RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03836
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070416

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

CI CONTENTION:  The applicant contents that she was not evaluated for her PTSD condition.  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 - 20070313	VARD - 20070719	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Degenerative Intervertebral Disk Disease, Lumbar Spine	5243	20%	20070628	
			Numbness in both Legs	8520	NSC	20070628	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain.  According to the narrative summary (NARSUM), the CI’s back pain began in basic training following two falls in March 2002.  X-rays on 3 April 2002 showed mild dextroscoliosis (lateral curve in spinal contour) with hypertrophy at L5-S1.  In February 2003, the CI fell again; however, radiographic studies were read as negative.  A later radiographic study in June 2006 showed degenerative disc bulge with annulus tear at L5-S1.  Despite treatment, physical therapy (PT), and the determination the CI was not a surgical candidate; the CI’s back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and was referred for a Medical Evaluation Board (MEB).  

The range of motion (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)	MEB/PT ~5 Mos. Pre-Sep	PT for MEB ~2 Mos. Pre-Sep	VA C&P ~2 Mos. Post-Sep	Rehab Medicine ~6 Mos. Post-Sep	
Flexion (90 Normal)	90 	90	40	“full”	
Combined (240)	240	230	180		
Comment	Pain limited, tender, torso strength 4/5 all planes	Pain limited, tender, min guarding/spasm without abnormal gait	Tenderness, does “not complain of pain at these extremes of motion,” tandem toe and heel walks without difficulty	Painful motion	
§4.71a Rating	10%	10%	20%	10%	

The MEB NARSUM exam on 17 January 2007 (3 months prior to separation) noted complaints of chronic low back pain 3/10 at rest with increasing pain with activities such as extension or prolonged standing or walking to 6/10.  The physical exam was a summary of the PT ROMs from approximately 5 months prior to separation as charted above.  Repeat PT evaluation 2 months before separation documented pain limited ROMs as charted above.  

At the VA Compensation and Pension (C&P) exam performed on 28 June 2007, 2 months after separation, the CI reported a similar history of pain in her low back with occasional episodes of left leg pain.  The CI reported limitations on walking, stiffness in the morning, no incapacitating episodes, no bowel or bladder dysfunction or balance issues.  On examination, there was no gross deformity of the thoracolumbar spine, no evidence of scoliosis, no evidence of muscle guarding or spasm, and minimal tenderness on palpation of the lumbar paravertebral musculature.  Neurological exam showed straight leg raise test (for radiating symptoms) with no discomfort, bilaterally; no sensory or motor deficit of either lower extremity; deep tendon reflexes of the lower extremities present and symmetrical at +2.  The examiner stated that there was no “radiculopathy or radicular irritation.”  The ROMs are summarized above with the examiner’s comments quoted.   There was no change in ROM with repetitive motion.  A consult exam from rehabilitation medicine performed on 30 October 2007 (6 months after separation), noted complaints of constant low back pain with occasional radiation into the legs with some tingling and numbness in the legs.  Exam showed no tenderness, with ROM full but “mildly painful in flexion and extension.”  Strength and gait were normal and there was no sensory deficit noted.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under code 5237 (chronic low back pain) citing ROM limited by pain and tenderness.  The VA assigned a 20% rating using code 5243 (degenerative intervertebral disk disease) based on the VA C&P examination 2 months after separation, citing forward flexion of 40 degrees from the VA C&P exam.  There is a disparity between examinations with implications for the Board's rating recommendation.  The Board deliberated the probative value of these conflicting evaluations, and carefully reviewed the entire file for corroborating evidence.  The preponderance of exams documented ROMs that were either painful or limited at greater than 60 degrees flexion or 120 degrees combined (10% rating level).  The 2-month post-separation VA exam was the single exam which documented ROM’s limited to the 20% rating level (flexion greater than 30 degrees but not greater than 60 degrees).  The Board deliberated if the examiner’s comments indicated a valid active ROM or a measurement of ROM where pain started, and which exam best represented the CI’s disability picture at separation given both earlier and later examination documenting greater ROM.  The Board adjudged that the PT/MEB exam had the highest probative value for rating at the time of separation.  

There was no associated radiculopathy for separate peripheral nerve rating.  Although the CI experienced radiating pain, there was no objective evidence of a radiculopathy or functional impairment with a direct impact on fitness.  Although paresthesias (abnormal sensations) in the legs was reported, there was no fixed neurologic deficit on examinations.  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 evidence in this case that there was radiculopathy with associated functional impairments separately functionally impairing.  The Board therefore concludes that additional disability rating was not justified on this basis.  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.  

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.  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 20140818, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 AR20160009386 (PD201403836)

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