RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03327
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080627

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Information Systems Operator/Analyst, medically separated for “lumbar degenerative disc disease,” 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 - 20080310	VARD - 20090203	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbar Degenerative Disc Disease without Motor Neurologic Deficit	5299-5242	10%	Degenerative Disc Disease Lumbar Spine	5243	10%	20080416	
Chronic Right Calf Pain (Slight/Frequent) without Electrophysiologic of a Right Sided Lumbar Radiculopathy	Not Unfitting	Compartment Syndrome Right Calf	NSC	20080416	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:

Lumbar Degenerative Disc Disease.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain began gradually in October 2005. Radiographic imaging showed some mild degenerative disc disease, mild foraminal narrowing (space through which the spinal nerve root passes) at L4-5 and L5-S1 from disc bulges, and minimal spinal canal stenosis.  There was no surgical indication, and despite treatment the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty, so he was referred for an MEB.  The MEB forwarded “chronic low back pain (slight/constant) secondary to multilevel spondylosis” for PEB adjudication.

The range of motion (ROM) examinations 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)	MEB NARSUM
~6 Mos. Pre-Sep	MEB Addendum
~4 Mos. Pre-Sep	VA C&P ~2 Mos. Pre-Sep	
Flexion (90 Normal)	20 (25,20,22)	65	75	
Combined (240)	130	200	175	
Comments	+Painful motion, tenderness. No spasm, normal gait	+Painful motion. Normal spine curves, no spasm or tenderness	+Painful motion, tenderness no spasm.	
§4.71a Rating	40%	10%	10%	
		
The MEB NARSUM examiner on 2 January 2008 (6 months prior to separation) reported complaints of low back pain, especially with forward bending.  He was unable to lift and carry heavy equipment, run, do sit-ups or push-ups, or ride in vehicles due to back pain.  Physical examination showed a normal gait and stance.  Spinal contour was not mentioned.

At the time of an MEB addendum on 6 March 2008 (4 months prior to separation), the CI reported constant pain, and that his condition had gotten worse.  An examination by physical medicine and rehabilitation (PM&R) on 21 March 2008 noted no muscle spasm, and guarding was not reported.  Tenderness was present, and painful motion was noted during lumbosacral flexion, extension and left lateral flexion but not during rotation.

At the 16 April 2008 VA Compensation and Pension (C&P) evaluation, performed 2 months before separation, the CI reported constant pain traveling to the legs, which could be elicited by physical activity and stress.  Incapacitation was denied.  He was able to drive a car, vacuum, climb stairs, take out the trash, and walk and shop, but he could not perform gardening or push a lawn mower.  Physical examination revealed no evidence of radiating pain on movement.  An abnormal gait was not attributed to lumbar pain.  Thoracolumbar ROM was limited as recorded in the chart, but the joint function was additionally limited by 10 degrees after repetitive use.  There was no motion beyond the onset of pain.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5242 (degenerative arthritis of the spine), citing forward flexion of 63 degrees.  The VA also rated the back condition 10% coded 5243 (intervertebral disc syndrome) based on the VA C&P examination 2 months before separation for limitation of motion.  While the NARSUM exam 6 months prior to separation supported a 40% rating for forward flexion of 30 degrees or less, the Board noted that this finding was not corroborated by other exams which were more proximal to separation.  It was concluded that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the MEB addendum and VA examinations proximate to separation.  There was no muscle 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.  Finally, 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 the alternate VASRD formula (for IVDS).  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 back condition.

Contended PEB Conditions.  

Right Calf Pain.  The CI was referred to an orthopedist in April 2007 for right calf pain that began in October 2005 and was thought to be due to compartment syndrome (elevated pressures in the leg).  However, the orthopedist considered the back condition as a possible etiology instead, and did not diagnose compartment syndrome.  The CI was eventually prescribed a cane because it helped with the calf pain.  However, electrodiagnostic studies in December 2007 did not show evidence of lumbar radiculopathy, and multiple STR entries between January and March 2008 noted denial of leg weakness, and examination evidence of a normal gait and normal right leg strength and sensation.

On the MEB Report of Medical History (DD Form 2807) on 2 January 2008 (6 months prior to separation) the CI checked “No” for “Impaired use of…legs” and wrote that he experienced numbness and tingling in his leg when standing or running, or walking for long periods of time.  Leg pain or weakness were not mentioned.  At the NARSUM evaluation on the same day, the examiner noted a history of right calf pain and a negative evaluation, but did not render a diagnosis.  Physical examination showed a normal gait, and no right leg swelling, muscle weakness, sensory deficit, tenderness or painful motion.

However, a PM&R examination on 26 February 2008 observed an antalgic gait (walking in a manner to avoid pain), but documented normal neurologic findings, a negative test for nerve root irritation and the ability to walk normally on his toes.  The NARSUM addendum on 6 March 2008 did not mention right calf pain, and examination showed a normal gait and no sign of nerve root irritation.  Follow-up with PM&R on 21 March 2008 reported that the CI was no longer using a cane, but despite normal lower extremity strength and sensation, and the ability to walk normally on his toes, an antalgic gait was present.

The CI informed the C&P examiner on 16 April 2008 (2 months prior to separation) that his right calf pain was due to compartment syndrome originally caused by running.  Pain resulted from physical activity and was relieved by rest.  Although he complained of leg weakness, easy fatigability and pain, he used a cane for ambulation because of leg weakness.  Physical examination however showed a normal gait and normal lower extremity neurologic findings, including muscle strength.  The examiner stated there was no evident pathology to render a diagnosis.

Although right calf pain was included in the L3 profile for the low back pain condition and was judged by the MEB to fail retention standards, the Board debated that there were no examination findings which could logically be associated with significant leg disability.  While the CI may have suffered additional pain from nerve involvement in the lumbar spine, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  Although a limping gait was noted on two examinations, this was an uncommon finding, was not supported by the presence of other expected examination findings and was not consistent with the neurologically-mediated pain of a lumbar condition or negative electrodiagnostic studies.  Likewise, the picture was not consistent with compartment syndrome, a conclusion noted in the pre-separation C&P examination and reflected in the VA rating decision, which declined to service-connect any calf-related disability.  There was no evidence from the record that the aforementioned condition 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 this contended condition and so no additional disability rating is recommended.

BOARD FINDINGS:  In the matter of the lumbar degenerative disc disease condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended right calf pain condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140623, 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 AR20160011470 (PD201403327)

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