RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03618
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080421

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Aviation Operation Specialist, medically separated for “chronic low back pain,” with a disability rating of 20%.

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 - 20080409	VARD - 20080829	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5235	20%	Lumbar Strain (Also Claimed as Groin Pain)	5237	10%	20070407	
Right Meralgia Paresthetica	Not Unfitting					
Bilateral Groin Pain & Numbness	Not Unfitting					
Hypertension	Not Unfitting	Hypertension	7101	0%	20070407	
Depressive Disorder, NOS	Not Unfitting	Depressive Disorder, Not Otherwise Specified	9434	10%	20070407	
Keloid Scarring	Not Unfitting	Keloid Scar	7802	0%	20070407	
Left Hand, Short Finger Pain	Not Unfitting	Left Little Finger Injury with Flexion Deformity	5230	0%	20070407	
Bilateral Knee Pain	Not Unfitting	Retropatellar Pain Syndrome, Left Knee	5260	10%	20070407	
		Retropatellar Pain Syndrome, Residual of Right Knee ACL Repair with Scar	5260	10%	20070407	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

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 (LBP) condition began in March 2004 while standing in the opening of the roof of his Humvee when it crashed into a concrete barricade.  He reinjured his back in June 2006 and complained of radiating pain in his groin.  The CI received physical therapy, chiropractic care, attended back classes and was seen by the pain clinic for pain management with limited relief of pain.  Surgical treatment was proposed and the CI’s refusal to undergo surgical treatment was determined to be reasonable.  The CI underwent an MRI study in June 2007 which showed an old compression fracture of the T11 vertebra (slight anterior wedging) with degenerative disease at L3-4.  Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded low back pain for PEB adjudication.

At the NARSUM examination dated October 2007, 7 months prior to separation, the CI reported back pain of 7-10/10 made worse with prolonged walking, lifting, and driving in a car and made better with stretching, rest, and avoiding the precipitating factors.  The CI also reported constant "pins and needles" type pain to the inner upper groin/thigh.  The CI denied bowel or bladder dysfunction.  The CI was taking narcotic pain medication and muscle relaxant medications.  The physical exam showed normal lower extremity strength and reflexes.  There was normal cremasteric (groin) reflex bilaterally.  There was decreased sensation to light touch to the bilateral groin and right lateral thigh.  The range of motion (ROM) measurements of the spine “were flexion 45, 35, 30 degrees, limited by pain” and are the same values as recorded by physical therapy (PT) dated August 2007, 9 months before separation, which are summarized in the chart below.

At the VA Compensation and Pension (C&P) examination in April 2008, performed 2 weeks before separation, the CI reported his back condition existed since 2004.  He noted stiffness, weakness, and aching, sharp and tingling pain with a pain level of 8/10 in his back.  His pain was also elicited by physical activity and stress.  Pain was relieved by rest, medication, icing and use of a heating pad.  The CI denied any incapacitating pain.  The physical examination showed a normal posture and gait.  There was no evidence of radiating pain on movement and muscle spasms were absent.  Straight leg raise testing (for radiating symptoms) was negative.  There was lumbar muscle tenderness, with limited motion as summarized in the chart below.  There were no signs of ankylosis or intervertebral disc syndrome with chronic and permanent nerve root involvement of the lumbar spine.

The 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 PT / NARSUM ~9 / 7 Pre-Sep	VA ~2 Weeks Pre-Sep	
Flexion (90 Normal)	30   (45, 35, 30)	70	
Combined (240)	160	210	
Comments	Dual Inclinometer; painful motion	Painful motion; tenderness	
§4.71a Rating	20%-40% (PEB 20%)	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under the code 5235 (vertebral fracture or dislocation), citing “forward flexion between 31 and 60 degrees.”  This was likely application of the average of forward flexion measurements (36.7 degrees) rather than consideration of DeLuca for decreased ROM following repetition of 30 degrees.  The VA assigned a 10% rating using the code 5237 (lumbosacral strain) based on the VA C&P examination 2 weeks before separation, citing pain elicited by physical activity and stress.  The VA subsequently increased their back rating to 20% effective December 2009 citing a VA treatment note of that date showing 60 degrees of forward flexion.

In assigning probative value to these somewhat conflicting examinations, the Board noted that the MEB PT ROMs were taken using a dual inclinometer method rather than the goniometric thoracolumbar ROM specified by the VASRD (§4.71a, Plate V; and §4.46 (accurate measurement)).  Members agreed that the VA examination was IAW VASRD §4.46, closest to the date of separation, more consistent with outpatient notes, more reflective of the anticipated severity based on the clinical pathology, and best represented the CI’s disability picture at the time of separation.  The Board therefore placed the greatest probative value for rating at separation on the VA examination.  The Board agreed that there was no limitation of ROMs to support a rating higher than the 20% assigned by the PEB.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.

The CI had intervertebral disc disease with radicular pain, and there were symptoms of radiating pain documented in the treatment records as well as groin paresthesias/pain and right thigh sensory deficit (diagnosed as right meralgia paresthetica-not caused by spine nerve irritation); however, examinations indicated normal strength, reflexes and gait, and the sensory changes did not affect his job.  The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting.  While the CI may have suffered additional pain from the nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  Therefore the critical decision is whether or not there was a significant motor weakness which would impact military occupation specific activities.  There is no evidence in this case that motor weakness existed to any degree that could be described as functionally impairing.  The Board therefore concluded that additional disability rating was not justified on this basis.  After due deliberation, and in consideration of all 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.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that right meralgia paresthetica; bilateral groin pain and numbness; hypertension; depressive disorder, not otherwise specified; keloid scarring (right head); left hand, short finger pain; and bilateral knee pain conditions were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  None of the contended conditions were profiled or implicated in the commander’s statement and none were judged to fail retention standards.  All were reviewed and considered by the Board.  Any potential disability from the right meralgia paresthetica or groin numbness conditions being radiculopathies from the unfitting back condition, were also considered with rating the unfitting back condition above.  There was no performance-based evidence from the record that any of these 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 any of the contended conditions and so no additional disability ratings are recommended.

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 contended right meralgia paresthetica; bilateral groin pain and numbness; hypertension; depressive disorder, not otherwise specified; keloid scarring; left hand, short finger pain; and bilateral knee pain 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, dated 20140718, 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, AR20160008673 (PD201403618)

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