RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04119
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20091015

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Motor Transport Operator, medically separated for “thoracolumbar strain…” with a disability rating of 20%.

CI CONTENTION:  The CI requested consideration of 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 based upon a 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 - 20090903	VARD - 20100816	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Thoracolumbar Strain…	5237	20%	Thoracolumbar Strain 	5237	20%	STR	
Posttraumatic Stress Disorder	Not Unfitting	Post-Traumatic Stress Disorder 	9411	30%	STR	
Postconcussive Syndrome Manifested by Headaches	Not Unfitting	Post-Concussive Syndrome 	8045	0%	STR	
Tinnitus	Not Unfitting	Tinnitus	6260	10%	STR	
Sensorineural Hearing Loss	Not Unfitting	Hearing Loss, Right Ear	6100	NSC	STR	
Plantar Warts	Not Unfitting	Plantar Warts, Right Foot	7899-7820	0%	STR	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Thoracolumbar (Back) Strain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back pain condition began while deployed after falling 6 to 7 feet off of a truck while fastening his load and landing on his back.  The CI was subsequently transported from the theater to Landstuhl Regional Medical Center where a neurosurgical evaluation presented a diagnosis of low mechanical back pain and no anatomical defects or abnormalities identified on a computed tomography scan or magnetic resonance imaging.  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 MEB.  The MEB forwarded “thoracolumbar pain due to chronic strain” for PEB adjudication.  

At the time of the neurosurgery clinic appointment on 28 October 2008, 12 months prior to separation, the CI reported sharp pain 8/10 to mid-to-lower back with numbness and tingling radiating to his feet.  The CI denied any previous injuries, trauma or surgeries.  The examiner found no evidence of neuropathy and his gait was intact.  The CI could perform a toe-and-heel walk but walked slowly and remained stiff legged to prevent pain.  The back was tender to palpation and there was no bruising or abrasions.  Radiographic studies performed in 2008 revealed a normal study from T11 to the sacrum (large, triangular bone at the base of the spine.)   

Physical therapy examination in April 2009, approximately 6 months prior to separation, recorded range of motion (ROM) of the lumbar spine at approximately “20 inches from the floor.”

At the MEB examination dated May 2009, 5 months prior to separation, the CI reported continued thoracolumbar pain that was at times relieved with medication.  His pain occurred daily.  The physical examination showed tenderness to palpation over several areas of the thoracolumbar spine.  The CI was able to rise on his heels and toes without difficulty, and motor and sensory functions were intact, although the CI complained of right lower extremity tingling sensation.  Evidence of neuropathy was absent.   ROM documented forward flexion to 60 degrees (NL=90) and a combined ROM of 210 degrees (340)

The CI did not attend a VA Compensation and Pension (C&P) evaluation within 12 months of separation.   

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under the 5237 code (lumbosacral strain), citing tenderness, spasm and forward flexion of 60 degrees.  The VA also assigned a 20% rating using the 5237 code (lumbosacral strain) based on the STR, citing forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees.  

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) and/or combined ROM (not greater than 120 degrees).  The Board also considered if additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  However, there was no objective evidence of a radiculopathy with functional impairment (such as weakness) that directly impacted fitness for duty.  The Board therefore concluded that an additional disability rating was not justified on this basis.  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).”  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 back strain condition.  

Contended PEB Conditions: Posttraumatic Stress Disorder (PTSD); Postconcussive Syndrome; Tinnitus; Sensorineural Hearing Loss; and Plantar Warts.  The Board’s main charge is to assess the fairness of the PEB’s determination that PTSD; postconcussive syndrome “manifested by headaches; tinnitus; sensorineural hearing loss and plantar warts” were not unfitting, “either separately or in combination.”  The Board noted that the condition of PTSD was profiled and judged to fail retention standards; however, no mental health condition was implicated in the commander’s statement.  The psychiatric MEB noted that his condition had mild impairment for social and industrial activity, and that symptoms which impacted his occupational and social functioning included restricted range of affect, irritability and depression.  The commander’s statement documented that the CI was not observed to have any issues with attention, or any periods where he was unable to perform occupational tasks due to mental health problem.  It was noted that he had effective work relationships with both supervisors and co-workers.  The PEB noted that there was no verification of the CI’s stressors and no evidence of his PTSD negatively impacting his performance of duties.  

The post-concussion syndrome “manifested by headaches; tinnitus; sensorineural hearing loss and plantar warts” conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.   There was no performance-based evidence from the record that any of the above conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, and 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 contended conditions and so no additional disability ratings are recommended.    

BOARD FINDINGS:  In the matter of the thoracolumbar strain condition and IAW VASRD §4.71a, the Board recommends no change in the PEB adjudication.  In the matter of the contended PTSD; postconcussive syndrome manifested by headaches; tinnitus; sensorineural hearing loss and plantar warts conditions, the Board unanimously or majority 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, 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 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

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
AR20160018247 (PD201404119)

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