RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03531
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041130

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Indirect Fire Infantryman, medically separated for “chronic low back pain” and “right S1 radiculopathy,” rated 10% and 10% respectively, with a combined disability rating of 20%.  

CI CONTENTION:  His conditions continue to worsen and negatively impact his daily activities.  Additionally, he was not evaluated for his PTSD, migraine and TBI 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 based upon a 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 - 20041028	VARD - 20051005	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5243	10%	Degenerative Disc Disease, Lumbosacral Spine	5243	10%	20050205	
Right S1 Radiculopathy	8720	10%	Radiculopathy, Right lower Extremity	8524-8624	10%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic low back pain condition began in September 2003 after a parachute landing fall.  He aggravated the low back pain condition in November 2003 after falling while patrolling on steep mountain terrain.  Trigger point injections of his right lower back were performed on 13 December 2003.  Diagnostic imaging (CT) studies on 3 January 2004 showed bulging intervertebral discs at L5-S1 and L4-L5 with degenerative disc disease on the right at L5-S1.  Diagnostic imaging (X-ray) studies on 15 March 2004 showed a normal lumbar spine with no abnormalities.  Diagnostic imaging (MRI) studies on 30 March 2004 showed bulging intervertebral discs on the right at L5-S1, with moderate to severe narrowing of the right lateral recess and abuts the right S1 nerve root.  There was no narrowing of the neural foramina at the S1 level.  An orthopedic evaluation in April 2004 noted complaints of low back pain with spasms and decreased motion.  The CI denied “any weakness, numbness, tingling, or popping to the back.”  Physical examination showed forward flexion to 90 degrees (normal) with pain on back motion and tenderness to palpation.  The CI was able to perform a full squat and provocative testing for radiculopathy was negative.  Muscle strength, reflex and sensory testing were normal.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “right lateral L5-S1 disc bulge with pressure on S1 nerve root,” 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)	Ortho ~8 Mo. Pre-Sep	MEB ~2 Mo. Pre-Sep	VA C&P ~2 Mo. Post-Sep 	
Flexion (90 Normal)	90	80	Full	
Combined (240)	unknown	205	Full	
Comments	Painful motion; tender	Pain on motion	Full ROM	
§4.71a Rating	10%	10%	0%	

During the MEB examination (recorded on DD Form 2807 Report of Medical History and DD Form 2808 Report of Medical Examination) dated 13 September 2004, 2 months prior to separation, the CI reported low back pain that radiated down his right lower extremity (mid-thigh) rated at 2-3/10 scale.  The pain was relieved by medication (Motrin, Flexeril, Robaxin, and Celebrex).  The pain prevented him from performing duties required of his military specialty and from performing his physical fitness test (no upper or lower body weight training) with the exception of being able to perform alternate aerobic events such as walk or bike.  He was able to perform most activities but the intensity and duration was limited, especially lifting, walking, and swimming.  He was prevented from moving with a fighting load for 2 miles, constructing an individual fighting position, performing 3-5 second rushes, and was deemed non-deployable.  Physical examination showed provocative maneuvers for signs of radiculopathy or radiating pain due to spinal nerve root or sciatic nerve involvement were negative.  Thoracolumbar ROM was limited by pain as recorded in the chart.  

At the 5 February 2005 VA Compensation and Pension (C&P) evaluation, performed 2 months after separation, the CI reported low back pain that radiated down his right leg but stopped at knee level.  He reported having severe exacerbations since his injury in 2003 where he was debilitated for up to a week.  He had no weakness or difficulty with bowel of bladder function.  Physical examination showed normal posture and gait, and the CI could walk on his heels and on his toes.  Reflexes and sensation in all extremities were normal.  Strength was normal on the general and spine C&P examinations.  Provocative maneuvers for signs of radiculopathy or radiating pain due to spinal nerve root or sciatic nerve involvement were negative.  Thoracolumbar ROM was normal as recorded in the chart above.  

Electrodiagnostic studies (EMG/NCV) performed on 10 February 2005 concluded with a diagnosis of acute chronic right S1 (vs L5) radiculopathy with evidence of axonal sprouting and re-innervation.  There was mild right peroneal neuropathy at the fibular head with NCV slowing noted across the knee (popliteal fossa-below fibular head).  Examination at that time noted decreased sensory examination around the right heel and slight (4/5 of normal 5/5) weakness of the extensor halluces longus with all other motor testing normal.  The physician’s diagnosis stated “there is some questionable weakness in the L5-S1 distribution on the right” and EMG revealed “an S1 radiculopathy on the right knee.”  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic low back pain condition 10% coded 5243 (intervertebral disc syndrome), citing multi-level degenerative disc disease with right S1 nerve impingement and a sensory right sided radiculopathy with tenderness to palpation.  The VA also rated the chronic low back pain condition 10% coded 5243 (intervertebral disc syndrome) based on the VA C&P examination 2 months after separation and the STRs, citing limited painful motion reported on the MEB examination contained within the STR and citing full ROM on the VA examination.  

The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and/or combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the MEB examination 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.  The Board considered whether a higher rating (§4.7) was achieved by using the alternate rating formula based on incapacitating episodes due to intervertebral disc syndrome (IVDS).  Although the CI had intervertebral disc disease there were no incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula (for IVDS).  

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 chronic low back pain condition.

Right S1 Radiculopathy.  The CI’s chronic right S1 (lower extremity) radiculopathy was associated with the CI’s chronic low back pain condition, and examinations cited above detailed the right lower extremity neurologic findings.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right S1 radiculopathy condition 10%, coded 8720 (neuralgia, sciatic nerve), citing no motor loss, muscle atrophy or reflex loss; “rated as mild sciatic neuralgia.”  The VA rated the right S1 radiculopathy condition 10%, coded 8524-8624 (paralysis-neuritis, internal popliteal nerve (tibial)), based on the VA C&P examination 2 months after separation, citing a normal examination with abnormal EMG/NCS results.  

The CI had a bulging disc which was concordant with his symptoms of radiating pain documented in the treatment records.  The preponderance of examinations indicated normal strength, reflexes and gait; however, there was abnormal electrodiagnostic testing and questionable weakness in the right lower extremity that did not affect gait.  Regardless of the nerve level selected, there was not sufficient evidence of a moderate peripheral nerve impairment to warrant any higher rating than that awarded by the PEB and VA.  

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 right S1 radiculopathy 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.  In the matter of the right S1 radiculopathy condition and IAW VASRD §4.124a, 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

21 NOV 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160017505 (PD201403531)

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.

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA