RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03730
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040526

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E4, Petroleum Supply Specialist, medically separated for “chronic low back pain, with lower lumbar myofascial trigger points…,” with a disability rating of 10%.

CI CONTENTION:  The CI requested that, in addition to the unfitting low back pain condition, other conditions not forwarded to the PEB for adjudication, be considered.  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 on 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 - 20040412	VARD - 20051011	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain…	5299-5237	10%	Low Back Pain with Lumbago	5237	20%	20050818	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain with Lower Lumbar Myofascial Trigger Points.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic low back pain condition began after heavy lifting in July 2003.  Diagnostic imaging (X-ray) in August 2003 showed mild disc space narrowing at L5-S1 level.  Magnetic resonance imaging in November 2003 showed no disc herniation or evidence of nerve impingement.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty. The MEB forwarded “chronic low back pain/lumbago” for PEB adjudication.
At the MEB Neurology NARSUM exam dated 22 February 2004, (3 months before separation), the CI reported pain aggravated by walking, standing, or stooping; radiation to the buttocks; and denied weakness, numbness and paresthesias.  The examiner documented a normal gait and posture, paraspinal muscle tenderness, and “full range of motion.”  At the MEB Neurology addendum exam dated 8 March 2004, (2 months before separation), the CI reported constant low back pain that prevented a continuous night’s sleep.  Physical exam showed normal gait, strength, and reflexes; range of motion (ROM) testing showed forward flexion to 80 degrees (normal 90), and tenderness of the paraspinal muscles.  The examiner further clarified that there was a “very mild decrement in forward flexion ROM due to pain.  Provocative maneuvers for signs of radiculopathy or radiating pain due to spinal nerve root or sciatic nerve involvement were negative at both the February and March MEB exams.  

At the VA Compensation and Pension (C&P) exam on 18 August 2005, (15 months after separation), the CI reported lower back pain with spasm, radiation to the right lower extremity, and weekly flare ups, lasting one day, causing “100% additional limitation.”  The pain was aggravated by physical therapy, walking (less than 1 mile), especially uphill, bending, twisting, and standing for long periods.  The examiner documented a forward flexion to 60 degrees, with painful motion, and no additional limitations after repetition.  There was a normal gait, normal curvature, “mild” spasm with moderate tenderness; and normal strength, reflexes, and sensation.  Provocative maneuvers for signs of radiculopathy or radiating pain due to spinal nerve root or sciatic nerve involvement were negative.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB rated the chronic low back pain condition 10% coded 5299-5237 (lumbosacral strain), citing limitation of painful motion.  The VA rated the chronic low back pain condition 20% coded 5237 (lumbosacral strain), based on the VA C&P examination 15 months after separation, citing limitation of forward flexion.  

The Board deliberated the probative value of the exams in evidence and the totality of the record.  The MEB NARSUM exam documented “full” ROM with tenderness of the paraspinal muscles.  The MEB Neurology addendum exam documented a flexion of 80 degrees with painful motion and localized tenderness, and further clarified that the decreased ROM was “very mild.”  Both exams supported a 10% rating for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees and localized tenderness not resulting in abnormal gait or abnormal spinal contour, respectively.  However, the MEB Neurology addendum exam used an inclinometer and the VA requires a goniometer be used for rating purposes.  The Board noted the earliest VA evaluation was 15 months after separation.  DoDI 6040.44 provides for consideration of post-separation VA findings, particularly within 12 months of separation, although the Board’s recommendation is premised on the degree of disability at separation.  The Board’s assessment must be derived from evidence that provides information regarding the status of the disability at the time of separation.  Although the VA examiner used a goniometer, and supported a higher rating based on flexion alone, the preponderance of the record did not approach this disability level; therefore, the more proximate to separation MEB NARSUM and MEB neurology addendum exams were adjudged to have the highest probative value for rating at separation.  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 chronic low back pain condition.  

The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  The CI reported intermittent radicular pain, however, examinations indicated normal strength, reflexes and gait, and the sensory changes did not affect her 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.  

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 20140808, w/atchs
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, AR20160011591 (PD201403730)

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