RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-03820
BRANCH OF SERVICE:  Army	Date of separation: 20060609

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Cavalry Scout medically separated for “chronic radiating thoracolumbar back pain,” with a disability rating of 10%.

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 – 20060519	VARD - 20070711	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Radiating Thoracolumbar Back Pain	5237	10%	Degenerative Disc Disease of Thoracic and Lumbar Spine	5299-5243	20%	20070502	
			Sciatica, Right Lower Extremity Associated With
Degenerative Disc Disease Of Thoracic And Lumbar Spine	8599-8520	10%		
			Sciatica, Left Lower Extremity Associated With
Degenerative Disc Disease Of Thoracic And Lumbar Spine	8599-8520	10%		
Corrected Myopia	Not Unfitting	No VA Placement	
Elevated Lipids			
Tobacco			
Treated Peptic Ulcer Disease			
COMBIEND RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Back Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s low back pain condition began in May 2003 after colliding with a convoy truck while deployed to Iraq.  At the time of a primary care clinic appointment on 11 May 2004, the CI reported numbness in his thighs after 15 minutes of sitting.  He denied any bowel or bladder problems.  On examination the CI had generalized tenderness of the spine.  Provocative maneuvers for signs of radiculopathy (nerve root irritation or injury) or radiating pain due to spinal nerve root or sciatic nerve involvement were positive on the right and left.  Additionally, the examiner noted decreased sensation of the right and left legs.  At the 29 June 2004 physical therapy examination, the provider again noted positive signs of radiculopathy or radiating pain through provocative maneuvers.  During a 16 September 2004 primary care appointment, the CI stated he re-injured his back by lifting a 140 pound safe by himself causing significant pain.  The physical examination documented an antalgic (assuming a gait or posture to lessen pain) gait and midline lumbar spine tenderness.  A 5 July 2005 lumbar spine diagnostic imaging (MRI) study showed early degenerative disc changes at T11-12 and T12-L1 and a small left disc protrusion at L5-S1 causing mild left central canal and lateral recess stenosis (narrowing).  At an orthopedic examination, on 18 July 2005, the CI relayed the continuance of constant pain, made worse with standing, walking, bending and lifting.  The pain made sleeping difficult.  He experienced numbness in his genital area along with the legs, but did not suffer any leg weakness.  Bowel and bladder function remained normal.  The examiner noted no evidence of scoliosis (abnormal lateral spine curvature) or asymmetry of the spine.  Trunk flexion was documented as the ability to reach the finger tips to 6 inches of the floor which approximates 90 degrees of thoracolumbar flexion.  Extension was stated as approximately 45 degrees.  The CI experienced pain at the extremes of flexion and extension.  The spine was not tender and the CI walked with a normal gait and successfully raised up on his toes and heels without incident.  Bilateral lower extremity strength was evaluated as 5/5, but sensation was slightly decreased to light touch on the posterior thighs, medial lower legs, and medial arches of the feet.  In the 3 August 2005 orthopedic consultation, the CI complained of stocking numbness to his legs but denied any radicular pain.  The physical examination documented a normal gait with no spine tenderness.  The examiner documented trunk flexion as the ability to reach the finger tips to the midpoint of the knees, which approximates 45-60 degrees of thoracolumbar flexion.  All other ranges of motion (ROM) were symmetrical without pain.  The straight leg raise ([SLR] assesses for herniated disc causing sciatic nerve root [L5-S1] radiculopathy), femoral stretching test (assesses for upper lumbar nerve root compression), and Patrick (assesses for hip and sacroiliac joint pathology) tests were negative.  Strength, sensation, and deep tendon reflexes (DTRs) were normal.  A 24 August 2005 orthopedic encounter documented that an electrodiagnostic (EDX) study showed no evidence of a lower extremity radiculopathy.  A 19 September 2005 thoracic spine MRI showed degenerative changes at T2-3 within the right lateral recess with moderate spinal canal narrowing.  At an 11 October 2005 neurology consultation, the CI complained of diffuse low back pain, numbness and tingling from the waist down, and “that after standing his legs will sometimes go numb.”  The examination documented the SLR tests were negative and pathologic reflexes were absent.  Strength, DTRs, and sensation were normal except for mild subjective change in sensation at the waist level and mild paresthesias (abnormal sensation, tingling, burning, prickling) at the T2 level in the upper back.  The neurologist performed an EDX which showed evidence of a right thoracic radiculopathy at the T2 level.  The examiner opined “I cannot find evidence of a lumbar or sacral radiculopathy, including at the L5 and S1 level where there is at least some mild suspicion because of a degree of disk protrusion…I think there is a degree of myelopathy [spinal cord irritation, injury, disease, or dysfunction] and radiculopathy in the upper thoracic level.”  The impression listed mainly mechanical low back pain with a degree of thoracic radiculopathy and possible mild thoracic level myelopathy.  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 “back pain with multiple levels of protruded discs the worst of which is at the T2-T3 level” for PEB adjudication.  The 20 December 2005 MEB examination 6 months prior to separation, showed the CI was tender over the spine and had diminished sensation to light touch through the entire circumference of both legs.  Active ROM measurements performed for the MEB were flexion of 60 (90 normal), extension of 30 (30), right lateral flexion of 30 (30), left lateral flexion of 25 (30), right rotation of 25 (30), and left rotation 20 degrees (30) degrees.  In the 21 March 2006 MEB orthopedic surgery consultation the CI stated, due to his back pain, he could only walk 3 blocks.  He continued to experience leg numbness and had difficulty getting out of a chair due to weakness.  Upon exam, the CI forward flexed with his fingertips to the tibial tubercles bilaterally, which approximates 45-60 degrees of thoracolumbar flexion.  Extension was limited and side bends and rotation were normal.  The physical examination revealed tenderness at L5-S1, strength and deep tendon reflexes (DTRs) were normal, and sensation was grossly normal.  The 11 April 2006 MEB NARSUM exam, 2 months prior to separation, noted complaints of ongoing upper and lower back pain without weakness in the legs or bowel or bladder incontinence.  The NARSUM author performed no physical examination and cited the previously mentioned MEB examination and various examinations performed by other consultants.  At the 2 May 2007 VA Compensation and Pension (C&P) examination, 11 months after separation, the CI complained of chronic back pain that radiated to the bilateral medial thigh/groin, lateral lower legs, and to all 10 toes.  He reported an associated constant tingling, decreased sensation, and mild leg weakness.  The CI reported urinary hesitancy, and occasional post-void dribbling, but denied urinary incontinence or saddle anesthesia.  The physical examination documented a normal gait.  Active ROM values were flexion of 60 (90), extension of 20 (30), bilateral lateral flexion of 20 (30), and bilateral rotation of 30 (30) degrees.  Limitations in ROM were due to painful motion and repetitive motion did not produce any further reductions.  Strength, DTRs, and sensation were normal except for complete numbness involving both ankles, feet, and all 10 toes.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic radiating thoracolumbar back pain condition 10% coded 5237 (lumbosacral strain), citing the condition was rated for tenderness.  The VA rated the degenerative disc disease of thoracic and lumbar spine condition 20% coded 5299-5243 (intervertebral disc syndrome), based on the VA C&P examination 11 months after separation, citing forward flexion limited to 60 degrees.  Additionally, the VA rated right and left lower extremity sciatica at 10% each under code 8599-8520 (incomplete paralysis of the sciatic nerve).  The Board considered whether a rating should be recommended under a peripheral nerve code for an associated radiculopathy.  While the CI complained of radiating pain, numbness, and tingling, serial exams documented normal strength, tone, DTRs, and gait.  There was no evidence of atrophy or pathologic reflexes.  Sensory findings were grossly normal except for variably diminished light touch sensation, to numbness, involving both distal lower extremities.  Subjective sensory disturbances were not consistent with dematomal (area of skin sensation via a single nerve from a single nerve root) distribution of nerves.  While the initial EDX showed no radiculopathy, the subsequent EDX showed an upper thoracic radiculopathy.  There was no evidence of a lumbar or sacral radiculopathy which could involve the lower extremities.  While the CI may have experienced radiating pain from the back condition, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There is no objective evidence of radiculopathy with associated functional impairments.  The Board therefore concludes that additional disability rating was not justified on this basis.  The Board agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees as reported on the DD Form 2808B, MEB Consult and VA examinations.  After due deliberation, and considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the chronic radiating thoracolumbar back pain condition, coded 5237.  

Contended PEB Conditions. Corrected myopia (nearsightedness), elevated lipids, treated peptic ulcer disease, and tobacco use.  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.  The corrected myopia, elevated lipids, and treated peptic ulcer disease were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All of these conditions 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.  Tobacco use is a condition that does not constitute a physical disability.  The Board therefore has no reasonable basis for recommending this condition as additionally unfitting for separation rating.  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 chronic radiating thoracolumbar back pain condition, the Board unanimously recommends a disability rating of 20%, coded 5237 IAW VASRD §4.71a.  In the matter of the contended corrected myopia, elevated lipids, treated peptic ulcer disease and tobacco use 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 recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Radiating Thoracolumbar Back Pain	5237	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140929, 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 
AR20160017353 (PD201403820)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA