RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-03649
BRANCH OF SERVICE:  ARMY                                                                  SEPARATION DATE:  20030324

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Personnel Service Specialist, medically separated for “chronic low back pain,” with a disability rating of 10%.

CI CONTENTION:  The CI’s conditions continue to worsen and negatively affect daily activities.  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 - 20021217	VARD - 20030425	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5299-5295	10%	Herniated Nucleus Pulposus at L4-L5	5292	10%	20030321	
			Radiculopathy, Right Lower Extremity	8599-8520	10%	20030321	
Posterior Tibial Tendinitis Right Leg	Not Unfitting					
Subacromial Bursitis/ Tendinitis, Right Shoulder 	Not Unfitting	Chronic Bicipitis Tendinitis, Dominant Right Shoulder	5201-5024	0%	20030321	
Tendinitis, Right Ankle	Not Unfitting	Right Ankle Condition	5271	NSC		
Pain Left Knee Etiology Undetermined	Not Unfitting	Retropatellar Pain Syndrome, Left Knee	5261-5019	0%	20030321	
COMBINED RATING:  10%	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 complained of intermittent low back pain (LBP) for approximately 9 years prior to referral for MEB.  Lumbosacral spine diagnostic imaging (X-ray) showed a transitional vertebra (congenital variation of lumbosacral joint involving lowermost lumbar vertebra or uppermost sacral segment) is present with hemisacralization (lowermost lumbar segment [L5] is fused to sacrum) of the left L5.  A lumbar spine diagnostic imaging (MRI) study showed a large L4-5 central disc protrusion with moderate central canal stenosis (narrowing) and minimal neuroforaminal (nerve root opening) stenosis and L5-S1 sacralization with possible right neuroforaminal stenosis.  At a neurology evaluation the CI reported a 7 to 8-year history of LBP.  He complained of a constant dull ache in the right paraspinal/sacroiliac region.  The CI complained of episodic sharp shooting pain radiating into the right buttocks and lower extremity (LE) along the S1 dermatome (area of skin sensation derived from a single nerve root).  He reported episodic right LE numbness and tingling in the L5/S1 dermatomes.  Symptoms were exacerbated by certain positions prolonged sitting, standing, and driving.  The CI denied paresis (partial or incomplete paralysis) and bowel or erectile dysfunction.  The physical examination documented a normal gait (normal base, toe, heel and tandem).  Strength (5/5), muscle tone, and deep tendon reflexes (DTRs) were normal and pathologic reflexes were absent.  Sensation was normal except for decreased perception (pin prick, light touch) in the right S1 dermatome.  The assessment listed mild right S1 radiculopathy and LBP secondary to myofascial derangement most likely caused by altered biomechanics as compensation for initial back/LE injury.  The neurologist documented “There is very little clinical indication to do EMG/NCV at this point.  Since the clinical findings suggestive of radiculopathy are very minor, the results of electroneuromyography are unlikely to change any therapy.”  A neurosurgery statement for the MEB documented the CI “… has had intermittent low back pain since '93 which has generally been tolerable, however at times somewhat disabling.  It has been intermittently associated with radiating R leg pain and parasthesias [abnormal sensation, tingling, burning, prickling]. … At times pain is quite tolerable and he is able to do most activities to include running and physical exertion.”  The back examination revealed moderate paraspinal spasm (L>R).  Range of motion (ROM) was reduced in all axes secondary to pain.  The straight leg raise (SLR) tests (assess for herniated disc causing sciatic nerve root [L5-S1] radiculopathy) were negative.  Strength (5/5) and DTRs were normal except for diminished right ankle jerk.  Sensation was normal except for right S1 dermatome hypesthesia (diminished sensation) and hypalgesia (diminished pain sensation).  The impression listed chronic LBP and right leg pain with mild to moderate fixed neurologic deficit secondary to L4-5 herniated nucleus pulposus ([HNP] prolapse of gelatinous disc core).  A lumbosacral spine X-ray noted left L5 sacralization but was interpreted as normal.  In the 7 October 2002 NARSUM, 5 months before separation, the CI reported a history of chronic recurrent LBP since October 1993 with no known injury.  The daily LPB ranged from 2-10/10 pain.  He complained of associated right buttock pain and intermittent radiating right leg/foot pain and paresthesias.  Symptoms were exacerbated by prolonged sitting, standing, driving, and running or other jarring activities.  The CI denied bowel or bladder incontinence.  He not improve with conservative management (activity modification, physical therapy [PT], and medication) and declined surgery because of concerns about potential complications.  The CI stated “… that his medical condition does not interfere with his ability to perform the duties of his MOS.”  The physical examination documented a normal gait.  The back examination revealed diffuse tenderness of the lower lumbar area.  Active ROM was full and the SLR tests were negative.  Strength, sensation, and DTRs were normal except for a depressed right Achilles reflex.  Pathologic reflexes were absent and there was no LE muscle wasting.  The diagnosis listed chronic LBP and right leg pain with mild to moderate fixed neurologic deficit secondary to L4-5 HNP.  In the 21 March 2003 compensation and pension (C&P) examination, the CI reported a history of a back condition and intermittent sharp pain into the right buttocks since 1993.  He complained of occasional pain and numbness down the back of the right leg.  

Symptoms were exacerbated by prolonged sitting, walking, bending, lifting, or any activity and relieved by stretching, walking, and medication.  “He states he was seen by the neurosurgeon and was told that surgery would just probably make things worse.”  The physical examination documented a normal gait (toes, heels, and tandem walk) and posture.  The back examination revealed no abnormal spinal curvature (kyphosis, lordosis, or scoliosis), paraspinal muscle spasms, or lumbar spine tenderness.  There was pain with extension, flexion and lateral bending.  Active ROM was full and there was no decreased ROM from pain.  Strength (5/5), sensation, and DTRs (2+) were normal and pathologic reflexes were absent.  The diagnosis listed chronic LBP with intermittent radiculopathy (nerve root irritation or injury) secondary to L4-5 HNP.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5295 code (lumbosacral strain) citing chronic LBP, L4-5 HNP, 5/5 motor strength, negative SLR, pain on motion, no muscle atrophy, and refused a surgical procedure.  The VA assigned a 10% rating under the 5292 code (spine, limitation of motion of, lumbar) based on the VA C&P examination 3 days before separation, citing chronic LBP, radicular symptoms into right foot,  L4-5 HNP, full ROM, pain-free ROM, a non-antalgic gait, and reoccurring symptoms comparable to slightly limited lumbar spine motion.  The Board considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  While the CI had an L4-5 HNP with intermittent radicular symptoms, proximate examinations documented normal strength, DTRs, and gait and the sensory disturbances did not affect his job.  Therefore the critical decision is whether or not there was a significant motor weakness or sensory impairment which would impact military occupation specific activities.  In accordance with DoDI 6040.44, the Board is required to recommend a rating IAW the VASRD in effect at the time of separation.  The Board noted that the 2002 VASRD standards for the spine, which were in effect at the time of separation, were changed to the current §4.71a rating standards in 2004.  The Board must correlate the above clinical data with the 2002 rating schedule and applicable diagnostic codes.  There was no vertebral fracture (5285), complete spine ankylosis (5286), lumbar spine ankylosis (5289), limitation of lumbar spine motion (5292), intervertebral disc syndrome (5293), or sacro-iliac injury/weakness (5294) for consideration under the respective codes.  Members agreed a 10% rating was supported under lumbosacral strain (5295) based on characteristic pain on motion.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  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.  

Contended PEB Conditions.  Dorsal ganglion cyst, bilateral wrists; subacromial bursitis/tendinitis, right shoulder; posterior tibial tendinitis right leg; tendinitis, right ankle; and pain left knee etiology undetermined.  The contended conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed and considered by the Board.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  After due deliberation 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 low back condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended dorsal ganglion cyst, bilateral wrists; subacromial bursitis/tendinitis, right shoulder; posterior tibial tendinitis right leg; tendinitis, right ankle; and pain left knee etiology undetermined 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 following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140801, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160017192 (PD201403649)

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