tenderness, normal X-ray and MRI findings, and no radiculopathy or muscle spasm.  The VARD, citing the C&P exam 9 months after separation, rated the low back condition 10%, also coded 5237.  The VARD cited chronic LBP, ROM reduced by pain, SI joint tenderness, negative straight leg raising tests, and no radiating pain or muscle spasm.  Board members agreed that the limitation of motion in the MEB/PT exam was consistent with 10% based upon the general rating formula for diseases and injuries of the spine.  The ROM in the NARSUM exam was consistent with the 0% rating, but 10% for tenderness is warranted.  The C&P ROM was also consistent with a 10% rating.  The Board assigned more probative value to the C&P exam because it measured comprehensive thoracolumbar ROMs.  The MEB/PT exam recorded incomplete lumbar ROMs and the NARSUM exam recorded lumbar ROMs.  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).”  The critical decision is whether or not there was significant motor weakness which would impact military occupation specific activities.  There was no evidence that motor weakness or sensory loss 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.  Other routes to a rating higher than the PEB’s 10% were considered, but there was no evidence of additional functional loss from repetitive use to warrant application of VASRD §4.45, and no evidence of incapacitating episodes that would justify a minimum rating under the alternative formula for rating intervertebral disc disease.  The Board agreed a 10% rating was supported by the limitation of motion.  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.  As discussed above, PEB reliance on AR 635-40 for rating the back condition was operant in this case and the condition was adjudicated independently of that regulation by this Board.  In the matter of the low back pain 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.  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 20141106, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

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, AR20160005455  (PD201402940)

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