RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03308
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20080316

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Engineer Diver, medically separated for “lumbosacral back strain” with a disability rating of 10%.

CI CONTENTION:  “Please consider all conditions”.  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 - 20080418	VARD - 20080902	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbosacral Back Strain	5237	10%	Degenerative Disc Disease L4-L5 and L5-Sl	5003-5237	0%	20080521	
Gastroesophageal Reflux Disease	Not Unfitting	Gastroesophageal Reflux Disease	7346	10%	20080521	
Headache	Not Unfitting	Migraine Headache	8100	0%	20080521	
Anxiety	Not Unfitting	Dysthymia (Claimed as Anxiety, Depression, Sleep
Disorder)	9435	10%	20080423	
Depression	Not Unfitting					
Nasal Fractures	Not Unfitting	No VA Placement	
Venereal Warts	Not Unfitting	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:

Lumbosacral Back Strain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in the fall of 2003 after heavy lifting.  At the time of the ortho clinic appointment on 24 October 2006, the CI reported low back pain for approximately 1 year.  The CI described the symptoms of dull aching pain located on the lower back area which increased with bending or stooping movement.  The physical examination showed a normal gait, reflexes, strength, and sensation.  There was a trace of positive straight leg raise test on the right side.  Radiographic studies showed a focal central left protrusion at L5-S1, which does not contact the traversing S1 nerve roots or case central canal stenosis.  A follow up study in April 2007 showed significant decrease in the size of the protrusion compared to the October 2006 study.  A spine surgeon opined the CI was not a good surgical candidate.  Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and he was referred for MEB.  The MEB forwarded “herniated nucleus pulposus” and “low back pain” for PEB adjudication.

At the physical therapy clinic appointment in March 2007, the CI reported constant ache, muscle spasm and “occasional radicular symptoms to L/R buttock but not down legs.”  The physical therapist recorded lumbar range of motion (ROM) flexion of 30 degrees noting discomfort at end range.  At the chiropractic clinic appointment in May 2007, the CI reported constant ache, shooting pain into lower extremities.  The examiner recorded tenderness to palpation, pain on motion, positive nerve root impingement and sacroiliac joint strain testing.  The CI had a normal gait and stance, no muscle spasms and lumbosacral spine exhibited a normal appearance. 

During the MEB examination (recorded on DD Forms 2807 and 2808) in October 2007, 5 months before separation, the CI reported recurrent back pain with numbness and tingling with the need to use a back brace.  Physical examination showed minor discomfort at ends of ROM for lateral bends.

During the MEB NARSUM examination also in October 2007, the CI reported low back pain.  Physical examination showed no scoliosis (abnormal contour), muscle spasms, tenderness to palpation and negative straight leg raises.  ROM flexion showed fingertip 6 inches from toe with painful motion.  The CI had good strength, sensation, normal deep tendon reflexes, and was able to heel walk, toe rise and deep knee bend.  A physical therapy ROM was also referenced, also performed in October 2007, which documented flexion 90 degrees (normal 90) and combined ROM of 225 (normal 240).

At the May 2008 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported constant sharp pain that travels down to backs of legs and knees, elicited by physical activity which was relieved by rest and medication.  The CI stated his back condition did not resulted in any incapacitations and he had not experienced functional impairment from this condition.  Physical examination showed normal posture and gait, no evidence of radiating pain on movement, no muscle spasms, no tenderness, no ankylosis and bilateral straight leg raise testing was negative.  The CI had full ROM with painful motion not cited.  However, the ROM was not limited additionally 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 Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating coded 5237 (lumbosacral strain), citing mild functional loss of ROM due to pain.  The VA assigned a 0% rating analogously coded 5003-5237 (arthritis, degenerative-lumbosacral strain), based on the VA C&P examination 2 months after separation, citing no limited motion, painful motion, and no additionally limited ROM by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use.

The Board agreed that a 10% rating, but no higher, was justified for limitation of combined ROM (greater than 120 degrees but not greater than 235 degrees) due to pain reported on the MEB NARSUM physical therapy examination.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour to support a 20% rating.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS).

The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy. The CI experienced radiating back which is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There was no objective evidence of a radiculopathy with functional impairment (such as weakness or sensory deficit) that significantly interfered with satisfactory duty performance at separation.  The Board therefore concluded that an additional disability rating was not justified.  After due deliberation, and 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 lumbosacral back strain condition.

Contended PEB Conditions:  Gastroesophageal Reflux Disease (GERD), Nasal Fractures, Venereal Warts, Headache, Anxiety, and Depression.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  

Anxiety and Depression.  The STR did not have evidence of evaluation and treatment of these conditions; however, at the MEB NARSUM examination in October 2007, the CI reported he had anxiety, depression, sleep disorder and had been counseled for various problems.  An STR entry in November 2007 noted the CI had reported being seen for depressive symptoms but had stopped over a year previously due to improvements during treatment.  The VA C&P examination, performed 1 month after separation, noted the CI developed anxiety, chronic insomnia and depression after a back injury.  Symptoms occurred intermittently twice a week that lasted 1-2 days.  He was not receiving any treatment.  The examiner noted his psychiatric symptoms were not severe enough to interfere with social and occupational functioning or to require continuous medication.

These contended conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  There was no performance-based evidence from the record that these contended conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended conditions and thus no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the lumbosacral back strain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the contended GERD, nasal fractures, venereal warts, headache, anxiety, and depression conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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, 20140708, 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 XXXXXXXXXXXXXXXXXXXXXXX AR20160011325 (PD201403308)

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