RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02980
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060810

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve, O3, Field Artillery Officer, medically separated for “Chronic Low Back Pain…,” with a disability rating of 10%.  

CI CONTENTION:  He contends that he was given a higher rating for his condition by the VA.  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 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:  

SERVICE PEB - 20060623	VARD - 20070201	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain…	5299-5243	10%	Degenerative Joint Disease, Lumbar Spine	5242	10%	20061227	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Low Back.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the low back pain began approximately 5 years prior to referral for an MEB.  At a clinic encounter the CI complained of acute onset of sharp low back pain when he lifted his son into the car.  He reported associated pain radiation to the bilateral mid thighs.  The back exam revealed normal alignment, no evidence of trauma, and no tenderness.  The range of motion (ROM) was normal.  Deep tendon reflexes (DTRs) were normal and pathologic reflexes were absent.  The assessment listed back pain and he was prescribed Naproxen, a nonsteroidal anti-inflammatory drug (NSAID), an analgesic (Tylenol), and a muscle relaxant (Robaxin).  The lumbosacral spine X-ray showed transitional anatomy (congenital variation at the lumbosacral joint involving the lowermost lumbar vertebra or uppermost sacral segment) at S1 with a rudimentary S1-2 disc but was otherwise normal.  The lumbar spine CT showed L-5 sacralization (congenital anomaly where the lowermost lumbar segment [L5] is fused to the sacrum) but was otherwise normal.  A lumbar spine magnetic resonance image (MRI) showed an isolated dessicated disc at L4-5 and a rudimentary disc at S1-S2 (normal anatomic variant).  

Physical medicine and rehabilitation (PM&R) performed a therapeutic and diagnostic right sacroiliac (SI) joint injection with local anesthetic (Lidocaine) and corticosteroid (Kenalog).  PM&R performed a therapeutic and diagnostic right S1 sacral selective nerve root block with local anesthetic (Lidocaine) and corticosteroid (Kenalog) to treat a radiculitis (irritation or injury of a nerve root) with degenerative disc disease (DDD).  A lumbar spine CT showed a stable small bulge at L4-L5 (not affecting the nerve roots) and mild facet hypertrophy at L5-S1.  The MEB (DD Form 2808, Report of Medical Examination) spine exam documented full ROM with left paraspinal region muscle spasm.  The NARSUM, 4 months before separation, recounted the history and interventions.  It documented a 6-year history of recurrent back pain with the most recent exacerbation occurring 15 months prior.  The CI complained of constant dull aching mid to low back pain with occasional sharp stabbing pain.  He reported 6/10 pain at rest and 8/10 pain with activity.  Exacerbating factors included any physical activity and there were no relieving factors.  The CI was awakened from sleep approximately two times per week due to the pain.  Associated symptoms were radiation to the anterior thighs and toes and numbness below the small of the back when lying supine.  The radiculopathy was exacerbated by sitting and standing and relieved by changing positions.  Pain was rated as moderate and constant.  He reported falling down due to his legs giving out on three occasions.  

The CI failed conservative management (activity modification, medications, PM&R steroid injections, physical therapy, and chiropractic manipulation) and was not deemed a candidate for surgery.  The spine/back exam revealed a normal appearance.  There was muscle spasm with tenderness to the left paraspinal region.  The straight leg raise tests (assess sciatic nerve root compression by a herniated disc) were negative.  Repetitive (X3) active ROM measured with a goniometer was flexion of 90/90/90 (90 normal), extension of 20/20/20 (30), right lateral flexion of 55/45/55 (30), left lateral flexion of 50/50/45 (30), right rotation of 45/50/60 (30), and left rotation of 50/60/60 (30) degrees.  The extremities were normal and without sensioneural deficits.  The examiner recounted the findings from the lumbar spine CTs and MRI.  The diagnosis listed low back pain.  

The VA Compensation and Pension (C&P) exam recounted the history and interventions.  The CI complained of constant 5/10 low back pain.  Back pain would flare two times per week to a 9/10 with some bilateral lower extremity tingling.  Conservative management provided only slight temporary relief.  Pain was exacerbated by sitting (>30-60 minutes), standing (>10 minutes), and physical activity.  He took an NSAID (Mobic) daily and a combination analgesic/opioid (Roxicet) one time per week.  He denied using any back braces or assistive devices.  The physical exam documented a normal gait with no assistive devices.  The repetitive (X3) active ROM values were flexion of 70 (90), extension of 35 (30), bilateral lateral flexion of 30 (30), and bilateral rotation of 45 (30) degrees.  There was no additional limitation in ROM or joint function following repetitions due to pain, fatigue, weakness, lack of endurance, or incoordination.  Strength, sensation, and DTRs were normal.  The examiner recounted the findings of the X-rays, CTs, and MRI.  The assessment listed L4-5 DDD confirmed on MRI.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous code 5299-5243 (intervertebral disc syndrome) citing chronic low back pain, secondary to DDD at L4/L5 without neural impingement, congenital L5 sacralization, tenderness, non-deforming muscle spasm, painful ROM, 90 degrees of flexion, and no radiculopathy.  The VA assigned a 10% rating under code 5242 (degenerative arthritis of the spine) based on the VA C&P exam 5 months after separation.  The VA cited chronic low back pain secondary to DDD and ROM.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  There was no associated radiculopathy for separate peripheral nerve rating.  Although the CI complained of bilateral radicular symptoms, there was no objective evidence of a radiculopathy or functional impairment with a direct impact on fitness.  The Board therefore concluded that additional disability rating was not justified on this basis.  The ROM values in the MEB and C&P exams were consistent with the 10% rating (flexion of greater than 60 degrees but not greater than 85 degrees; or a combined ROM of greater than 120 degrees but not greater than 235 degrees of the thoracolumbar spine).  The higher 20% rating would require (flexion of greater than 30 degrees but not greater than 60 degrees; or a combined ROM of not greater than 120 degrees of the thoracolumbar spine).  While the NARSUM exam documented left paraspinal muscle spasm and tenderness, there was no evidence of guarding, abnormal spinal contour, or abnormal gait.  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.  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:  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.  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 20140617, w/atchs
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, AR20160007952 (PD201402980)

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