RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03348
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080205

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E3, Unit Supply Specialist, medically separated for “chronic lower back pain,” 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 – 20080506	VARD	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Lower Back Pain	5299-5237	10%	Lumbosacral Strain	5237	10%	20080404	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:

Chronic Low Back Pain.  A reference in the service treatment record to the CI’s condition indicated that “after participating in a unit road march, she commenced to experience low back pain [on 3] August 2005” and received medical evaluation on 7 August 2005.  A lumbar spine series for sciatica dated 7 August 2005 demonstrated marginal levocurvature (curvature to the left) of the spine either based on position or minimal levoscoliosis (left leaning curvature of the spine) and a marginal decrease in L5-S1 disc height.  Treatment with physical therapy and the medications diazepam (a muscle relaxer), hydrocodone/acetaminophen (narcotic/pain reliever), and ibuprofen (a nonsteroidal anti-inflammatory drug [NSAID]) diminished her pain, which was diagnosed as a lower back sprain and sciatica.  Physical therapy evaluation for persistent low back pain in March 2007 indicated the CI had normal gait and full range of motion (ROM) with pain at the end range of flexion and side bending.  Lumbar spine X-rays demonstrated no significant abnormality in May 2007.  A subsequent examination noted the CI’s lower back pain worsened with coughing or sneezing, but there was no radiation to the legs or muscle spasms of the lower back.  Examination of the thoracolumbar spine was normal as were follow-up examinations in July 2007.  A detailed physical therapy examination, however, did note normal ROMs of the lumbar spine with pain at the end of flexion and right side bending as well as positive left side quadrant (to assess lumbar spine facet joints between vertebrae), Thomas (to determine hip flexion contracture) and piriformis (to determine the effect of the muscle on the sciatic nerve) tests.  Orthopedic evaluation in August 2007 noted recurring left-sided back pain radiating into the left buttock and posterior aspect of the mid-thigh in the absence of trauma.  Clinical findings of tenderness of the left sciatic notch, left straight leg raising (to determine nerve root irritation) and a left sciatic tension test were positive, although no motor or sensory abnormalities were present.  Magnetic resonance imaging in August 2007 revealed no evidence of degenerative disc disease, disc herniations, neural compression or evidence of moderate or severe apophyseal (facet) joint disease.

The commander’s statement dated 26 September 2007 indicated the CI could perform “without unreasonable durations of rest” and “the difficulty [had] not impacted her industrial adaptability or other medical problems.”  At the Medical Evaluation Board (MEB) narrative summary examination, dated 28 November 2007, 2 months before separation, the CI reported a 3-year history of recurrent left-sided lower back pain with numbness and tingling extending into her left gluteus (buttock) and down the posterior aspect of her thigh proximal to her knee.  She failed all conservative treatment measures and was not a surgical candidate, although she had full active ROM of her back, neck, upper and lower extremities.  There was some mild tenderness to palpation along the left sciatic notch and the left mid gluteal region without evidence of erythema (redness), edema, ecchymosis (black and blue), palpable deformity or spasm within the lumbosacral paraspinous region, left mid gluteal region or posterior thigh.  There was no hypertrophy or atrophy in the lower back or the lower extremities.  Neurologic examination was unremarkable including a negative straight leg raise and a negative femoral nerve stretch test.  The examiner’s diagnosis was lower back pain and mild sciatica, but he opined that the clinical findings did not support the CI’s chief complaint of chronic lower back pain.

At the DD Form 2807-1, Report of Medical History, dated 1 October 2007, the CI reported that she had chronic lower back pain, had numbness in her legs sometimes, could not bend at times and had trouble sleeping due to back pain.  On that same date, the DD Form 2808, Report of Medical Examination, documented tenderness of the left S1 (sacroiliac) joint and tenderness of the left sacral area on squatting and palpation.  A permanent L3 profile for chronic lower back pain was issued on 5 December 2007 with limitations of all military functional activities except wearing a protective mask and all chemical defense equipment.  She could not run, do sit-ups for physical fitness training or testing, or lift or carry more than 25 pounds.

At the VA Compensation and Pension (C&P) examination dated 4 April 2008, 2 months after separation, the CI noted back and sciatica since 2005 and reported a severity of 5/10 (10 being the worst pain), but was taking no medication and had no incapacitation.  Examination revealed normal posture and a normal gait.  Her leg lengths were 82.5 cm on the right and 83 cm on the left, the differences of which were considered not significant.  There was no evidence of radiating pain on movement of the thoracolumbar spine.  Muscle spasm was absent, but there was tenderness at the left lower back.  Straight leg raising was negative bilaterally and there was no ankylosis of the spine.  The spine was symmetrical with normal curvatures.  Additionally, there were no signs of the intervertebral disc syndrome with chronic and permanent nerve root involvement.  ROM measurements were normal; pain occurred at the end of all of the movements except flexion and joint function was additionally limited only by pain after repetitive use.  The evaluations 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)	PT
~6 Mo. Pre-Sep
	Military Clinic
~6 Mo. Pre-Sep
	MEB
~2 Mo. Pre-Sep
	VA C&P
~2 Mo. Post-Sep
	
Flexion (90 Normal)	Within Normal Limits	Limited ROM	Full ROM	90	
Extension (30)	-	-	-	30	
R Lat Flexion (30)	-	-	-	30	
L Lat Flexion (30)	-	-	-	30	
R Rotation (30)	-	-	-	30	
L Rotation (30)	-	-	-	30	
Combined (240)	--	--	--	240	
Comment	Pain with end range of flexion and right side bending; positive quadrant, Thomas and piriformis tests	Painful motion, no tenderness on palpation; lumbosacral muscle spasms and step deformity	Tenderness to palpation along the left sciatic notch and left mid gluteal region; no spasm edema, or palpable deformity	Pain at the end of all motions except flexion	
§4.71a Rating	-	-	(PEB 10%)	(VA 10%)	

The Board directed attention to its rating recommendation based on the evidence above.  The PEB assigned a 10% rating using code 5299-5237 (Lumbosacral strain) for chronic lower back pain which at times radiated into the left buttock and posterior thigh.  The VA assigned a 10% rating using code 5237 for lumbosacral strain.  The Board sought a route for a higher rating, but was unable to find one in the absence of ankylosis, decreased ROMs, or muscle spasm or guarding resulting in an abnormal gait or abnormal spinal contour.  The Board then considered whether an additional service rating could be recommended under a peripheral nerve code.  Firm Board precedence requires a functional impairment linked to fitness to support a recommendation for addition of a peripheral nerve rating to Service disability in spine conditions.  Although the pain component of the neuropathy is appropriately subsumed in the spine rating IAW VASRD §4.71, which states that “rating is performed with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease,” there was no sensory component with any significant functional implications and no motor weakness was in evidence.  Therefore, the radiculopathy could not be recommended for additional disability rating.  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 chronic 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 20140627, 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, AR20160007983 (PD201403348)

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