RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03470
BRANCH OF SERVICE:  Army  	SEPARATION DATE:  20080811

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4, Motor Transport Operator, medically separated for low back pain (LBP) with radicular symptoms, rated at 20%.  

CI CONTENTION:  The CI contends that a rating of 20% for the amount of pain experienced on a daily occurrence is an unfair compensation.  The remaining contention relates to issues outside the Board’s purview and is addressed below.  His 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 – 20080502	VARD - 20080818	
Condition	Code	Rating	Condition	Code	Rating	Exam	
LBP with Radicular Symptoms	5299-5237	20%	Degenerative Changes L5-S1; Lumbar Spine	5242	10%	20080818	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Low Back Condition.  The service treatment record documents that the CI strained his back lifting and throwing a tent.  A lumbar spine X-ray showed degenerative disease at the L5-S1 level.  A pain management encounter recorded a 4-year history of progressive LBP with right leg radicular (irritation or injury of a nerve root) symptoms.  Pain was 6/10 at rest and 7/10 with activity.  Back exercises helped to maintain function but physical therapy (PT) with traction provided no relief.  The physical examination documented a normal gait.  The back examination revealed tenderness of the bilateral lower paraspinal regions with no spine abnormalities.  The most prominent finding was hypertonic and sensitized right paralumbar muscles.  Lumbosacral spine pain was elicited by motion in all planes, worst with extension.  The CI reported pain with maneuvers not expected to elicit pain based on the known pathology.  Straight leg raise (SLR) tests (assesses sciatic nerve root compression by a herniated disc) and Flexion, ABduction, External Rotation, and Extension (FABERE) tests (assesses hip and sacroiliac joint pathology) were negative.  Strength and sensation were normal.  The examiner performed myofascial release, acupressure, desensitization, and muscle energy therapy with immediate gain in ROM.  He opined that the causes for back pain were multifactorial and included discogenic disease, facet syndrome, and myofascial pain.  The assessment listed back strain, back sprain, and facet syndrome.  A lumbar spine MRI showed minor disc bulges throughout the lumbar spine without significant central canal or foraminal (nerve root openings) narrowing.  A bone scan showed focal uptake within the (L>R) hip joint regions.  The radiologist opined that these likely represented focal stress changes, focal degenerative changes, or less likely posttraumatic changes.  The general physical examination documented no spinal tenderness but diagramed bilateral lumbar and right thoracic paraspinal tenderness.  Range-of-motion (ROM) was flexion (with pain) of 70 (90 normal) and extension of 5-10 (30) degrees.  A modified seated SLR test caused numbness in the right lower extremity.  Deep tendon reflexes (DTRs) were normal.  Thoracolumbar spine ROM was measured by PT with a goniometer for the MEB.  Repetitive (X3) active ROM was flexion of 55/58/66 (90), extension of 15/15/18 (30), left lateral flexion of 27/30/28 (30), right lateral flexion of 24/25/25 (30), left rotation of 23/25/27 (30), and right rotation of 30/30/30 (30) degrees.  Active ROM was limited by pain but there was no localized tenderness, spasm, guarding, abnormal gait, or abnormal spinal contour.  The narrative summary (NARSUM), 4 months before separation, recounted the history and interventions.  The CI reported his LBP, and right leg radicular symptoms, worsened while serving as a tactical vehicle gunner in Iraq.  He sought care for back muscle spasms and right leg numbing/tingling and was treated with nonsteroidal anti-inflammatory drugs (NSAIDs) and an analgesic.  The CI complained of 6 years of chronic mid to low back pain with intermittent right leg radicular symptoms (numbing/sensory disturbance).  The 5-6/10 pain was characterized as sharp, throbbing, and shocking and ranged from 4-8/10 over the previous week.  Symptoms were exacerbated by load bearing, running, walking fast, jumping, sit-ups, pushups, lifting, bending, stooping, reaching, twisting, and stress.  Symptoms were relieved by rest, lying on his side with knee bent and shoulder flat, and avoiding exacerbating activities.  Flare-ups occurred at least weekly and lasted 1-7 days.  The examiner documented “It is estimated that he experiences a 75% loss of ROM with a flare, with weakness in the right leg, loss of endurance, increased clumsiness and instability and is easily fatigued during a flare.”  The CI failed conservative management which included activity modification, chiropractic care, PT, traction, transcutaneous electrical nerve stimulation (TENS), exercises, and medications.  Active medications were an NSAID and a muscle relaxant.  Under the physical exam, the examiner cited findings from the general physical exam, pain management exam, and ROM by PT for the MEB exam.  The examiner noted that the CI's ROM was done on a day with average pain.  A lumbar spine X-ray suggested minimal rightward deviation at the mid-thoracic spine with no significant sclerosis (pathological tissue hardening/thickening).  The diagnosis listed chronic low back pain with radicular symptoms.  The examiner opined that the condition was stable and the prognosis for return to full duty was poor.  The compensation and pension (C&P) examination recounted the history and interventions.  The CI complained of progressive worsening of LBP and "every so often get sciatica [pain radiating along distribution of sciatic nerve] going down my leg."  He complained of constant 4/10 pain with flare-ups to 9/10.  Flare-ups occurred 4-5 times a month and lasted about one day.  The radiation was characterized as "tingling", started at the medial groin, descended the medial right leg into the great toe, and occurred about 3-4 times a month.  The CI denied associated weakness, stiffness, swelling, heat, redness, instability, giving way, locking, falls, fatigability, lack of endurance, erectile dysfunction, or bladder/bowel incontinence.  He did not identify any actions that consistently precipitated symptoms and pain was relieved by hot baths, warm showers, and medications.  Active medications were an NSAID and a muscle relaxant, which yielded good results.  The CI was able to perform his usual occupation without restrictions.  The physical examination documented a normal gait without ambulatory aides or braces.  The thoracolumbar spine examination revealed no deformity, bony abnormalities, abnormal spinal contour, asymmetry, rigidity, muscle atrophy, guarding, or tenderness.  The active ROM was flexion of 90 (90), extension of 30 (30), bilateral lateral flexion of 30 (30), and bilateral rotation of 30 (30) degrees.  There was no objective evidence of any additional functional loss of ROM due to pain, fatigue, weakness, or lack of endurance following repetitive (X3) use.  The SLR tests were negative.  Strength, sensation, and DTRs were normal.  A lumbar spine X-ray showed mild lower lumbar facet arthropathy (joint disease).  The assessment listed unchanged and mild degenerative disease of L5-S1.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 20% (coded 5299-5237) citing low back pain, radicular symptoms, normal spine by X-ray, minor disc bulges without central canal or foraminal narrowing by MRI, normal gait, positive Waddell signs, weekly pain flare-ups, non-narcotic pain medication, episodes of incoordination, and ROM.  The VA continued a previous low back condition rating of 10% (coded 5242) citing the C&P examination a week after separation.  The VARD cited pain, L5-S1 joint space narrowing by X-ray, L5-S1 degenerative disease, full ROM, no pain with ROM, no objective indication of additional functional loss of ROM due to pain, fatigue, weakness, lack of endurance, or incoordination, gait grossly unimpaired, and thoracolumbar spine showed no deformity, no asymmetry, no muscle atrophy, and no rigidity.  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 experienced radiating pain, 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 ROMs in the C&P examination were full and did not attain the minimum 10% rating based upon the general rating formula for diseases and injuries of the spine.  The ROMs in the PT examination for the MEB 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).  The proximate exams did not document abnormal gaits or abnormal spinal contours.  Other routes to a rating higher than the PEB’s 20% 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:  IIn 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 20140630, 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, AR20160008098 (PD201403470)

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