RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03746
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090125

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Avenger Crewmember, medically separated for “lumbar strain,” with a disability rating of 10%.

CI CONTENTION:  The CI contends his condition was more severe than the service diagnosis of lumbar strain.  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 20081124	VARD 20090320  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lumbar Strain	5237	10%	Lumbar Spine Strain	5237	20%	20090219	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Lumbar Strain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), in August 2007 the CI dismounted from a 5-ton vehicle during a training exercise and landed awkwardly on his back.  Subsequently, he reported constant localized low back pain, graded 3-4/10, without lower extremity radiation or neurological symptoms that increased to 8-10/10 with exacerbations, which occurred 3-4 times per week.  Radiographic views of the lumbosacral spine in April 2008 were negative.  The CI underwent conservative treatment with physical therapy and pain medication.  Serial evaluations in the STR in the 12 months before separation noted normal lumbar active range of motion (ROM) and a single examination noted limitation of only lateral flexion.  Despite treatment, the CI’s back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s Military Occupational Specialty (MOS) and he was referred for a Medical Evaluation Board (MEB).  

The goniometric ROM evaluations 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)	
PT ~7 Mo. Pre-Sep
	
MEB ~3 Mo. Pre-Sep
	
VA C&P ~1 Mo. Post-Sep
	
Flexion (90 Normal)	AROM WNL*	70	60	
Combined (240)	n/a	215	210	
Comments	*trunk and lumbar mobility as noted; - SLR	Neg. Deluca	Neg. Deluca; no radiating pain	
§4.71a Rating	0%	10%	20%	

At the MEB examination (recorded on DD Forms 2807 and 2808) dated September 2008, 4 months prior to separation, physical examination showed 2/4 deep tendon reflexes and 5/5 muscle strength for upper and lower extremities.  There was negative straight leg raise (SLR) bilaterally and positive tenderness to palpation (TTP) along the paraspinal muscles at L3-L4 vertebra.

The MEB NARSUM examination on 14 October 2008 (3 months prior to separation) noted the CI’s complaints of constant low back pain (2-3/10 at rest) with 3-4 exacerbations a week (due to walking > 1 mile; lifting > 20 pounds and squatting) where pain increased to 8-10/10.  The CI had no radicular symptoms (LE radiating pain, numbness, or weakness), no loss of bowel or bladder function and the pain improved with rest. In addition to physical examination findings above, the NARSUM physical examination found no limitation of (ROM due to fatigue, lack of endurance, or incoordination with repetitive testing and the CI reported minimal soreness of his low back during ROM testing.

At the VA Compensation and Pension (C&P) Spine examination on 19 February 2009, performed 1 month after separation, the CI reported mild low back pain, without radiation, that occurred 1-6 times per week and lasted for minutes.  He reported the pain was associated with decreased motion, stiffness, weakness, and spasm and was precipitated by bending, prolonged standing, or lying down.  The physical examination showed a normal posture, head position and symmetry in appearance.  The CI’s gait was normal.  There were no abnormal spinal curvatures noted.  There were no incapacitating episodes or flare-ups of spine disease.  There was no muscle spasm noted.  Muscle strength was 5/5 for all muscle groups related to the lumbosacral spine.  There was a normal sensory examination for upper and lower extremities bilaterally. Reflexes were 2+ bilaterally.  Painful motion was noted on ROM testing but there were no additional limitations following repetitive motion and no radicular symptoms were noted.  Lumbar X-rays on 9 February 2009 were normal without degenerative changes noted.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5257 code (lumbosacral strain), citing forward flexion limited to 70 degrees, based on the MEB NARSUM examination 3 months prior to separation.  The VA assigned a 20% rating using the 5237 code based on the VA C&P examination 1 month after separation, citing flexion limited to 60 degrees.    

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) reported on the MEB NARSUM examination, 3 months prior to separation.  Although the VA examination, 1 month after separation, was closer to separation and demonstrated forward flexion limited to 60 degrees, the Board considered that flexion was noted to be within normal at all evaluations in the STR in the l2 months before separation and that the MEB NARSUM examination was consistent with the 10% rating criteria.  Additionally, all ROM other than flexion was normal at the C&P examination.  Member consensus was that the sole measure of flexion of 60 degrees at one examination in record was insufficient to support the next higher evaluation of 20% based on ROM criteria.  There was also no muscle spasm or guarding severe enough to result in abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.   Furthermore, VASRD §4.3 (reasonable doubt) was not met in this case as the preponderance of evidence supported a 10% rating given the CI’s normal radiographic views of spine, the absence of radicular symptoms, additional limitation of motion, fatigue, lack of endurance or coordination with repetitive motion.  VASRD §4.7 (Higher of two evaluations), states “where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating.  Otherwise, the lower rating will be assigned.”  In this case, based on the evidence in record, the Board adjudged that the 10% rating “more nearly approximates” the disability due to the back condition at separation.  There was no evidence of intervertebral disc syndrome resulting in incapacitating episodes requiring bed rest prescribed by a physician to warrant consideration of a higher rating under the alternate VASRD formula based on incapacitating episodes due to intervertebral disc syndrome.  Finally, there was no evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve rating.  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 lumbar strain condition.  

BOARD FINDINGS:  In the matter of the lumbar strain 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 20140812, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXXXXX AR20160009333 (PD201403746)

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