RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03867
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060425

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

CI CONTENTION:  His back condition has not improved.  He was not evaluated for PTSD, sleep apnea and knee injuries.  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 – 20060404	VARD - 20060921	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Low Back Strain	5237	10%	20060921	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:

Chronic Low Back Pain.  The service treatment record (STR) documented that low back pain (LBP), without a specific injury, began while the CI was deployed to Afghanistan.  A lumbosacral spine X-ray was unremarkable except for exaggeration of the lordotic (anterior spine curvature) curvature.  A lumbosacral spine magnetic resonance imaging (MRI) showed a small disc bulge at L4-L5 and mild degenerative disc changes at L5-S1.  The CI was referred for an electrodiagnostic study (electromyogram [EMG]/nerve conduction velocity [NCV]) to evaluate pain radiating from the left lumbar spine to the proximal left thigh.  The physical exam revealed no muscle atrophy and strength, sensation, and deep tendon reflexes (DTRs) were normal.  The straight leg raise (SLR) tests (assesses sciatic nerve root compression by a herniated disc) were negative.  The EMG/NCV was interpreted as normal.  At a pain management consultation, the CI complained of some low back discomfort while deployed in Afghanistan, but did not feel it was necessary to have it evaluated.  He subsequently had an injury at a water park where fell off a tube and stated it felt like "he broke his back.”  He waited 2 weeks and was evaluated at an Urgent Care and was prescribed an anti-inflammatory and a muscle relaxant.  Baseline 2/10 low back discomfort was exacerbated to 5/10 with prolonged driving or carrying heavy equipment.  Pain was relieved by a prescribed opioid-like analgesic (Ultram) and a muscle relaxant (Soma).  He complained of intermittent numbness and tingling of the left anterior leg, and occasionally the left foot.  The examiner recounted the findings from the MRI and EMG.  The physical exam documented that the CI could heel and toe walk.  The back exam revealed left lumbar paraspinal and sacral region tenderness and no rash or redness.  The spine range of motion (ROM) was flexion of 60 (90 normal) and extension of 20 (30) degrees with mild pain/discomfort.  The SLR test was positive on the left and negative on the right.  The Patrick tests (assesses hip and sacroiliac joint pathology) were negative.  Strength, sensation, and DTRs were normal.  The assessment listed low back pain, intermittent left leg radiculopathy, and L4-L5 bulging disc.  The examiner recommended lumbar epidural steroid injections but the CI declined.  

The general history and physical (H&P) for the MEB documented 2/10 lower back pain.  The physical exam revealed tenderness from T10-L4, pain with flexion at 70 degrees, and radiation to the left lower extremity.  The bilateral SLR tests were positive.  The diagnoses listed chronic LBP, L4-L5-S1 degenerative disc disease, and radiculopathy (irritation or injury of a nerve root).  The narrative summary (NARSUM), 3 months before separation, recounted the history and interventions.  The CI complained of low back pain, with tightness, occasional sharp exacerbations, and radiation down his left leg.  Active medications were an opioid-like analgesic (Ultram), a muscle relaxant (Soma), and an antidepressant (Pamelor).  The examiner restated the General H&P for the MEB exam findings and recounted the X-ray, MRI, and EMG findings.  No surgical options were available and the CI declined pain management epidural steroid injections.  The diagnosis listed low back pain.  Physical therapy (PT) measured thoracolumbar ROM for the MEB with a goniometer (rotation) and inclinometer (flexion/extension/side-bending).  Repetitive (X3) active ROM was flexion of 40/40/40 (90), extension of 20/20/20 (30), bilateral side-bending of 25/25/25 (30), and bilateral rotation of 70/70/70 (30) degrees.  There was pain at end points of ROM with flexion.  

The Compensation and Pension (C&P) exam recounted the history and interventions.  The CI complained of left low lumbar pain and a history of referred left leg pain with occasional numbness.  He denied any referred pain down the leg for a couple of months.  The CI could not recall a specific inciting back injury and denied bowel or bladder incontinence.  He reported increased weakness, fatigue, soreness, tenderness, and backache with repetitive motion.  Symptoms were exacerbated by heavy lifting, prolonged sitting, and “moving wrong.”  Flare-ups were relieved by rest, in about an hour.  Reported medications were an opioid-like analgesic (Ultram), a muscle relaxant, and an antidepressant (Amitriptyline).  The physical exam revealed the CI walked with an erect posture and no limp.  He was able to walk on his toes and heels without difficulty.  The examiner documented “He lay straight down on the table, sat straight up, and he dressed standing up with no problem.”  The spine exam revealed that it was muscular and straight and without tenderness.  The active ROM recorded flexion as “He bent to within 3 inches of the floor.  He did it twice.”  Extension was 20 (30), bilateral side-bending was 30 (30), and bilateral rotation was 45 (30) degrees.  Sensation was normal and there were no pathologic reflexes.  The DTRs were normal and symmetric (except for left knee 3+ and right knee 2+).  The examiner recounted the MRI findings.  The impression listed “He has chronic back strain with reduced reflex on the left and symptoms of referred pain.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the low back condition 10% (coded 5237).  The PEB cited chronic low back pain, no specific incident of trauma or injury, painful flexion to 70 degrees, tenderness, and L4-L5 disc bulge and mild L5-S1 degenerative disc changes by imaging.  The VA, citing the C&P exam 4 months after separation, rated the back condition 10% (coded 5237).  The VA cited left low lumbar pain, no referred pain down the leg for several months, walks erect, no limp, without symptoms and able to forward bend to within 3 inches of the floor, extend 20, twist right and left 45, and tip right and left 30 degrees, and L4-L5 disc bulge with mild degenerative changes by MRI.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  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 was no evidence in this case that there was radiculopathy with associated functional impairments which separately interfered with performance of duties.  The ROMs in the NARSUM and C&P exams were consistent with the 10% rating (flexion of greater than 60 degrees but not greater than 85 degrees; or a combined ROM of greater than 120 degrees but not greater than 235 degrees of the thoracolumbar spine).  The ROMs in the PT exam for the MEB were consistent with the 20% rating (flexion of greater than 30 degrees but not greater than 60 degrees; or a combined ROM of not greater than 120 degrees of the thoracolumbar spine).  The Board assigned less probative value to the NARSUM and C&P exams because they did not quantify comprehensive ROM measurements, did not specify use of a goniometer, and did not perform ROM with three repetitions.  The Board assigned more probative value to the PT exam for the MEB because it quantified comprehensive ROM measurements in degrees, specified measurement with a goniometer and inclinometer, and performed ROM with three repetitions.  The proximate exams did not document abnormal gaits or abnormal spinal contours.  Other routes to a rating higher than the PEB’s 10% were considered, but there was no evidence of additional functional loss from repetitive use to warrant application of VASRD §4.45, and no evidence of incapacitating episodes that would justify a minimum rating under the alternative formula for rating intervertebral disc disease.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommended a disability rating of 20% for the low back condition.

BOARD FINDINGS:  In the matter of the low back condition, the Board unanimously recommends a disability rating of 20%, coded 5237 IAW VASRD §4.71a.  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 his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Chronic Low Back Pain	5237	20%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140806, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

Dear 

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board's recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.

This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

A copy of this decision has also been provided to the Department of Veterans Affairs.

Enclosure